CMS Expands Definition of “Primarily Health Related” Benefits

April 2018 ~

CMS, announced on April 2, that it has expanded its definition of “primarily health related” benefits which carriers are allowed to include in their Medicare Advantage (MA) policies.

In the announcement, CMS notes that some MA plans offer supplemental benefits so that enrollees have more healthcare benefits and options than what they would receive under the Medicare fee-for-service (FFS) Program. The agency goes on to explain that MA plans use rebate dollars and plan premiums to fund supplemental benefit offerings and that he statute limits supplemental benefits to health care benefits.

“Supplemental healthcare benefits” are interpreted as an item or service: (1) not covered by Original Medicare, (2) that is primarily health related, and (3) for which the Medicare Advantage plan must incur a direct medical cost.

Previously, CMS has not allowed an item or service to be eligible as a supplemental benefit if the primary purpose includes daily maintenance. Under the new definition, CMS will allow supplemental benefits if they are used to “diagnose, prevent, or treat an illness or injury, compensate for physical impairments, act to ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and healthcare utilization.”

According to the agency, this expansion will help drive patient access to types of services they do not have today, as well as lead to an increase in the number of allowable supplemental benefit options, and provide patients with benefits and services that may improve their quality of life and health outcomes.

Source(s): CMS Press Release; Kaiser Health News;