SDOH, SSBCI and the 2020 Final Call Letter

Social Determinants of Health are rapidly gaining traction throughout the healthcare industry. Medicare Advantage Organizations (MAOs) and CMS seem to be in agreement that an expansive definition of benefits to be offered under Medicare Advantage can help MAOs help their members.

Enter Special Supplemental Benefits for the Chronically Ill (or SSBCI for those of us who can’t resist just one more acronym). The CMS 2020 Final Call Letter released on April 1st, 2019 offers some detail on Special Supplemental Benefits for the Chronically Ill (all the following quotes are drawn from that letter).  They begin with a general definition of SSBCI:

SSBCI include supplemental benefits that are not primarily health related and may be offered non-uniformly to eligible chronically ill enrollees

CMS makes a point of letting MAOs know that they have freedom in designing SSBCIs:

In general MA organizations have broad discretion in developing the items and services they may offer as SSCBCI provided that the items or services have a reasonable expectation of improving or maintaining the health or overall function of the enrollee as it relates to the chronic condition or illness.

It is that reference to chronically ill enrollees which can be seen as an important limiting factor in the design of SSCBI. To clarify, CMS refers back to the regulatory definition of chronically ill enrollees:

Section 1852(a)(3)(D)(ii), as amended, defines a chronically ill enrollee as an individual who:
1) has one or more comorbid and medically complex chronic conditions that is life threatening or significantly limits the overall health or function of the enrollee;
2) has a high risk of hospitalization or other adverse health outcomes; and
3) requires intensive care coordination.

CMS further calls out the fact that the majority of current MA members meet the definition of chronically ill enrollees:

We note that a large percentage of the current Medicare Advantage population (about 73%) have one or more chronic conditions on the list of chronic conditions in Chapter 16b.

On the other hand, at least for now CMS is not allowing for the offering of Supplemental Benefits to individuals who are not chronically ill:

CMS solicited comments on whether we should permit consideration of other factors, like financial need, in determining permissible supplemental benefits for chronically ill enrollees. Overall, comments were supportive of using social determinants or social risk factors to establish benefit eligibility. However, we clarify here that the statute expressly limits these supplemental benefits to enrollees that are chronically ill. We have not identified authority to allow for other
criteria or social risk factors to be used when determining eligibility for these benefits.

Will CMS at some point, perhaps, identify an authority that would allow other criteria for the offering of Supplemental Benefits? It certainly seems like they are leaving the door open for a change like that.

In the meantime, MAOs have the opportunity to be creative in offering benefits that can help the 73% of their population who are chronically ill. To deliver successful innovations, MAOs need to identify SDOH barriers at the member level, implement solutions with trusted benefit providers, and communicate those benefits effectively to the eligible population. And then, of course, they will need to measure the impact of these SSBCIs.

At BeneLynk, our SDOH services are designed to engage MA members, leading with help, and allowing MAOs to document SDOH barriers and offer solutions. We believe that effective ongoing communication with the member is at the center of addressing SDOH.  We are, of course, encouraged to see the growing support within the industry for creative solutions to SDOH barriers. As always, if you are interested in talking about SDOH in managed care, please drop me a note at Sean.Libby@BeneLynk.com.