This benefit season, more than any other, it’s critical to address medical services that target complex medical needs and non-medical services that target social factors, to stay competitive.

With each passing bid season, there’s more and more evidence that when clinical care is delivered in conjunction with non-clinical services that also affect health, our members do better; we improve health outcomes and lower costs. The pandemic brought into stark relief what many industry experts have been telling us for a long time, our most vulnerable enrollees have complex medical needs as well as social risk factors that play a crucial role in their overall health and wellbeing. This benefit season, more than any other, it’s critical to address both sides of the equation, medical services that target complex medical needs and non-medical services that target social factors, to stay competitive.

A paradigm shift

The “essential” benefits that got you where you are today are not enough to keep you here because nearly all plans provide them now. As plans’ understanding of Center of Medicare & Medicaid Services’ benefit flexibilities grows in sophistication, more and more organizations will offer benefits that are progressively creative, laser-targeted and tailored to meet individualized needs of members, whether those needs are disease-specific, lifestyle driven, or related to social determinants of health. This year, consider evolving your benefit design so that your benefits do more than just attract new members to your plan; each benefit should also serve as many of the following functions as possible:

  • Retain your existing members
  • Increase member satisfaction and net promoter scores
  • Improve clinical outcomes
  • Lower costs

You may want to look at the specific design of each benefit with a very critical eye, especially your supplemental benefit offerings, to determine how many of the functions above each one checks off. Looking at each benefit anew, critically, will help you ask yourself if your benefit is working as expected, whether you’ve had any operational challenges, access problems, or if you’re compromising any of the above important elements. You’ll also want to evaluate how your providers, vendors, and partners are delivering the benefit, and whether your members are delighted or disappointed.

Understanding the increased benefit flexibilities is key to good design

Get to know the complex rules around the latest changes; Uniform Benefit Flexibility (Uniformity/Flexibility), Special Supplemental Benefits for the Chronically Ill (SSBCI) and Value Based Insurance Design (VBID) each has its own set of rules and requirements as well as unique bid preparation instructions. It’s important to get knowledgeable about these changes to best leverage these flexibilities either on their own, or in combination with each other to tailor your benefit design to best fit your unique enrollee population.

Now is the time for strategic considerations

Keeping in mind the four functions above, now is the time to rely on your data experts to help you determine how you could use benefits to:

  • Address lagging Star measures (where are you close, what are the weight changes, who are your vendors, are members happy)
  • Drive better management of certain member cohorts (think about flexibilities around high value providers and differentiating copays based on participation in programmatic efforts)
  • Improve clinical outcomes (think about how addressing social factors may remove potential barriers to care or improve access)
  • Control costs (weigh the costs of any benefit with the potential cost savings or increased revenue it may provide)

Finally, recognize that benefit design is complex, but doing it thoughtfully and expertly can pay huge dividends down the road if you leverage your benefits to improve clinical outcomes, reduce costs and delight your members. Now is the time to put it all together.  If you don’t have expertise inhouse, lean on your actuarial firm, industry consultants, or even your vendor partners to help. They have invested resources in subject matter expertise that will be worth its weight in gold when it comes time to pull the trigger on your final design.


About the author

Ana Handshuh, principal at CAT5 Strategies, is a government programs executive with expertise in creating and implementing corporate programs for the health care industry. Her background includes quality, core measures, care management, benefit design and bid submission, accreditation, regulatory compliance, revenue management, communications, community-based bare management programs and technology integration.

Handshuh currently serves on the board of the Resource Initiative and Society for Education (RISE) and is the chair of the RISE Association's Quality & Revenue Community.  She is a sought after speaker on the national health care circuit in the areas of quality, Star ratings, care management, member and provider engagement, and revenue management.