New Medicare Advantage Benefits May Be Hard to Find — and Qualify For

If you’re tempted by the new benefits some Medicare Advantage plans are touting, the annual open enrollment season (Oct. 15 through Dec. 7) is the time to look. But finding a plan offering the benefits might be hard.

Medicare Advantage, also known as Medicare Part C, is administered by private insurers and offers the same Medicare Part A and Part B benefits as Original Medicare. Many plans also include limited dental, vision and hearing coverage, and even gym memberships.

Starting in 2019, new government rules have allowed Medicare Advantage plans to expand benefits even further. Commonly referred to as Special Supplemental Benefits for the Chronically Ill, or SSBCI, the new benefits can go beyond strict medical care and provide support that can help improve and prolong a sick person’s life.

Government research shows that more than 70% of seniors live with at least one chronic illness, although eligibility rules for the new benefits also require “a high risk of hospitalization or other adverse health outcomes.”

These new rules open the door to coverage for adult day care services, home-based palliative care, in-home support services, caregiver support, non-opioid pain management, memory fitness services, home and bathroom safety devices and modifications, transportation, meal delivery, pest control, over-the-counter health items, virtual health services, acupuncture and others.

Additional support for chronically ill older adults is great news. But it’s important to remember that these supplemental benefits are just that, supplemental. A provider can decide which ones, if any, to offer, and the benefits are not available to everyone in a specific plan.

So far, insurers and consumers have been slow to embrace the new rules. Only an estimated 4.6% of plans are offering any new benefit, according to Brown University research published in May 2020.

Before you sign up for one of these expanded plans, be sure you know the limits involved, warns David Lipschutz, associate director/ senior policy attorney at the Center for Medicare Advocacy. Here’s what to keep in mind.

Understand what’s being offered

Benefits aren't universally available

As part of the new rules, the government has altered what’s known as the “uniformity standard,” explains Lipschutz. Until now, Medicare Advantage plans had to offer the same benefits to all enrollees in a certain area, usually a county. So, if you’re eligible for twice-yearly dental checkups under your plan, so is everyone else enrolled in the plan.

For SSBCI benefits, however, insurers determine who qualifies. Grab bars, for instance, could be available only to patients who have already experienced a fall. Memory care may be reserved only for those patients diagnosed with a form of dementia.

It can be hard to determine if you qualify

You won’t know which, if any, of these new benefits you’ll receive until you are enrolled in a plan that offers them. That’s because the plan will need to confirm your diagnosis and determine if you meet the plan’s eligibility rules, something that can’t be done before you are a member.

This makes comparing plans difficult. Using Medicare.gov’s Plan Finder tool, you can determine what benefits are offered, but not if you will qualify. Keep in mind that agents, brokers or anyone else representing a plan can’t guarantee your eligibility. That includes customer service reps who answer the phone for an insurer, so, in this case, calling a plan directly won’t help much, says Lipschutz.

Check out limits

Each plan is allowed to determine how much of a given benefit it will cover. “We have found most to be fairly limited,” says Lipschutz. Services like meal delivery may be once a day for only a set period of weeks. Home-health aides may be limited to 12 visits a year.

To find out how the plans you are considering limit supplemental benefits, check the “Evidence of Coverage” document, which spells out coverage details. You can find this document on the insurer’s website or often through a link on Medicare.gov’s Plan Finder tool.

You can change your mind

If you find you’ve enrolled in a Medicare Advantage plan and you aren’t happy with it for whatever reason, you can change to another Medicare Advantage plan during the three-month Medicare Advantage open enrollment period starting Jan. 1 and ending March 31. This can be helpful if you signed up for a plan because of the supplemental benefits offered but once enrolled discover you don’t qualify for those benefits.

Be aware that you may change plans only once during this special enrollment period. This is different from the end-of-the-year open enrollment period (Oct. 15 - Dec. 7) when you may move back and forth between plans as much as you like.

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