Managing Conflicts of Interest in This New World of Medicare Advantage

1. Managing Conflicts of Interest in This New World of Medicare Advantage Bonnie Burns, SHIP TA Center Rebecca Kinney, ACL Marissa Whitehouse, ACL

2. Agenda • The New Medicare Advantage Landscape • The Business Acumen Initiative • Exploring Conflicts of Interest • Ideas for Managing Conflicts and Risks • Questions

3. What is happening? The New Medicare Advantage Landscape

4. Special Supplemental Benefits for the Chronically Ill (SSBCI) • CMS released guidance in April 2019 for MA plans for calendar year 2020 benefits • SSBCI greatly broadens benefits MA plans can offer to chronically ill enrollees only. Includes: • Reduced cost sharing for Medicare covered benefits, • Reduced cost sharing for primarily health related supplemental benefits, • Additional primarily health related supplemental benefits, and/or • Non-primarily health related supplemental benefits.

5. SSBCI (cont.) • Meals • Transportation • Pest control • Indoor air quality equipment • Social needs benefits • Complementary therapies • Services supporting self-direction • Home modifications • Plans may require enrollees to participate in a care management program or use a high value provider as a condition of the new benefits. • Examples of possible items or services include:

6. SSBCI (cont.) • Plans will be allowed to vary or target the benefits as they related to individual enrollee’s specific medical conditions and needs. • Plans are responsible for clearly identifying in their EOBs: • What will and will not be covered and • Any limitations on coverage. • Plans may include the supplemental benefits in marketing and communication materials but they cannot mislead or misrepresent these benefits to enrollees and cannot state that they are guaranteed.

7. The Business Acumen Initiative

8. What is Business Acumen? • Definition: Keenness and quickness in dealing with and understanding a business situation in a manner that is likely to lead to a good outcome. • Understanding: • The market • Your competitors • Your value/business case • Knowing how to: • Forge relationships/ partnerships • Sell your services/ negotiate your contract • Ensure scalability/volume • Address quality/performance management/accreditation

9. Why focus on Business Acumen? • AAAs and other community-based partners are financially motivated to find new sources of revenue • These new Medicare policies provide greater opportunities for CBOs to partner with MA plans

10. ACL’s Efforts to Support Business Acumen Work • ACL/AoA has been funding and supporting business acumen exploration and learning opportunities for years • Learning Collaboratives hosted by NCOA’s Center for Healthy Aging and n4a’s Aging and Disability Business Institute. • Aging & Disability Business Institute

11. NCOA’s Learning Collaboratives • Medicare Advantage Learning Collaborative • Provide community-based organizations (CBOs) with the knowledge and skills to pursue partnerships and contracts with Medicare Advantage plans for home and community-based services and supports. • Network Development Learning Collaborative • Provide community-based organizations (CBOs) with the knowledge and skills to create, enhance, and/or successfully manage community integrated network partnerships.

12. Exploring Conflicts of Interest

13. SHIP Statute states: • Grantees must “provide assurances that staff members (including volunteer staff members) of the health insurance information, counseling, and assistance program have no conflict of interest in providing the counseling”

14. VRPM Policy 3.35 Conflict of Interest (Required) No person who has a conflict of interest in connection with the work they will do at the SMP/SHIP, whether personal, philosophical, or financial may serve as a volunteer. Volunteers do not promote any personal or business interest while undertaking their SMP/SHIP assignment. One example of persons with an inherent conflict of interest is anyone who receives compensation for enrolling beneficiaries in a specific insurance plan or plans.

15. What this means* • A conflict of interest is an interest that prevents, or could prevent, a person from performing some task objectively. • SMP/SHIP volunteers must be neutral, objective, unbiased. • Conflicts can be actual or simply the appearance of conflict. • A conflict might exist for the volunteer, a family member, or a business interest connected to a potential volunteer. • Most conflict questions show up during the application process, but they can occur at any time if the volunteer changes their situation. *Pulled from Center webinar conducted April 2019

16. Exploring Conflicts of Interest • What is a conflict of interest for SHIPs? • No definition, rules, guidance of conflicts • Exchange of money (obvious) • Appearances (perceptions) • Personal views (expressed or implied) • Ingrained bias (expressed as preferences, or affecting information provided)

17. May be different for each entity • Parent agency of a SHIP • State agency • Local agency of state government • County Board of Supervisors • Area Agency on Aging • Another non-profit or organization These entities may have broad conflict of interest requirements related to the organization but not to the activities of SHIP

18. SHIP grantees • Internal bylaws or parent organization standards • Probably not specific to SHIP or SHIP activities and conflicts of interest • Ship Director and staff • Administration and supervision of staff • Providing and distributing unbiased community information, education • Recruiting, screening, training, and supervising volunteer counselors • SHIP counselors • Need standards and guidance • One on one interaction with consumers • Providing unbiased information (ingrained or actual bias)

19. Ideas for Managing Risks

20. First step – Evaluating • Start exploring, if you haven’t already, what is happening with your AAAs and other partners • Awareness is first step in risk management • Evaluate the risks identify and determine level of comfort with each • Can you live with the risk with some modifications? Or is the risk too great?

21. Work with Partners • Have open and honest discussions on the risks and negotiate possible solutions • Keep in mind that your partners have their own set of risks they are managing

22. Examples • Develop firewalls within agencies • One side of the house focus on Federal grant funded programs (OAA, SHIP, SMP, etc.), and the other side focus on Plan contract work. • Staff would not work on both funding streams • Develop consortiums • Plan contracts would be held by third party • All referrals and reimbursements are managed by the this entity • CBOs maintain a level of distance from Plan’s • Can be set up so that the CBO doesn’t know the payment source of each referral

23. Defining Standards and Expectations

24. ACL Guidance • ACL OHIC is working on developing clearer guidance in this area • Need to include perspectives from across ACL along with the SHIP and SMP grantees

25. Workgroup Opportunity If you’re interested in helping us gather and synthesize best practices to support policy development -or- You’re willing to share details about your state’s experience with safeguarding against this type of conflict, email: Marissa Whitehouse Marissa.whitehouse@acl.hhs.gov

26. Questions?