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Reinterpretation of “Primarily Health Related” for Supplemental Benefits

Posted on Friday, May 4, 2018 3:40 PM

“Beginning in CY 2019, CMS is expanding the definition of “primarily health related” to consider an item or service as primarily health related if it is used to diagnose, compensate for physical impairments, acts to ameliorate the functional/psychological impact of injuries or health conditions, or reduces avoidable emergency and healthcare utilization. A supplemental benefit is not primarily health related under the previous or new definition if it is an item or service that is solely or primarily used for cosmetic, comfort, general use, or social determinant purposes.

For CMS to approve a supplemental benefit, the benefit must focus directly on an enrollee’s health care needs and be recommended by a licensed medical professional as part of a care plan, if not directly provided by one. We expect organizations will establish reasonable safeguards to ensure enrollees are appropriately directed to care.”

The following benefits are allowable as a result of CMS’s reinterpretation of the of “primarily health related” definition: adult day care services, home-based palliative care, in-home support services, respite support for caregivers of enrollees, medically-approved non-opioid pain management, stand-alone memory fitness benefit, home and bathroom safety devices & modifications, transportation and over-the-counter medication benefits.

Click here to read the full CMS memo.


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