Paying for Nonmedical Needs

THE CHALLENGE

Aging well means many needs are met, not just medical needs. As we get older, the majority of us will need some nonmedical help to remain independent. It might be picking up groceries and/or preparing meals, getting to social affairs, bringing helpers into our homes, and the list goes on.

Medicare beneficiaries with multiple chronic conditions and nonmedical needs spend the majority of Medicare dollars. Families struggle to care for older loved ones with these challenges, which can be physically and emotionally draining with substantial out-of-pocket costs.

The financial implications are profound.

As it stands, families cover more than half of long-term care (LTC) costs through out-of-pocket spending, so having a nonmedical need subjects a majority to catastrophic financial risk. Hear from Bernie and Rita.

Working with the National Opinion Research Center, we track public opinion on LTC financing and related issues. Check out the latest.

The Opportunity

We work with knowledgeable partners and policymakers to develop solutions on how to better finance and deliver quality care to older adults with complex care needs. A significant achievement came in 2018 with passage of the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act. This federal law allowed health plans and providers to pay for medical and nonmedical care for those in Medicare Advantage plans, and those with dual Medicare and Medicaid coverage.

 

Aim and Approach

Covering Nonmedical Needs Through Medicare Advantage

For the first time, Medicare Advantage plans have significant flexibility in designing Special Supplemental Benefits for the Chronically Ill (SSBCI) that meet the individual needs of enrollees. While the SSBCI are a relatively small part of the Medicare Advantage program, they represent a turning point. Medicare can now pay for nonmedical services, such as adding grab bars to bathrooms, installing wheelchair ramps in homes, and more. In addition, people with limited transportation can use telehealth options to talk to clinicians by phone or over the computer.

Learn more about Medicare-Medicaid flexibilities and particular use cases since the pandemic.

Our Thought Partners

To achieve long-term adoption of SSBCI in a manner that improves health care for the chronically ill, Medicare Advantage payers and providers needed new principles to guide the implementation. ATI Advisory (ATI) and the Long-Term Quality Alliance (LTQA) convened and led a working group comprised of national experts on Medicare Advantage and long-term care to develop Guiding Principles for New Flexibility Under SSCBI.

These principles illustrate how Medicare can create the flexibility to meet people’s needs while still balanced with appropriate guardrails to protect beneficiaries, providers, Medicare Advantage plans, and the integrity of the Medicare program overall. The principles reflect a shared vision to guide diverse stakeholders as they develop, implement, and offer SSBCI. ATI and LTQA also produce data insights that track and benchmark nonmedical benefit trends.

Other Approaches to Financing Nonmedical Needs

There are other approaches to supporting people’s nonmedical needs outside of health care. Partners have worked in this space to identify and demonstrate methods, such as making long-term care insurance (LTCI) a more affordable, flexible option for families.

Our Thought Partners

The Bipartisan Policy Center (BPC) develops workable policy solutions focused on how to finance and deliver quality care to people with complex care needs. In their latest report, they identify solutions for making LTC more affordable for those who do not qualify for Medicaid. Their 2018 roadmap of policy solutions unpacks the barriers to financing and delivering person- and family-centered, coordinated health and social services and supports.

In the earliest stages of this work, we partnered with AARP and LeadingAge to fund data analytics and economic modeling completed by the Urban Institute and Milliman, Inc. Urban and Milliman contributed high-level insurance models for LTC financing. This work spoke to the complex approaches to expanding access to LTC coverage. It also identified important tradeoffs that policymakers can consider in evaluating solutions.

Formative Reports

Urban Institute

Microsimulation Analysis of Financing Options for LTSS​​

Older adults face a significant risk of developing chronic health problems and becoming unable to perform basic tasks on their own. In 2011, 7.7 million adults ages 65 and older received help…

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Milliman, Inc.

Premium Estimates for Policy Options to Finance LTSS​

This resource focuses on premiums expressed in 2015 dollars for individuals purchasing LTCI coverage and  draws comparisons to premiums for policies commonly sold in the private market…

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Health Affairs

Financing LTSS: Options Reflect Tradeoffs for Older Americans and Federal Spending​

Under current policy, people needing long-term services and supports (LTSS) will cover roughly half…

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Infographics

Half of adults in the United States age 65 and older will need high levels of help with daily activities.

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One in seven of all older adults will need help with everyday activities for five or more years.

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Women, who average two-and-a-half years of high-level needs, face greater costs.

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Families cover more than half of LTC costs through out-of-pocket spending.

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Get informed.

This ATI white board video describes the need for new LTC financing solutions and encourages all Americans to join the conversation.

Also, The Case for Financing Older America’s Long-Term Care Need resource is available for download and wide use.