Medicare Advantage Regulation Finalized: What it Means for Home-Based Care Providers

On April 2, the Centers for Medicare and Medicaid Services (CMS) finalized the 2019 rule for Medicare Advantage (MA). There are two areas impacting home-based care providers:

Home Health
For the first time, CMS is allowing nonskilled in-home care services as a supplemental benefit for MA plans in 2019. The benefit marks the first time CMS has allowed supplemental benefits that include daily maintenance in MA.

“CMS is expanding the definition of ‘primarily health related,’” the agency stated in its announcement. “Under the new definition, the agency will allow supplemental benefits if they compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room utilization.”

As many home health agencies currently provide nonskilled services, this is an opportunity for growth and a way to underscore the value of home health care in well-coordinated and integrated care.

Hospice/Palliative/Advanced Illness Care
With outreach from ElevatingHOME and other hospice, palliative, and advanced illness care representatives, CMS modified the proposed rule to allow in the final rule:

  • Exclude patients getting palliative care from the opioid restrictions.
  • Revise the 90 morphine milligram equivalents opioid dose limit with a care coordination edit.
Specifically, on the care coordination edit, CMS stated that “In implementing this edit, sponsors should instruct the pharmacist to consult with the prescriber, document the discussion, and if the prescriber confirms intent, use an override code that specifically states that the prescriber has been consulted. Sponsors will have the flexibility to include a prescriber and/or pharmacy count in the opioid care coordination edit. Sponsors will also have the flexibility to implement hard safety edits (which can only be overridden by the sponsor) and set the threshold at 200 MME or more and may include prescriber/pharmacy counts.”

Please contact Joy Cameron with any questions or concerns.


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