What Do You Need to Know About the New Medicare Advantage Rules?


In April of this year, the Centers for Medicare & Medicaid Services (CMS) released the final updates to the Medicare Advantage (MA) program. The new rules help support the trend toward value-based care and increases flexibility and efficiency for both providers and patients, particularly as it relates to nonmedical issues that may impact health outcomes. Non-traditional services—such as transportation, nutrition support, and medically necessary home renovations—are potential opportunities for providers to expand, monetize, and flex coverage options to better care for patients.

Key Changes to MA Rules

Managing chronic illnesses is a monumental effort, and the new MA rules support efforts to implement preventative and maintenance efforts earlier, especially for those where there is the possibility of improving or maintaining health. Healthcare providers can now partner with community organizations and companies to provide necessary support to chronically ill patients, such as Uber and Lyft for transportation, Meals on Wheels for nutrition support, and local community-based centers for in-home care services. Previously uncovered benefits—the installation of air conditioning for asthmatic patients for example—are now potential opportunities for providers to initiate early preventative measures that provide significant savings and improved quality of care.

Partnering with nonmedical service providers creates unique opportunities and challenges for the current landscape. Whether providers tackle these services on their own or partner with external groups, navigating and taking full advantage of these opportunities requires a new model of healthcare, specifically one that focuses on integration and collaboration while moving away from the traditional one-size-fits-all approach of yesteryear.

Potential Impacts to Patients and Providers

Perhaps the most impactful change of the new MA rules is that providers can now monetize nonmedical support services. MA enrollments are expected to almost double by 2025 to 38 million, and there is a significant opportunity for providers to create individualized plans that more effectively meet patient needs while improving care delivery. In addition, the ability to tie in disparate nonmedical services allows providers to more accurately gauge both quality and cost. Patients, particularly the chronically ill, will ideally see the benefits of innovation, cost decreases, improved efficiencies, and expanded coverage options.

There are, however, potential drawbacks. The cost of healthcare has steadily risen over time, and there is the risk that the new social services may succumb to similar issues. As providers consider their opportunities, they should carefully examine which benefits are truly beneficial and which are not. One industry—long-term care insurance—could face significant risks associated with these MA rule changes. Long-term care insurance has already faced significant declines. Enrollment declined almost 14% between 2015 and 2016, and the market has decreased eight-fold since peaks in 2002. If providers begin assuming some of the roles traditionally managed by long-term care insurance, the industry will face significant pressure to adapt.

The expanded coverage options and ability to directly partner with nonmedical social services are clear gains in the continual efforts to reduce costs, improve efficiencies, and better serve the patient. The new Medicare Advantage rules promote the drive to value-based care with increasingly broad and comprehensive support for patients. As providers seek opportunities to either partner with external groups or develop their own resources, priority should be given to efforts that truly improve outcomes and care results.

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