United States Government Accountability Office Report to Congressional Committees MEDICARE January 2023 ADVANTAGE Plans Generally Offered Some Supplemental Benefits, but CMS Has Limited Data on Utilization GAO-23-105527 January 2023 MEDICARE ADVANTAGE Plans Generally Offered Some Supplemental Benefits, but CMS Has Limited Data on Utilization Highlights of GAO-23-105527, a report to congressional committees Why GAO Did This Study What GAO Found MA plans decide which, if any, Under Medicare Advantage (MA), a private plan option in Medicare, plans can supplemental benefits to offer. These offer supplemental benefits not covered under Original Medicare. Supplemental benefits may be attractive to Medicare benefits have long included traditional health-related benefits. In 2022, all but one beneficiaries, but little is known about plan reviewed by GAO offered at least one such benefit; the most common were their use. vision and hearing. (See figure.) MA plans can also offer two newer types of The Bipartisan Budget Act of 2018 benefits. First, starting in 2019, plans could offer benefits intended to reduce includes a provision for GAO to review avoidable health care use, among other things. Second, starting in 2020, plans supplemental benefits. Among other could offer benefits with a reasonable expectation of improving or maintaining the things, this report describes the health or function of chronically ill enrollees. In 2022, about one-third of plans supplemental benefits offered by MA reviewed offered at least one of the newer types of benefits; the most common plans in 2022 and examines the were in-home support services and food and produce. information that CMS has on enrollees' use of supplemental benefits and their Most Common Supplemental Benefits, by Type, Offered by Medicare Advantage (MA) Plans effects on enrollees' health and Reviewed, 2022 function. GAO analyzed plan benefit data for 3,893 MA plans in the 50 states and District of Columbia. GAO excluded certain plans, such as plans participating in the Value-Based Insurance Design Model and employer plans, to ensure comparability between plans. GAO also reviewed CMS regulations and guidance and MA plans are required to submit detailed, service-level utilization data to the interviewed officials from CMS and six Centers for Medicare & Medicaid Services (CMS), the agency that oversees MA. MA organizations selected based on These data-known as encounter data-must include supplemental benefits to enrollment, geographic coverage, and the extent required by CMS. However, GAO found that information submitted by other factors. plans on enrollees' use of supplemental benefits is limited for two reasons: What GAO Recommends • CMS guidance on encounter data does not specifically mention the GAO is making two recommendations submission of such data for supplemental benefits, although it says plans to CMS: (1) clarify guidance on the must submit encounter data for each benefit provided to an enrollee. CMS extent to which encounter data officials told GAO that the inclusion of supplemental benefits in this submissions must include data on the requirement is clear, noting the guidance does not differentiate between utilization of supplemental benefits and supplemental and Original Medicare benefits. However, officials from three (2) address circumstances where MA organizations told GAO they are not required to submit encounter data submitting encounter data for for some or all supplemental benefits and therefore do not do so. supplemental benefits is challenging • Officials from CMS and two MA organizations told GAO there are challenges for MA plans, such as when a given collecting and submitting encounter data for certain supplemental benefits. benefit lacks an applicable procedure For example, officials said there is no procedure code for some of the newer code. The Department of Health and supplemental benefits, such as food and produce. Human Services concurred with the recommendations. As of October 2022, CMS was in the early stages of assessing the completeness of the encounter data for supplemental benefits and identifying options for collecting enrollee utilization data for the newer benefits but did not have a View GAO-23-105527. For more information, contact Michelle B. Rosenberg at (202) 512- workplan or timeline for next steps. More complete information on enrollees' use 7114 or RosenbergM@gao.gov. of supplemental benefits would put CMS in a stronger position to ensure the benefits effectively support the health and social needs of enrollees. United States Government Accountability Office Contents Letter 1 Background 5 Almost All MA Plans Reviewed Offered Traditional Supplemental Benefits; Fewer Offered Newer Benefits 9 MA Plans' Projected Costs for Supplemental Benefits Varied Widely in 2022; Most Expected to Finance the Benefits with Rebates 18 CMS Has Limited Information on Enrollees' Use of Supplemental Benefits and Their Effects 24 Conclusions 27 Recommendations for Executive Action 28 Agency Comments 28 Appendix I Supplemental Benefits Offered by Medicare Advantage Plans GAO Reviewed 30 Appendix II Supplemental Benefits Offered by Medicare Advantage Special Needs Plans (SNP) and Non-SNPs GAO Reviewed 34 Appendix III Supplemental Benefits Offered by Medicare Advantage Plans GAO Reviewed in the Value-Based Insurance Design Model 39 Appendix IV Comments from the Department of Health and Human Services 45 Appendix V GAO Contact and Staff Acknowledgments 48 Tables Table 1: Types of Supplemental Benefits Offered by Medicare Advantage Plans 6 Table 2: Most Common Traditional Supplemental Benefits Offered by Medicare Advantage Plans, 2022 10 Table 3: Expanded Primarily Health-Related Supplemental Benefits Offered by Medicare Advantage Plans, 2022 12 Page i GAO-23-105527 Medicare Advantage Supplemental Benefits Table 4: Most Common Special Supplemental Benefits for the Chronically Ill (SSBCI) Offered by Medicare Advantage Plans, 2022 13 Table 5: Types of Supplemental Benefits Offered by Medicare Advantage Special Needs Plans (SNP) Compared to Non-SNPs, 2022 14 Table 6: Medicare Advantage Plans' Expected Financing Sources for Supplemental Benefits, 2022 22 Table 7: Supplemental Benefits Offered by Medicare Advantage Plans, 2022 30 Table 8: Supplemental Benefits Offered by Medicare Advantage Special Needs Plans (SNP) Compared to Non-SNPs, 2022 34 Table 9: Examples of Supplemental Benefits Offered by Medicare Advantage Plans in the Value-Based Insurance Design Model, Including Special Needs Plans (SNP) and Non- SNPs, 2022 41 Figures Figure 1: Medicare Advantage (MA) Plans' Financing Options for Supplemental Benefits 9 Figure 2: Examples of Supplemental Benefits Offered by a Higher Percentage of Medicare Advantage Special Needs Plans (SNP) Compared to Non-SNPs, 2022 16 Figure 3: Examples of Supplemental Benefits Offered by a Lower Percentage of Medicare Advantage Special Needs Plans (SNP) Compared to Non-SNPs, 2022 17 Figure 4: Medicare Advantage Plans' Net Projected Costs for Supplemental Benefits, 2022 19 Figure 5: Variation in Medicare Advantage Plans' Net Projected Costs for Dental Supplemental Benefits, 2022 20 Figure 6: Examples of Medicare Advantage Plans' Expected Use of Projected Available Resources, 2022 23 Page ii GAO-23-105527 Medicare Advantage Supplemental Benefits Abbreviations CMS Centers for Medicare & Medicaid Services MA Medicare Advantage SNP special needs plan SSBCI Special Supplemental Benefits for the Chronically Ill VBID Value-Based Insurance Design This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Page iii GAO-23-105527 Medicare Advantage Supplemental Benefits Letter 441 G St. N.W. Washington, DC 20548 January 31, 2023 Chair Ranking Member Committee on Finance United States Senate The Honorable Cathy McMorris Rodgers Chair The Honorable Frank Pallone, Jr. Ranking Member Committee on Energy and Commerce House of Representatives The Honorable Jason Smith Chair The Honorable Richard Neal Ranking Member Committee on Ways and Means House of Representatives In April 2022, about 49 percent of eligible Medicare beneficiaries (28.81 million beneficiaries) were enrolled in Medicare Advantage (MA), a private plan alternative to Original Medicare, and that percentage is projected to exceed 50 percent by 2023. 1 MA plans have long been able to offer additional or supplemental benefits not covered under Original Medicare, including coverage for dental, vision, and hearing. 2 More recently, MA plans were allowed to offer two newer types of supplemental benefits. First, starting in 2019, plans could offer benefits intended to ameliorate the effect of injuries or health conditions or reduce avoidable health care 1Under Original Medicare, the Centers for Medicare & Medicaid Services (CMS) pays claims for health care services directly to health care providers. In contrast, CMS pays MA plans a fixed monthly payment per enrollee to provide health coverage no matter how many services are provided or how much those services cost. 2Ingeneral, MA plans must offer all benefits covered under Original Medicare and can choose whether, and to what extent, to offer supplemental benefits. In addition, MA plans may also offer other enhancements not covered by Original Medicare. These include the extension of Original Medicare benefits (such as covering additional skilled nursing facility days), reductions in cost-sharing (such as copayments) for Original Medicare benefits, or reductions in premiums. These other enhancements are outside the scope of this report. Page 1 GAO-23-105527 Medicare Advantage Supplemental Benefits use, among other things. 3 For example, plans could offer support for caregivers of enrollees as a supplemental benefit. Second, starting in 2020, plans could offer benefits that had a reasonable expectation of improving or maintaining the health or function of chronically ill enrollees. For example, transportation for non-medical needs (e.g., to a grocery store or a bank) was among the newer supplemental benefits that plans could offer. The intended purpose of this type of benefit was, in part, to enable MA plans to address gaps in care and improve health outcomes for chronically ill enrollees. 4 MA plans may offer supplemental benefits, in part, to differentiate themselves from Original Medicare or other MA plans. Plans have flexibility in determining what supplemental benefits they offer. Plans must submit information on plan benefits each year to the Centers for Medicare & Medicaid Services (CMS), which is the agency within the Department of Health and Human Services that oversees the MA program, for review and approval. This information includes the supplemental benefits that plans are offering, whether they are offering a given benefit to all enrollees or targeting the benefit at certain subgroups of enrollees (such as chronically ill enrollees), and how they are financing those benefits. Supplemental benefits may be attractive to beneficiaries and may contribute to the growing enrollment in MA. However, little is known about the extent to which MA enrollees are using supplemental benefits and the extent to which the benefits are serving their intended purpose. The Bipartisan Budget Act of 2018 includes a provision for us to review MA supplemental benefits. 5 This report 1. describes the supplemental benefits offered by MA plans in 2022, 2. describes MA plans' projected costs for supplemental benefits in 2022 and how plans expected to finance them, and 3See Centers for Medicare & Medicaid Services, Medicare Drug & Health Plan Contract Administration Group, Reinterpretation of "Primarily Health Related" for Supplemental Benefits (Baltimore, Md.: Apr. 27, 2018). 4See Centers for Medicare & Medicaid Services, Medicare Drug & Health Plan Contract Administration Group, Implementing Supplemental Benefits for Chronically Ill Enrollees (Baltimore, Md.: Apr. 24, 2019). 5Pub. L. 115–123, § 50322(b), 132 Stat. 64, 201–02. Page 2 GAO-23-105527 Medicare Advantage Supplemental Benefits 3. examines the information that CMS has on enrollees' use of supplemental benefits and their effects on enrollees' health and function. To describe the supplemental benefits offered by MA plans in 2022, we analyzed the plan benefit data submitted to CMS for 2022 and enrollment data as of April 2022, which were the most recent data at the time of our analysis. 6 We focused on mandatory supplemental benefits for which enrollees receive coverage by default of being enrolled in the plan. 7 We analyzed data for 3,893 MA plans in the 50 states and District of Columbia for each of 63 supplemental benefits reviewed. 8 Our analysis included special needs plans (SNP), which provide care for beneficiaries in one of three classes of special needs such as having a severe or chronic condition. 9 To ensure comparability between plans, we excluded Medicare-Medicaid Plans, Program of All-Inclusive Care for the Elderly plans, Cost plans, plans that did not offer prescription drug benefits, plans participating in the Value-Based Insurance Design (VBID) Model, and employer plans. 10 The plans included in our analysis had total enrollment 6We analyzed the second quarter Plan Benefit Package data for 2022, which is the first version that contains information on the full range of supplemental benefits offered by each plan, as approved by CMS. We use "plan" to refer to each unique set of benefits submitted by an MA organization (the legal entity that has a contract with the Medicare program to provide coverage) for a specific geographic region. A plan can offer a specific benefit to all enrollees or to targeted subgroups of enrollees, but each plan was only counted once when determining the number of plans that offered a specific benefit. 7We excluded optional supplemental benefits for which individual enrollees must specifically elect to receive coverage and pay a separate premium. 8The Plan Benefit Package data have predefined fields for almost all supplemental benefits. For certain types of supplemental benefits, plans can offer and specify other supplemental benefits that are not already defined. We analyzed whether plans offered at least one benefit not in the predefined list for each applicable type. However, we did not further analyze these fields because of the unique nature of the benefits entered by plans. 9Medicare beneficiaries can enroll in a SNP if they are dually eligible for Medicare and Medicaid, require an institutional level of care, or have a severe or chronic condition. We excluded SNPs focused on end-stage renal disease because of differences in the reporting format of some of their data. 10The VBID Model, which began in 2017 and is scheduled to run through 2024, is designed to test a broad array of alternative ways to deliver and pay for services in MA. For example, in 2022, VBID plans could target benefits to enrollees based exclusively on socioeconomic status. Page 3 GAO-23-105527 Medicare Advantage Supplemental Benefits of about 15.98 million in April 2022. 11 This represented approximately two-thirds of enrollees in non-employer MA plans in the 50 states and District of Columbia. We assessed the reliability of the plan benefit and enrollment data by reviewing related documentation, interviewing knowledgeable officials, and checking for internal and external consistency for a subset of variables. We determined the data were sufficiently reliable for the purposes of this report. To describe MA plans' projected costs for supplemental benefits in 2022 and how plans expected to finance them, we analyzed bid pricing data submitted by MA plans to CMS for 2022, which were the most recent data available at the time of our analysis. Specifically, we analyzed data on each plan's net projected costs and expected financing sources. 12 We assessed the reliability of these data by reviewing related documentation, interviewing knowledgeable officials, and checking for internal consistency. We determined the data were sufficiently reliable for the purposes of this report. We also interviewed officials from six MA organizations that operated plans with supplemental benefits. We selected the organizations based on criteria such as enrollment and geographic coverage. We requested and reviewed summary data on projected costs for supplemental benefits from these organizations. Although the perspectives and data from these six organizations are not generalizable across all MA organizations, they enrolled about 16.89 million Medicare beneficiaries as of April 2022 and provided insights on supplemental benefits. 13 We also interviewed officials from two beneficiary advocacy groups. To examine the information that CMS has about enrollees' use of supplemental benefits and their effects on enrollees' health and function, we reviewed relevant CMS regulations and guidance and interviewed officials from CMS about the information it receives on enrollees' use of supplemental benefits from the encounter data and bid pricing data 11Not all enrollees in a plan may be eligible for a given benefit because plans may offer supplemental benefits to targeted subgroups of enrollees. 12The Bid Pricing Tool data on plans' net projected costs are the amounts that plans expected to pay for supplemental benefits and do not include cost-sharing (such as copayments) that plans may require of enrollees. In addition, the plans' projected costs do not reflect actual or final spending for 2022. 13Some of the 16.89 million MA enrollees were in plans not included in our review. Page 4 GAO-23-105527 Medicare Advantage Supplemental Benefits submitted by plans. 14 We also interviewed the officials about CMS's efforts to assess the completeness and reliability of these data and plans for improving the data on supplemental benefits. We assessed this information against the initiative in CMS's 2022 strategic framework, which calls for the agency to increase the use of data in decision- making. 15 To supplement this information, we also interviewed representatives from the six selected MA organizations, the two beneficiary advocacy groups, and researchers from two organizations about plans' experiences and challenges with reporting utilization data on supplemental benefits to CMS or what is known about the effects of those benefits on enrollees' health and function. We conducted this performance audit from October 2021 to January 2023 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Background MA Plans and Types of MA plans are generally available to all Medicare beneficiaries in the Supplemental Benefits plans' service areas, although there are some MA plans with more specific eligibility requirements. For example, SNPs exclusively serve Medicare beneficiaries who are dually eligible for Medicare and Medicaid, require an institutional level of care, or have a severe or chronic condition. SNPs are required to provide certain specialized services, such as performing health risk assessments, creating individualized care plans, and providing an interdisciplinary care team for each enrollee. 14MA plans submit encounter data on benefits provided to enrollees. As instructed by CMS, encounter data must include the procedure code for each benefit provided, which enrollee used it, who provided it, and the date or dates of service, among other information. 15Specifically, the agency has a cross-cutting initiative to accelerate the appropriate use of data to deliver on its mission and allow it to make more informed policy decisions. See Centers for Medicare & Medicaid Services, "2022 CMS Strategic Framework" (Baltimore, Md.: June 8, 2022), accessed Aug. 12, 2022, https://www.cms.gov/files/document/2022- cms-strategic-framework.pdf. Page 5 GAO-23-105527 Medicare Advantage Supplemental Benefits In addition to generally covering all the benefits offered under Original Medicare, MA plans can offer supplemental benefits. These supplemental benefits may include traditional health-related supplemental benefits (referred to in this report as traditional supplemental benefits), such as dental and vision. 16 In addition, beginning in 2019 and 2020 respectively, MA plans could begin offering two newer types of supplemental benefits-(1) expanded primarily health-related supplemental benefits and (2) Special Supplemental Benefits for the Chronically Ill (SSBCI), which do not have to be primarily health related. 17 As shown in table 1, each type of benefit addresses different aspects of enrollees' health and function. Table 1: Types of Supplemental Benefits Offered by Medicare Advantage Plans Type (number of benefits GAO First year reviewed) Examples of benefits available Purpose Traditional supplemental benefits Traditional supplemental • Visionb Prior to 2019 Primary purpose is to prevent, cure, benefits (47a) • Fitness or diminish an illness or injury. • Hearingb • Dentalb • Transportation for medical needs (e.g., to a doctor's office) • Over-the-counter items (e.g., nonprescription pain relievers) Newer types of supplemental benefits Expanded primarily • In-home support services (e.g., to assist 2019 Act to ameliorate the health-related individuals in performing activities such as functional/psychological effect of supplemental benefits dressing, eating, and housework) injuries or health conditions or (5) • Support for caregivers of enrollees reduce avoidable emergency and health care utilization, among other • Therapeutic massage things. • Home-based palliative care • Adult day health services 16Traditional supplemental benefits are not the same as benefits covered under Original Medicare. Rather, they are extra benefits that can only be offered as part of MA. Traditional supplemental benefits are primarily health related under CMS's pre-2019 definition of the term; that is, the benefits' primary purpose is to prevent, cure, or diminish an illness or injury. 17See Centers for Medicare & Medicaid Services, Reinterpretation of "Primarily Health Related" for Supplemental Benefits and Implementing Supplemental Benefits for Chronically Ill Enrollees. Page 6 GAO-23-105527 Medicare Advantage Supplemental Benefits Type (number of benefits GAO First year reviewed) Examples of benefits available Purpose Special Supplemental • Food and produce (e.g., frozen foods, canned 2020 Do not have to be primarily health Benefits for the goods, and produce to assist enrollees in related, but must have a reasonable Chronically Ill (SSBCI) meeting nutritional needs) expectation of improving or (11c) • Meals beyond a limited basis maintaining the health or overall function of chronically ill enrollees. • Transportation for non-medical needs (e.g., to a grocery store or a bank) • General supports for living (e.g., subsidies for rent or utilities) Source: GAO review of Centers for Medicare & Medicaid Services (CMS) guidance. | GAO-23-105527 a Plans report to CMS whether they offer each of 46 traditional supplemental benefits defined by CMS. Plans can also report up to three other traditional supplemental benefits not in the defined list-which GAO collapsed into and counted as a single benefit. b There are multiple vision, hearing, and dental benefits. For example, specific dental benefits include oral exams, cleaning, fluoride, and X-rays. c Plans report to CMS whether they offer each of 10 SSBCIs defined by CMS. Plans can also report up to five other SSBCIs not in the defined list-which GAO collapsed into and counted as a single benefit. Plans can target these three types of supplemental benefits to subgroups of enrollees in different ways. • Traditional and expanded primarily health-related supplemental benefits. Plans can offer these benefits uniformly to all enrollees in their plans. Plans may also target the benefits to enrollees based on health status or disease state, or to chronically ill enrollees as defined by CMS. 18 For example, a plan could offer transportation to primary care visits only to enrollees with congestive heart failure. • SSBCI. Plans must target SSBCIs only at chronically ill enrollees as defined by CMS. 18If a plan offers a benefit only to targeted subgroups of enrollees, it must offer the benefit to all plan enrollees with the specified health status or disease state(s). See Centers for Medicare & Medicaid Services, Medicare Drug & Health Plan Contract Administration Group, Reinterpretation of the Uniformity Requirement (Baltimore, Md.: Apr. 27, 2018). CMS defines chronically ill enrollees as individuals who (1) have one or more comorbid and medically complex chronic conditions that is life-threatening or significantly limits the overall health or function of the enrollee, (2) have a high risk of hospitalization or other adverse health outcomes, and (3) require intensive care coordination. When determining and designing benefits to be offered, plans may consider social determinants of health, such as socioeconomic status, as secondary criteria. See Centers for Medicare & Medicaid Services, Implementing Supplemental Benefits for Chronically Ill Enrollees. Page 7 GAO-23-105527 Medicare Advantage Supplemental Benefits In addition, MA plans vary in their level of coverage for given supplemental benefits and may require enrollees to pay cost-sharing, such as copayments. For example, the Medicare Payment Advisory Commission reviewed the 2,400 MA plans that had a hearing aid benefit in 2016. The commission found 123 unique variations of hearing aid coverage. Variations included dollar limits on the amount of coverage, in- network or out-of-network providers, type of hearing aids covered, and type of cost-sharing. 19 Financing for MA plans' options for financing supplemental benefits depend, in part, on Supplemental Benefits the bids they submit each year to CMS with their projected costs to provide the benefits covered under Original Medicare. In particular, the amount of the plan's bid relative to CMS's benchmark, the bidding target for that locality (i.e., county) or MA region, determines if the plan will receive a rebate from CMS, which is one potential financing source for supplemental benefits. 20 If a plan's bid is below the benchmark, CMS pays the plan a rebate, which is a percentage of the difference between the bid and the benchmark. 21 A plan can only use its rebate to finance supplemental benefits, other MA enhancements (such as reductions in cost-sharing for benefits covered under Original Medicare), and plans' related administrative expenses and profit margins as applicable. In addition, another financing source, supplemental premiums paid by enrollees, is available to all plans regardless of their bid relative to the benchmark. Namely, plans can charge a supplemental premium in order to finance supplemental benefits and other MA enhancements that are not otherwise financed through the rebate. 22 (See fig. 1.) 19Medicare Payment Advisory Commission, Report to the Congress: Medicare and the Health Care Delivery System (Washington, D.C: June 2017). 20CMS determines the benchmark for each county based on statutory formulas and average Original Medicare spending per beneficiary. CMS determines the regional benchmark for each MA region, which covers one or more entire states, using a different statutory formula that incorporates regional plans' bids. In addition, the benchmark also varies based on the plan's quality rating. In general, a bonus amount is added to the benchmark for plans within contracts with the highest quality ratings. 21The rebate is 50, 65, or 70 percent of the difference between the plan's bid and the benchmark after it is adjusted for beneficiary characteristics such as age and prior health conditions. A higher percentage is generally used for plans with higher quality ratings. 22A plan with a bid that is above the benchmark also charges an enrollee basic premium, which is equal to the difference between the bid and benchmark. Page 8 GAO-23-105527 Medicare Advantage Supplemental Benefits Figure 1: Medicare Advantage (MA) Plans' Financing Options for Supplemental Benefits An MA plan's financing options for supplemental benefits depend, in part, on the amount of its bid (its projected costs to provide benefits covered under Original Medicare) relative to the benchmark (bidding target). Notes: The figure shows MA plans' financing options for mandatory supplemental benefits for which enrollees receive coverage by default of being enrolled in the plan. Benchmarks differ by locality (i.e., county) or MA region. The supplemental premium shown is separate from the enrollee basic premium charged by plans with a bid that is above the benchmark. The enrollee basic premium is equal to the difference between the bid and benchmark. These plans use their rebate for MA enhancements other than supplemental benefits. a Almost All MA Plans Reviewed Offered Traditional Supplemental Benefits; Fewer Offered Newer Benefits Page 9 GAO-23-105527 Medicare Advantage Supplemental Benefits Over 99 Percent of Plans CMS data show the 3,893 MA plans that we reviewed differed in the Offered At Least One types and number of supplemental benefits they offered in 2022. Over 99 percent of the plans offered at least one traditional supplemental benefit, Traditional Supplemental while about 34 percent of the plans offered at least one of the newer Benefit, and One-Third types of benefits that were first allowed in 2019 and 2020. Offered At Least One Newer Benefit in 2022 Traditional Supplemental All but one of the plans we reviewed offered at least one traditional Benefits supplemental benefit in 2022. Plans offered a median of 23 out of the 47 traditional supplemental benefits reviewed. The most commonly offered benefits were vision, hearing, fitness, and dental. For example, nearly 98 percent of plans offered at least one vision benefit, and just over 94 percent of plans offered at least one hearing benefit. (See table 2.) In addition, a majority of plans offered annual/routine physical exams, over- the-counter items, remote access technology (e.g., nurse hotlines), and meals for a limited period (e.g., after an inpatient hospital stay). Less than half of the plans reviewed offered other traditional supplemental benefits in 2022. For example, about 48 percent of plans offered transportation for medical needs (e.g., to a doctor's office). Even fewer plans offered other benefits. For example, about 3 percent of plans reviewed offered readmission prevention and post-discharge in-home medication reconciliation. Table 2: Most Common Traditional Supplemental Benefits Offered by Medicare Advantage Plans, 2022 Number of plans that offered benefit Supplemental benefit (N=3,893) Percent Visiona 3,801 97.6 Hearinga 3,668 94.2 Fitness 3,632 93.3 Dentala 3,539 90.9 Annual/routine physical examb 3,327 85.5 Over-the-counter items (e.g., nonprescription pain 3,190 81.9 relievers) Remote access technology (e.g., nurse hotlines) 3,118 80.1 Meals for a limited period (e.g., after an inpatient 2,485 63.8 hospital stay) Any of the 47 traditional supplemental benefits 3,892d >99.9d GAO reviewedc Source: GAO analysis of Centers for Medicare & Medicaid Services (CMS) data. | GAO-23-105527 Page 10 GAO-23-105527 Medicare Advantage Supplemental Benefits Notes: Traditional supplemental benefits have a primary purpose of preventing, curing, or diminishing an illness or injury. GAO uses "plan" to refer to each unique set of benefits submitted by a Medicare Advantage organization for a specific geographic region. GAO excluded certain plans, including plans outside the 50 states and District of Columbia, Medicare-Medicaid plans, Cost plans, plans that did not offer prescription drug benefits, plans participating in the Value-Based Insurance Design Model, and employer plans. a There are multiple vision, hearing, and dental benefits. For example, specific dental benefits include oral exams, cleaning, fluoride, and X-rays. A plan is counted as offering the benefit if it offers at least one such specific benefit. b In general, Original Medicare covers an initial preventive physical exam within the enrollee's first 12 months of Medicare enrollment. It also covers an annual wellness visit that includes a health risk assessment. However, it does not cover a routine physical exam that is not related to treating or diagnosing a specific illness, symptom, complaint, or injury. c Plans report to CMS whether they offer each of 46 traditional supplemental benefits defined by CMS. Plans can also report up to three other traditional supplemental benefits not in the defined list-which GAO collapsed into and counted as a single benefit. d The number and percentage do not equal the sum of the previous rows because not all benefits are listed. In addition, plans could offer more than one benefit. Given the overall prevalence of traditional supplemental benefits, nearly all of the MA enrollees in the plans we reviewed were in plans that offered at least one traditional supplemental benefit. Traditional supplemental benefits were generally offered by plans uniformly to all enrollees. However, some plans may require enrollees to seek advance approval for certain benefits. Newer Types of Supplemental Expanded primarily health-related. Almost one-quarter of the plans we Benefits reviewed offered at least one expanded primarily health-related supplemental benefit in 2022. Of the plans that offered these benefits, about 69 percent offered only one such benefit, and about 31 percent offered two or more of the five benefits reviewed. The most commonly offered expanded benefit was in-home support services (e.g., to assist individuals in performing activities such as dressing, eating, and housework), which was offered by slightly over 17 percent of plans reviewed. Support for caregivers of enrollees and therapeutic massage were the next most commonly offered expanded benefits. (See table 3.) Page 11 GAO-23-105527 Medicare Advantage Supplemental Benefits Table 3: Expanded Primarily Health-Related Supplemental Benefits Offered by Medicare Advantage Plans, 2022 Number of plans that offered benefit Supplemental benefit (N=3,893) Percent In-home support services (e.g., to assist individuals 672 17.3 in performing activities such as dressing, eating, and housework) Support for caregivers of enrollees 233 6.0 Therapeutic massage 181 4.6 Home-based palliative care 128 3.3 Adult day health services 73 1.9 Any of the five expanded primarily health- 931a 23.9a related supplemental benefits GAO reviewed Source: GAO analysis of Centers for Medicare & Medicaid Services data. | GAO-23-105527 Notes: Expanded primarily health-related benefits act to ameliorate the functional/psychological effect of injuries or health conditions or reduce avoidable emergency and health care utilization, among other things. GAO uses "plan" to refer to each unique set of benefits submitted by a Medicare Advantage organization for a specific geographic region. GAO excluded certain plans, including plans outside the 50 states and District of Columbia, Medicare-Medicaid plans, Cost plans, plans that did not offer prescription drug benefits, plans participating in the Value-Based Insurance Design Model, and employer plans. a The number and percentage do not equal the sum of the previous rows because plans could offer more than one of these benefits. Almost one-quarter of the MA enrollees in the plans we reviewed were in plans that offered an expanded primarily health-related benefit. Expanded benefits were generally offered uniformly to all enrollees in the plan, although plans may require enrollees to seek advance approval for certain benefits. However, some of the plans that offered an expanded benefit did so only for a targeted subgroup of enrollees. For example, approximately 40 percent of the plans that offered adult day health services targeted the benefit to chronically ill enrollees. SSBCI. Slightly over one-fifth of the plans we reviewed offered at least one SSBCI in 2022. The most commonly offered benefit of the 11 SSBCIs reviewed was food and produce (e.g., frozen foods, canned goods, and produce to assist enrollees in meeting nutritional needs), which was offered by almost 15 percent of plans. Meals beyond a limited basis and transportation for non-medical needs (e.g., to a grocery store or a bank) were the next most commonly offered benefits. (See table 4.) Other SSBCIs were offered by less than 2 percent of the plans reviewed. These included structural home modifications (e.g., permanent mobility ramps or Page 12 GAO-23-105527 Medicare Advantage Supplemental Benefits widening of hallways), services supporting self-direction (e.g., interpreter services for encounters with health care providers, financial literacy classes, or other services that help enrollees to be responsible for managing their care), and complementary therapies (therapies offered alongside traditional medical treatment). Table 4: Most Common Special Supplemental Benefits for the Chronically Ill (SSBCI) Offered by Medicare Advantage Plans, 2022 Number of plans that offered benefit Supplemental benefit (N=3,893) Percent Food and produce (e.g., frozen foods, canned 571 14.7 goods, and produce to assist enrollees in meeting nutritional needs) Meals beyond a limited basis 257 6.6 Transportation for non-medical needs (e.g., to a 236 6.1 grocery store or a bank) Social needs benefit (e.g., access to community or 204 5.2 plan-sponsored programs and events to address enrollee isolation) General supports for living (e.g., subsidies for rent 193 5.0 or utilities) Pest control 191 4.9 Any of the 11 SSBCIs GAO revieweda 851b 21.9b Source: GAO analysis of Centers for Medicare & Medicaid Services (CMS) data. | GAO-23-105527 Notes: SSBCIs do not have to be primarily health related, but must have a reasonable expectation of improving or maintaining the health or overall function of chronically ill enrollees. When determining and designing benefits to be offered, plans may consider social determinants of health, such as socioeconomic status, as secondary criteria. GAO uses "plan" to refer to each unique set of benefits submitted by a Medicare Advantage organization for a specific geographic region. GAO excluded certain plans, including plans outside the 50 states and District of Columbia, Medicare-Medicaid plans, Cost plans, plans that did not offer prescription drug benefits, plans participating in the Value-Based Insurance Design Model, and employer plans. a Plans report to CMS whether they offer each of 10 SSBCIs defined by CMS. Plans can also report up to five other additional SSBCIs not in the defined list-which GAO collapsed into and counted as a single benefit. b The number and percentage do not equal the sum of the previous rows because not all benefits are listed. In addition, plans could offer more than one benefit. Almost one-fifth of the MA enrollees in the plans we reviewed were in plans that offered at least one SSBCI. However, not all of these enrollees would be eligible to receive the benefits because the benefits are only available to chronically ill enrollees. Page 13 GAO-23-105527 Medicare Advantage Supplemental Benefits Appendix I provides more information on the number of plans offering each supplemental benefit and the number of enrollees in those plans. Compared to Non-SNPs, a Among the MA plans we reviewed, a higher percentage of SNPs Greater Percentage of compared to non-SNPs offered at least one of the newer types of benefits in 2022. 23 For example, as shown in table 5, about 45 percent of the 745 SNPs Reviewed Offered SNPs we reviewed offered at least one SSBCI compared to about 16 the Newer Types of percent of the 3,148 non-SNPs. In addition, a higher percentage of SNP Supplemental Benefits enrollees were in plans that offered at least one of the newer types of benefits compared to non-SNP enrollees. (See app. II for additional information on the number of enrollees in the plans that offered each benefit. 24) Table 5: Types of Supplemental Benefits Offered by Medicare Advantage Special Needs Plans (SNP) Compared to Non-SNPs, 2022 SNPs that offered at least one Non-SNPs that offered at least one Percentage point benefit benefit difference in plans Type of supplemental Number of Number of non- Percent of non- that offered at least benefit SNPs (N=745) Percent of SNPs SNPs (N=3,148) SNPs one benefit Any of the 47 traditional 744 99.9 3,148 100.0 <1.0 ■ supplemental benefits GAO revieweda Any of the five expanded 257 34.5 674 21.4 13.1 ▲ primarily health-related supplemental benefits GAO reviewedb Any of the 11 Special 337 45.2 514 16.3 28.9 ▲ Supplemental Benefits for the Chronically Ill (SSBCI) GAO reviewedc Legend: ▲: A higher percentage of SNPs than non-SNPs offered at least one benefit of that type ■: A similar percentage of SNPs and non-SNPs offered at least one benefit of that type Source: GAO analysis of Centers for Medicare & Medicaid Services data. | GAO-23-105527 Note: GAO uses "plan" to refer to each unique set of benefits submitted by a Medicare Advantage organization for a specific geographic region. GAO excluded certain plans, including plans outside the 50 states and District of Columbia, Medicare-Medicaid plans, Cost plans, plans that did not offer 23SNPs exclusively serve Medicare beneficiaries who are dually eligible for Medicare and Medicaid, require an institutional level of care, or have a severe or chronic condition. Almost every SNP and all non-SNPs we reviewed offered at least one traditional supplemental benefit; therefore, there was no overall difference in the percentage of plans that offered at least one of these benefits. 24We separately analyzed plans participating in the VBID Model, which includes a majority of SNP enrollees. See appendix III for more information about VBID plans. Page 14 GAO-23-105527 Medicare Advantage Supplemental Benefits prescription drug benefits, plans participating in the Value-Based Insurance Design Model (which includes most SNP enrollees), and employer plans. a Traditional supplemental benefits have a primary purpose of preventing, curing, or diminishing an illness or injury. b Expanded primarily health-related benefits act to ameliorate the functional/psychological effect of injuries or health conditions or reduce avoidable emergency and health care utilization, among other things. c SSBCIs do not have to be primarily health related, but must have a reasonable expectation of improving or maintaining the health or overall function of chronically ill enrollees. When determining and designing benefits to be offered, plans may consider social determinants of health, such as socioeconomic status, as secondary criteria. Within each type of supplemental benefit, there were also specific benefits that SNPs offered more often than non-SNPs. For example, for traditional supplemental benefits, a higher percentage of SNPs than non- SNPs offered transportation for medical needs and over-the-counter items. In addition, a higher percentage of SNPs than non-SNPs offered the expanded primarily health-related benefit of in-home support services and all SSBCIs, including food and produce. (See fig. 2.) Page 15 GAO-23-105527 Medicare Advantage Supplemental Benefits Figure 2: Examples of Supplemental Benefits Offered by a Higher Percentage of Medicare Advantage Special Needs Plans (SNP) Compared to Non-SNPs, 2022 Notes: GAO uses "plan" to refer to each unique set of benefits submitted by a Medicare Advantage organization for a specific geographic region. GAO excluded certain plans, including plans outside the 50 states and District of Columbia, Medicare-Medicaid plans, Cost plans, plans that did not offer prescription drug benefits, plans participating in the Value-Based Insurance Design Model (which includes most SNP enrollees), and employer plans. Transportation for medical needs can include destinations such as doctor's offices. Over-the-counter items can include nonprescription pain relievers. In-home support services assist individuals in performing activities such as dressing, eating, and housework. Food and produce can include frozen foods, canned goods, and produce to assist enrollees in meeting nutritional needs. Transportation for non-medical needs can include trips to grocery stores or a bank. General supports for living can include subsidies for rent or utilities. a Traditional supplemental benefits have a primary purpose of preventing, curing, or diminishing an illness or injury. b Expanded primarily health-related benefits act to ameliorate the functional/psychological effect of injuries or health conditions or reduce avoidable emergency and health care utilization, among other things. c SSBCIs do not have to be primarily health related, but must have a reasonable expectation of improving or maintaining the health or overall function of chronically ill enrollees. When determining and designing benefits to be offered, plans may consider social determinants of health, such as socioeconomic status, as secondary criteria. Page 16 GAO-23-105527 Medicare Advantage Supplemental Benefits There were also specific traditional and expanded primarily health-related benefits that SNPs offered less often than non-SNPs. 25 For example, a lower percentage of SNPs offered annual/routine physical exams, fitness, remote access technology, and meals for a limited period. (See fig. 3.) Figure 3: Examples of Supplemental Benefits Offered by a Lower Percentage of Medicare Advantage Special Needs Plans (SNP) Compared to Non-SNPs, 2022 Note: GAO uses "plan" to refer to each unique set of benefits submitted by a Medicare Advantage organization for a specific geographic region. GAO excluded certain plans, including plans outside the 50 states and District of Columbia, Medicare-Medicaid plans, Cost plans, plans that did not offer prescription drug benefits, plans participating in the Value-Based Insurance Design Model (which includes most SNP enrollees), and employer plans. a Traditional supplemental benefits have a primary purpose of preventing, curing, or diminishing an illness or injury. b In general, Original Medicare covers an initial preventive physical exam within the enrollee's first 12 months of Medicare enrollment. It also covers an annual wellness visit that includes a health risk assessment. However, it does not cover a routine physical exam that is not related to treating or diagnosing a specific illness, symptom, complaint, or injury. c Expanded primarily health-related benefits act to ameliorate the functional/psychological effect of injuries or health conditions or reduce avoidable emergency and health care utilization, among other things. 25There were no SSBCIs that SNPs offered less often than non-SNPs. Page 17 GAO-23-105527 Medicare Advantage Supplemental Benefits MA Plans' Projected Costs for Supplemental Benefits Varied Widely in 2022; Most Expected to Finance the Benefits with Rebates MA Plans Reviewed Had a The 3,893 MA plans reviewed had a median net projected cost for Median Net Projected supplemental benefits of about $27 per enrollee per month in 2022- approximately $6.4 billion in total-according to our analysis of the CMS Cost for Supplemental bid pricing data. 26 The net projected costs reflect the amounts that plans Benefits of $27 per expected to pay for supplemental benefits and do not include cost-sharing Enrollee per Month in (such as copayments) that plans may require of enrollees. 27 2022, but Amounts Varied Widely Dental supplemental benefits accounted for the largest portion of plans' net projected costs for supplemental benefits. As shown in figure 4, the median net projected cost for dental benefits was approximately $11 per enrollee per month for plans that offered these benefits. In comparison, the median net projected cost for vision benefits was approximately $3 per enrollee per month for plans that offered these benefits. 26The total amount of net projected costs for all MA plans, including those that were not in our analysis, would be higher than $6.4 billion. 27This amount also does not include plans' administrative expenses or profit margins for supplemental benefits. Page 18 GAO-23-105527 Medicare Advantage Supplemental Benefits Figure 4: Medicare Advantage Plans' Net Projected Costs for Supplemental Benefits, 2022 Notes: Plans' net projected costs are rounded to the nearest dollar and do not include cost-sharing (such as copayments) that plans may require of enrollees. They also do not include plans' administrative expenses or profit margins for supplemental benefits. GAO uses "plan" to refer to each unique set of benefits submitted by a Medicare Advantage organization for a specific geographic region. The median costs shown are for the plans that offered the benefit. Plans report separate data only for dental (offered by 3,539 plans out of 3,893 plans analyzed), vision (offered by 3,801 plans), transportation (offered by 1,848 plans), and hearing (offered by 3,668 plans). Plans report combined data for all other supplemental benefits (offered by 3,871 plans). GAO excluded certain plans, including plans outside the 50 states and District of Columbia, Medicare-Medicaid plans, Cost plans, plans that did not offer prescription drug benefits, plans participating in the Value-Based Insurance Design Model, and employer plans. Although the MA plans we reviewed had a median net projected cost of about $27 per enrollee per month, this amount varied widely. For example, the middle 50 percent of the plans' net projected costs ranged from about $17 to $43 per enrollee per month. In addition, the median net projected cost was slightly over $57 per enrollee per month for SNPs reviewed compared to slightly over $24 for non-SNPs reviewed. Beneficiary Understanding of One reason for the variation in plans' net projected costs could be Supplemental Benefits differences in the number, type, and levels of coverage for benefits. For Enrollees may not understand the different example, as shown in figure 5, plans that offered more dental benefits levels of coverage for benefits, according to had a higher median net projected cost than plans that offered fewer beneficiary advocacy groups GAO interviewed. For example, officials from one dental benefits. However, there was still wide variation in costs within beneficiary advocacy group said dental is the each category, which may be due in part to differences in the mix of supplemental benefit on which they receive the most complaints, often about plans' limits individual dental benefits and the levels of coverage for those benefits. on what or how much is covered. The group For example, of the plans that offered all 11 dental benefits, the middle 50 said enrollees might complain because, although they were able to get a cleaning and percent of plans' net projected costs ranged from about $11 to $23 per X-rays, they also need dentures or implants. enrollee per month. Source: GAO interviews of beneficiary advocacy groups. | GAO-23-105527 Page 19 GAO-23-105527 Medicare Advantage Supplemental Benefits Figure 5: Variation in Medicare Advantage Plans' Net Projected Costs for Dental Supplemental Benefits, 2022 Notes: Plans' net projected costs are rounded to the nearest dollar and do not include cost-sharing (such as copayments) that plans may require of enrollees. They also do not include plans' administrative expenses or profit margins for these benefits. GAO uses "plan" to refer to each unique set of benefits submitted by a Medicare Advantage organization for a specific geographic region. GAO excluded certain plans, including plans outside the 50 states and District of Columbia, Medicare-Medicaid plans, Cost plans, plans that did not offer prescription drug benefits, plans participating in the Value-Based Insurance Design Model, and employer plans. Out of the plans reviewed, 3,539 plans offered at least one dental benefit, such as oral exams, cleaning, fluoride, X-rays, periodontics, and extractions. Plans may differ in the mix of individual dental benefits offered and levels of coverage for those benefits. The figure shows 3,395 plans after the exclusion of 144 plans whose net projected costs for dental benefits were identified as outliers within each category of plans. GAO identified outliers as those with net projected costs greater than 1.5 times the interquartile range below the 25th percentile or above the 75th percentile. Another reason for variation in plans' net projected costs can be differences in plans' projections of enrollees' use of specific benefits and the expected cost per use, according to officials from MA organizations interviewed. Officials said they projected enrollees' use of a benefit based on several factors including: past rates of use where available, estimates of the number of enrollees who would be eligible for the benefit (e.g., SSBCI estimates would be based in part on the number of enrollees with the targeted chronic illness), the type or extent of outreach being Page 20 GAO-23-105527 Medicare Advantage Supplemental Benefits conducted for the benefit, and the effect of cost-sharing. 28 As a result, different plans have different projected costs for specific supplemental benefits. For example, information provided by three of the MA organizations in our review indicated that their plans that offered fitness benefits had net projected costs of around $1, $2, and $4 per enrollee per month respectively in 2022. For in-home support services, information from two MA organizations showed net projected costs of less than $1 per enrollee per month in their plans that offered the benefit. In contrast, information from another MA organization showed two different types of in-home support services-one with net projected costs of around $2 per enrollee per month and the other with net projected costs of around $1 per enrollee per month in their plans that offered these benefits. Over 80 Percent of MA In 2022, according to our analysis of the CMS bid pricing data, slightly Plans Reviewed Expected over 83 percent of the 3,893 MA plans reviewed expected to finance supplemental benefits solely with rebates, and the remaining plans to Finance Supplemental expected to use supplemental premiums alone or in combination with Benefits in 2022 Solely rebates. 29 (See table 6.) Further, almost 86 percent of MA enrollees in the with Rebates plans reviewed were in plans that expected to finance their supplemental benefits with rebates alone. In addition, about 96 percent of the SNPs we reviewed expected to finance supplemental benefits solely with rebates. 28The percentage of enrollees who use supplemental benefits can vary, according to data for 2020 provided by two MA organizations interviewed, although utilization in that year was affected by the start of the COVID-19 pandemic. For example, about 21 and 6 percent of enrollees in applicable plans used the dental benefit in the two MA organizations respectively. About 26 percent of enrollees in applicable plans used the vision benefit (eye exams or eyewear) in one of the MA organizations, and about 24 percent used the eye exam benefit and about 15 percent used the eyewear benefit in the other MA organization. 29Some plans that expected to both receive a rebate and also charge a supplemental premium reported they expected to use only one or the other to finance their supplemental benefits. Specifically, there were 3,240 plans that expected to finance supplemental benefits with rebates alone-160 of which charged a supplemental premium that was used for MA enhancements other than supplemental benefits. In addition, there were 208 plans that expected to finance supplemental benefits with the supplemental premiums alone-183 of which received a rebate that was used for MA enhancements other than supplemental benefits. Page 21 GAO-23-105527 Medicare Advantage Supplemental Benefits Table 6: Medicare Advantage Plans' Expected Financing Sources for Supplemental Benefits, 2022 Percent of Financing source reported by plan Number of plans plans Rebatea 3,240 83 Supplemental premium 208 5 Both rebate and supplemental premium 444 11 Not applicable; plan did not offer supplemental 1 <1 benefits Total number of plans GAO reviewed 3,893 100 Source: GAO analysis of Centers for Medicare & Medicaid Services (CMS) data. | GAO-23-105527 Note: Totals may not sum due to rounding. GAO uses "plan" to refer to each unique set of benefits submitted by a Medicare Advantage organization for a specific geographic region. GAO excluded certain plans, including plans outside the 50 states and District of Columbia, Medicare-Medicaid plans, Cost plans, plans that did not offer prescription drug benefits, plans participating in the Value- Based Insurance Design Model, and employer plans. a CMS pays a rebate to a plan if its projected costs to provide benefits covered under Original Medicare are below CMS's bidding target for the plan's locality (i.e., county) or Medicare Advantage region. Officials from some of the MA organizations in our review cited two factors that may influence plans' decisions on the use of different financing sources for supplemental benefits. First, officials from two MA organizations cited overall market pressures not to charge any premiums-meaning supplemental benefits are financed solely by rebates. For example, officials from one of those two MA organizations said they need to offer plans without premiums to be competitive in their market. These officials said that, instead of charging a premium, they will adjust their projected profit margins to generate the rebate needed to finance the supplemental benefits that they want to offer. Second, officials from two other MA organizations said that they may have plans that charge premiums alongside plans in that same market that do not charge premiums. According to those officials, a plan with a premium may offer more supplemental benefits, as well as other MA enhancements, such as lower copayments or a greater extension of Original Medicare services. In addition to financing supplemental benefits, MA plans could also use these financing sources (rebates, supplemental premiums, or both) for other MA enhancements, such as reductions in the cost-sharing for benefits covered under Original Medicare. According to our analysis of the CMS bid pricing data, the share of available resources from those financing sources allocated by plans to supplemental benefits varied-as did their net projected costs for supplemental benefits and their projected Page 22 GAO-23-105527 Medicare Advantage Supplemental Benefits amounts of available resources. See figure 6, which provides examples of how three different plans expected to use their available resources. These examples are from the plans with net projected costs for supplemental benefits at the 25th percentile, median, and 75th percentile respectively. 30 Figure 6: Examples of Medicare Advantage Plans' Expected Use of Projected Available Resources, 2022 Notes: Plans have resources from CMS or enrollees that they can use to finance supplemental benefits and other Medicare Advantage enhancements such as reductions in cost-sharing for benefits covered under Original Medicare. This figure shows how three Medicare Advantage plans expected to use their projected available resources. These three plans' net projected costs for supplemental benefits were at the 25th percentile, median, and 75th percentile respectively. The amount that plans expected to use to finance supplemental benefits equal their net projected costs for the benefits. The net projected costs are rounded to the nearest dollar and do not include cost-sharing (such as copayments) that plans may require of enrollees. They also do not include plans' administrative expenses or profit margins for these benefits. 30In figure 6, the second plan shown (plan B) had net projected costs for supplemental benefits equal to the median of about $27 per enrollee per month for all plans reviewed. Page 23 GAO-23-105527 Medicare Advantage Supplemental Benefits The information CMS collects on supplemental benefits offered by MA CMS Has Limited plans is limited; it does not include complete information on the extent to Information on which enrollees are using the supplemental benefits that plans offer. According to federal regulation, plans must submit encounter data for Enrollees' Use of supplemental benefits to the extent required by CMS. 31 However, we Supplemental found that encounter data submitted by plans do not provide complete information on enrollees' use of supplemental benefits for two primary Benefits and Their reasons: Effects • Confusion about reporting requirements. CMS's current guidance on the submission of encounter data does not specifically mention or discuss the submission of encounter data for supplemental benefits. The guidance says that plans must submit encounter data for each service or item covered by the plan and provided to an enrollee. CMS officials told us that the inclusion of supplemental benefits in this requirement is clear and noted that the guidance does not differentiate between Original Medicare benefits and supplemental benefits. However, officials we interviewed from selected MA organizations in our review had mixed understandings of the requirement and do not consistently report data for supplemental benefits. For example, officials from two of the MA organizations interviewed said they are not required to submit encounter data for some supplemental benefits and submit encounter data for a limited set of supplemental benefits. One of the two MA organizations submitted encounter data for transportation, meals, and vision, according to organization officials. Officials from a third MA organization said they are not required to submit encounter data for any supplemental benefits and therefore do not submit such data. In contrast, officials from one MA organization said they are required to submit encounter data for all supplemental benefits and submit encounter data for as many supplemental benefits as possible. • Challenges with procedure codes. Officials from two MA organizations and CMS said that procedure-code challenges can 31Each MA organization must submit to CMS (in accordance with CMS instructions) the data necessary to characterize the context and purposes of each item and service provided to a Medicare enrollee by a provider, supplier, physician, or other practitioner. To the extent required by CMS, those data must account for benefits covered under Original Medicare, Medicare-covered benefits for which Medicare is not the primary payer, and supplemental benefits. 42 C.F.R. § 422.310(b)(c). In general, CMS uses encounter data, which are similar to provider claims data in Original Medicare, to adjust payments to MA plans to reflect beneficiaries' projected health care costs. CMS also uses the data for other purposes such as quality measurement and program evaluation. Page 24 GAO-23-105527 Medicare Advantage Supplemental Benefits make it difficult to collect and submit encounter data for certain supplemental benefits. The officials said that, in some cases, there are no procedure codes for the benefit, such as SSBCIs, and CMS officials said its system does not currently take in encounter data for benefits that do not have procedure codes. As a result, officials from one MA organization said they used a general procedure code for submitting encounter data on their supplemental benefit that provides deliveries of fruit and vegetables to enrollees because there was not an applicable procedure code. In addition, officials from another organization said the procedure codes for some supplemental benefits do not align with how they offer the benefits, which may cause them not to report utilization of those benefits at all. For example, they said there is a procedure code for an annual gym membership, but they did not know how to use that procedure code to report utilization for an enrollee who, for example, attends two different gyms at the same time, as allowed under that organization's fitness benefit. 32 CMS officials reported starting some efforts to analyze the extent to which the encounter data submitted by plans include supplemental benefits and otherwise understand enrollees' use of supplemental benefits. Specifically, as of October 2022, CMS was in the early stages of assessing the completeness of the encounter data it receives for supplemental benefits. According to CMS officials, the agency's current focus on encounter data for supplemental benefits is because of the increased offering of such benefits. CMS's prior focus was on the data for required benefits, namely those covered under Original Medicare. CMS officials told us that, as part of the current efforts, the agency had started to determine which procedure codes match the supplemental benefits being offered by plans, which they said could allow them to assess how 32Officials from CMS and four MA organizations interviewed said that MA plans may also find it challenging to submit encounter data for services provided or managed through vendors. For example, plans may not receive utilization data from their vendors in a standard claims format and with all data elements needed for submitting encounter data. However, CMS does not have a direct role in what data plans receive from their vendors, according to agency officials. The format and extent of data received instead depend on the contracts plans have with their vendors, entities plans pay to provide or manage given benefits. Page 25 GAO-23-105527 Medicare Advantage Supplemental Benefits those benefits are being reported. 33 CMS was also in the early stages of identifying options for collecting enrollee utilization data on SSBCIs, which are less likely to have associated procedure codes. Officials said these options could include the creation of new procedure codes or a new data submission format, but also said they needed to do more work to know about the feasibility of these options. Finally, in August 2022, CMS asked the public for information on, among other things, the rate at which enrollees use food-, nutrition-, and physical activity-related supplemental benefits. 34 However, as of October 2022, CMS officials told us the agency did not have a workplan or timeline for future analyses or actions that the agency could take based on those efforts. As a result, it is not clear whether these efforts will result in more complete information on enrollees' use of supplemental benefits. Having more complete information on the extent to which enrollees are using supplemental benefits, such as from the encounter data, would put CMS in a stronger position to make more informed policy decisions, consistent with its 2022 strategic framework, and meet goals it has stated related to supplemental benefits. 35 For example, CMS has a goal of gaining a greater understanding of how supplemental benefits are meeting their intended purposes, such as improving or maintaining 33CMS officials said the agency was exploring how to assess the encounter data and address certain complexities in the data. For example, one complexity is assessing when certain benefits (such as dental, vison, and hearing) were covered by plans as a supplemental benefit or as an Original Medicare benefit. This is because Original Medicare covers dental, vision, and hearing services in limited circumstances, such as covering one pair of eyeglasses or contact lenses after cataract surgery with the insertion of an intraocular lens. According to CMS officials, the same procedure codes can be used for supplemental and Original Medicare benefits. 3487 Fed. Reg. 46,918 (Aug. 1, 2022). In this request for information, CMS also asked for information on standardized data elements that it could collect to better understand the effects of supplemental benefits on enrollees' health outcomes, social determinants of health, and health equity. As of October 2022, CMS was still reviewing the responses received from this request for information. 35In CMS's 2022 strategic framework, the agency established a cross-cutting initiative to accelerate the appropriate use of data to deliver on the agency's mission and allow it to make more informed policy decisions. As part of this initiative, the agency said it is working to fully leverage the value of data by improving its data collection and management, among other things. See Centers for Medicare & Medicaid Services, 2022 CMS Strategic Framework. Page 26 GAO-23-105527 Medicare Advantage Supplemental Benefits enrollees' overall health and social needs. 36 A second goal is ensuring that supplemental benefits are addressing the most critical care gaps and barriers to care. 37 A third goal is improving the transparency of how Medicare dollars are being spent on certain benefits, including supplemental benefits. 38 Although limited, encounter data are currently the agency's primary source of information on enrollees' use of supplemental benefits. The bid pricing data submitted by plans to CMS also contain some information on the use of certain supplemental benefits. The purpose of these data, however, is to show how each plan developed its projected costs for providing those benefits. As such, there are certain factors that limit the use of these data in assessing utilization of supplemental benefits. For example, plans report utilization data separately for certain traditional supplemental benefits only: dental, hearing, transportation, and vision. The data for all other supplemental benefits-which includes other traditional supplemental benefits (such as fitness or over-the-counter items) and all newer types of benefits-are rolled up into two other categories. 39 Furthermore, even for types of supplemental benefits reported separately, there was some variation in the units of services used by plans. For example, according to the bid pricing instructions, plans have the option of reporting dental benefits in terms of the number of visits or in the number of procedures. In recent years, MA plans have been allowed to offer a wider range of Conclusions supplemental benefits. These include newer types of benefits that are intended to ameliorate the effect of injuries or health conditions, reduce avoidable emergency and health care utilization, or have a reasonable expectation of improving or maintaining the health or overall function of chronically ill enrollees. Supplemental benefits, which are financed mostly 36Meena Seshamani, Elizabeth Fowler, and Chiquita Brooks-LaSure, "Building on the CMS Strategic Vision: Working Together for a Stronger Medicare," Health Affairs Forefront, Jan. 11, 2022. 37Centers for Medicare & Medicaid Services, Advance Notice of Methodological Changes for Calendar Year (CY) 2023 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies (Feb. 2, 2022). 38In May 2022, CMS finalized regulations that will require plans to report the amounts spent on certain supplemental benefits starting in 2023. See 87 Fed. Reg. 27,831 (May 9, 2022). 39One is for benefits listed in the Medicare managed care manual, and the other is for all other supplemental benefits. However, CMS officials told us there are differences in how various plans assign benefits into each of those two categories. Page 27 GAO-23-105527 Medicare Advantage Supplemental Benefits from CMS rebates, have net projected costs of about $6.4 billion in 2022 for the plans we reviewed. The offering of supplemental benefits is one way that MA plans differentiate themselves from their competitors, and they may be attractive to Medicare beneficiaries when deciding whether to enroll in MA and which MA plan to select. However, CMS has limited information on enrollees' use of supplemental benefits, especially the newer types. Our review found that selected MA organizations were not always reporting encounter data for supplemental benefits. This is because the agency's guidance does not clearly indicate that information on enrollees' use of supplemental benefits must be included in MA plans' encounter data submissions, and some supplemental benefits lack procedure codes, which are required in the submission of encounter data. While CMS has begun to look at the procedure code issue, it is not yet clear whether CMS will make changes allowing it to collect more complete information on enrollees' use of supplemental benefits. Having such information would put CMS in a stronger position to make informed policy decisions about supplemental benefits. For example, more complete information on the utilization of supplemental benefits could help CMS determine whether or to what extent they support the health and social needs of Medicare enrollees. We are making the following two recommendations to CMS: Recommendations for Executive Action The Administrator of CMS should clarify guidance to MA plans on the extent to which encounter data submissions must include data on the utilization of supplemental benefits. (Recommendation 1) The Administrator of CMS should take actions to address circumstances where submitting encounter data for supplemental benefits is challenging for MA plans, such as when a given benefit lacks an applicable procedure code. Such actions may include the creation of new procedure codes or a new data submission format. (Recommendation 2) The Department of Health and Human Services provided written Agency Comments comments on a draft of this report, which are reproduced in appendix IV. In its written comments, the department concurred with our recommendations and said it plans to issue guidance to clarify the extent to which MA plans' encounter data submissions must include data on supplemental benefit utilization. It also noted a commitment to addressing challenges that MA plans experience when submitting encounter data for Page 28 GAO-23-105527 Medicare Advantage Supplemental Benefits supplemental benefits. The department provided technical comments, which we incorporated as appropriate. We are sending copies of this report to the appropriate congressional committees, the Secretary of Health and Human Services, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or RosenbergM@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix V. Michelle B. Rosenberg Director, Health Care Page 29 GAO-23-105527 Medicare Advantage Supplemental Benefits Appendix I: Supplemental Benefits Offered Appendix I: Supplemental Benefits Offered by Medicare Advantage Plans GAO Reviewed by Medicare Advantage Plans GAO Reviewed Table 7 provides the number and percentage of Medicare Advantage (MA) plans we reviewed that offered each supplemental benefit in 2022 along with the number and percentage of enrollees in those plans. The number and percentage of enrollees in a plan that offers a given benefit show the potential reach of that benefit but do not necessarily reflect the number of enrollees who are eligible for or receive the benefit. This is because plans can target their benefits to certain enrollees. For example, plans can offer two of the three types of supplemental benefits- traditional and expanded primarily health-related supplemental benefits- only to targeted subgroups of enrollees based on health status or disease state. 1 In addition, the third type of supplemental benefits-Special Supplemental Benefits for the Chronically Ill-are only for chronically ill enrollees, and plans may consider social determinants of health, such as socioeconomic status, as secondary criteria when determining and designing benefits to be offered. Table 7: Supplemental Benefits Offered by Medicare Advantage Plans, 2022 Plans Enrollment in April 2022 Number in Number thousandsa Supplemental benefit (N=3,893) Percent (N=15,980) Percent Traditional supplemental benefitsb Any transportation for medical needs (e.g., to a doctor's office) 1,848 47.5 6,570 41.1 Acupuncture 1,046 26.9 5,150 32.3 Over-the-counter items (e.g., nonprescription pain relievers) 3,190 81.9 13,310 83.3 Meals for a limited period 2,485 63.8 10,970 68.7 Other supplemental services not defined by the Centers for Medicare & 775 19.9 3,760 23.5 Medicaid Services (CMS)c Annual/routine physical examd 3,327 85.5 14,680 91.9 Health education 1,437 36.9 5,900 36.9 Nutritional/dietary benefit 1,158 29.7 4,650 29.1 Smoking and tobacco cessation counseling 1,301 33.4 4,270 26.7 Fitness 3,632 93.3 15,550 97.3 Enhanced disease management 256 6.6 1,170 7.3 Telemonitoring services 255 6.6 1,100 6.9 Remote access technology (e.g., nurse hotlines) 3,118 80.1 13,920 87.1 1For example, a plan may offer a certain number of transports to primary care visits only to enrollees with congestive heart failure. If a plan offers a benefit only to targeted subgroups of enrollees, it must offer the benefit to all plan enrollees with the specified health status or disease state(s). Page 30 GAO-23-105527 Medicare Advantage Supplemental Benefits Appendix I: Supplemental Benefits Offered by Medicare Advantage Plans GAO Reviewed Plans Enrollment in April 2022 Number in Number thousandsa Supplemental benefit (N=3,893) Percent (N=15,980) Percent Home and bathroom safety devices and modifications 486 12.5 2,080 13.0 Counseling services 567 14.6 1,750 11.0 In-home safety assessment 226 5.8 920 5.8 Personal emergency response system 886 22.8 4,250 26.6 Medical nutrition therapy 419 10.8 1,510 9.5 Post discharge in-home medication reconciliation 106 2.7 360 2.3 Re-admission prevention 115 3.0 300 1.9 Wigs for hair loss related to chemotherapy 144 3.7 420 2.6 Weight management programs 198 5.1 500 3.1 Alternative therapies 212 5.4 810 5.1 Any dental 3,539e 90.9e 14,910e 93.3e Oral exam 3,520 90.4 14,860 93.0 Prophylaxis (cleaning) 3,513 90.2 14,800 92.7 Fluoride treatment 2,528 64.9 10,730 67.1 Dental X-rays 3,481 89.4 14,740 92.2 Non-routine services 2,266 58.2 9,000 56.3 Diagnostic services 2,541 65.3 11,060 69.2 Restorative services 2,870 73.7 11,730 73.4 Endodontics 2,466 63.3 9,790 61.3 Periodontics 2,663 68.4 11,300 70.7 Extractions 2,719 69.8 11,320 70.9 Prosthodontics 2,638 67.8 10,850 67.9 Any vision 3,801e 97.6e 15,840e 99.1e Routine eye exams 3,771 96.9 15,750 98.6 Other eye exam 606 15.6 2,180 13.6 Contact lenses 3,551 91.2 14,790 92.6 Eyeglasses (frames and lenses) 3,289 84.5 14,060 88.0 Eyeglass lenses 2,563 65.8 8,660 54.2 Eyeglass frames 2,567 65.9 8,670 54.3 Eyewear upgrades 1,885 48.4 5,980 37.4 Any hearing 3,668e 94.2e 14,670e 91.8e Routine hearing exams 3,631 93.3 14,530 90.9 Fitting/evaluation for hearing aids 2,823 72.5 9,550 59.8 Hearing aids (all types) 3,502 90.0 14,160 88.6 Hearing aids - inner ear 28 0.7 10 0.1 Page 31 GAO-23-105527 Medicare Advantage Supplemental Benefits Appendix I: Supplemental Benefits Offered by Medicare Advantage Plans GAO Reviewed Plans Enrollment in April 2022 Number in Number thousandsa Supplemental benefit (N=3,893) Percent (N=15,980) Percent Hearing aids - outer ear 28 0.7 10 0.1 Hearing aids - over the ear 28 0.7 10 0.1 Any of the 47 traditional supplemental benefits GAO reviewed 3,892e >99.9e 15,980e >99.9e Expanded primarily health-related supplemental benefitsf Therapeutic massage 181 4.6 480 3.0 Adult day health services 73 1.9 110 0.7 Home-based palliative care 128 3.3 610 3.8 In-home support services (e.g., to assist individuals in performing 672 17.3 2,600 16.3 activities such as dressing, eating, and housework) Support for caregivers of enrollees 233 6.0 940 5.9 Any of the five expanded primarily health-related supplemental 931e 23.9e 3,570e 22.3e benefits GAO reviewed Special Supplemental Benefits for the Chronically Ill (SSBCI)g Food and produce (e.g., frozen foods, canned goods, and produce to 571 14.7 1,990 12.5 assist enrollees in meeting nutritional needs) Meals beyond a limited basis 257 6.6 1,040 6.5 Pest control 191 4.9 800 5.0 Any transportation for non-medical needs (e.g., to a grocery store or a 236 6.1 1,050 6.6 bank) Indoor air quality equipment and services 69 1.8 230 1.4 Social needs benefit (e.g., access to community or plan-sponsored 204 5.2 460 2.9 programs and events to address enrollee isolation) Complementary therapies (therapies offered alongside traditional 30 0.8 60 0.4 medical treatment) Services supporting self-direction (e.g., interpreter services for 52 1.3 130 0.8 encounters with health care providers, financial literacy classes, or other services that help enrollees to be responsible for managing their care) Structural home modifications (e.g., permanent mobility ramps or 53 1.4 150 0.9 widening of hallways) General supports for living (e.g., subsidies for rent or utilities) 193 5.0 490 3.1 Other SSBCIs not defined by CMSh 197 5.1 780 4.9 Any of the 11 SSBCIs GAO reviewed 851e 21.9e 2,760e 17.3e Source: GAO analysis of CMS data. | GAO-23-105527 Note: GAO uses "plan" to refer to each unique set of benefits submitted by a Medicare Advantage organization for a specific geographic region. GAO excluded certain plans, including plans outside the 50 states and District of Columbia, Medicare-Medicaid plans, Cost plans, plans that did not offer prescription drug benefits, plans participating in the Value-Based Insurance Design Model, and employer plans. The benefits are listed in the same order as the benefit information plans submit to CMS. Page 32 GAO-23-105527 Medicare Advantage Supplemental Benefits Appendix I: Supplemental Benefits Offered by Medicare Advantage Plans GAO Reviewed a Enrollment numbers are rounded to the nearest ten thousand. b Traditional supplemental benefits have a primary purpose of preventing, curing, or diminishing an illness or injury. c Plans can submit up to three other traditional supplemental benefits not defined by CMS. For example, in 2022, some plans listed compression socks or face masks as a traditional supplemental benefit. The count of plans reflect any plans that offered at least one other benefit. d In general, Original Medicare covers an initial preventive physical exam within the enrollee's first 12 months of Medicare enrollment. It also covers an annual wellness visit that includes a health risk assessment. However, it does not cover a routine physical exam that is not related to treating or diagnosing a specific illness, symptom, complaint, or injury. e The number and percentage of plans for a group of benefits or a given type of benefit do not equal the sum of the related rows because plans could offer more than one of these benefits. f Expanded primarily health-related benefits act to ameliorate the functional/psychological effect of injuries or health conditions or reduce avoidable emergency and health care utilization, among other things. g SSBCIs do not have to be primarily health related, but must have a reasonable expectation of improving or maintaining the health or overall function of chronically ill enrollees. When determining and designing benefits to be offered, plans may consider social determinants of health, such as socioeconomic status, as secondary criteria. h Plans can submit up to five other SSBCIs not defined by CMS. For example, in 2022, some plans listed support for service animals as an SSBCI. The count of plans reflect any plans that offered at least one other benefit. Page 33 GAO-23-105527 Medicare Advantage Supplemental Benefits Appendix II: Supplemental Benefits Offered Appendix II: Supplemental Benefits Offered by Medicare Advantage Special Needs Plans by Medicare Advantage Special Needs Plans (SNP) and Non-SNPs GAO Reviewed (SNP) and Non-SNPs GAO Reviewed There are some Medicare Advantage plans with specific eligibility requirements. For example, certain plans, referred to as special needs plans (SNP), exclusively serve Medicare beneficiaries who are dually eligible for Medicare and Medicaid, require an institutional level of care, or have a severe or chronic condition. Table 8 shows the number and percentage of SNPs and non-SNPs we reviewed that offered each supplemental benefit in 2022 along with the number and percentage of enrollees in those plans. The number and percentage of enrollees in a plan that offers a given benefit show the potential reach of that benefit but do not necessarily reflect the number of enrollees who are eligible for or receive the benefit. This is because plans can target their benefits to certain enrollees, such as enrollees who are chronically ill or who have a specified health status or disease state. 1 Table 8: Supplemental Benefits Offered by Medicare Advantage Special Needs Plans (SNP) Compared to Non-SNPs, 2022 SNPs that offered benefit Non-SNPs that offered benefit Enrollment in Enrollment in April 2022 in Number of April 2022 in Percentage Number of thousandsa non-SNPs thousandsa point difference SNPs (percent) (percent) (percent) (percent) in plans that Supplemental benefit (N=745) (N=1,510) (N=3,148) (N=14,470) offered benefitb Traditional supplemental benefitsc Transportation for medical needs 619 (83) 1,260 (83) 1,229 (39) 5,320 (37) 44.0 ▲ (e.g., to a doctor's office) Acupuncture 175 (23) 460 (31) 871 (28) 4,690 (32) 4.2 ▼ Over-the-counter items (e.g., 677 (91) 1,440 (95) 2,513 (80) 11,870 (82) 11.0 ▲ nonprescription pain relievers) Meals for a limited period 449 (60) 1,110 (74) 2,036 (65) 9,860 (68) 4.4 ▼ Other supplemental services not 166 (22) 360 (24) 609 (19) 3,400 (24) 2.9 ▲ defined by the Centers for Medicare & Medicaid Services (CMS)d Annual/routine physical exame 410 (55) 770 (51) 2,917 (93) 13,910 (96) 37.6 ▼ Health education 213 (29) 580 (38) 1,224 (39) 5,320 (37) 10.3 ▼ Nutritional/dietary benefit 215 (29) 650 (43) 943 (30) 4,010 (28) 1.1 ▼ Smoking and tobacco cessation 182 (24) 580 (38) 1,119 (36) 3,690 (26) 11.1 ▼ counseling 1For example, a plan may offer a certain number of transports to primary care visits only to enrollees with congestive heart failure. If a plan offers a benefit only to targeted subgroups of enrollees, it must offer the benefit to all plan enrollees with the specified health status or disease state(s). Page 34 GAO-23-105527 Medicare Advantage Supplemental Benefits Appendix II: Supplemental Benefits Offered by Medicare Advantage Special Needs Plans (SNP) and Non-SNPs GAO Reviewed SNPs that offered benefit Non-SNPs that offered benefit Enrollment in Enrollment in April 2022 in Number of April 2022 in Percentage Number of thousandsa non-SNPs thousandsa point difference SNPs (percent) (percent) (percent) (percent) in plans that Supplemental benefit (N=745) (N=1,510) (N=3,148) (N=14,470) offered benefitb Fitness 542 (73) 1,310 (87) 3,090 (98) 14,240 (98) 25.4 ▼ Enhanced disease management 13 (2) 20 (1) 243 (8) 1,150 (8) 6.0 ▼ Telemonitoring services 50 (7) 70 (5) 205 (7) 1,020 (7) 0.2 ▲ Remote access technology (e.g., 492 (66) 1,290 (86) 2,626 (83) 12,630 (87) 17.4 ▼ nurse hotlines) Home and bathroom safety devices 105 (14) 240 (16) 381 (12) 1,850 (13) 2.0 ▲ and modifications Counseling services 129 (17) 410 (27) 438 (14) 1,340 (9) 3.4 ▲ In-home safety assessment 38 (5) 110 (8) 188 (6) 810 (6) 0.9 ▼ Personal emergency response 317 (43) 870 (58) 569 (18) 3,380 (23) 24.5 ▲ system Medical nutrition therapy 13 (2) 70 (5) 406 (13) 1,440 (10) 11.2 ▼ Post discharge in-home medication 10 (1) 30 (2) 96 (3) 330 (2) 1.7 ▼ reconciliation Re-admission prevention 27 (4) 70 (5) 88 (3) 230 (2) 0.8 ▲ Wigs for hair loss related to 25 (3) 20 (1) 119 (4) 390 (3) 0.4 ▼ chemotherapy Weight management programs 36 (5) 60 (4) 162 (5) 440 (3) 0.3 ▼ Alternative therapies 55 (7) 70 (5) 157 (5) 740 (5) 2.4 ▲ Any dental 655 (88)f 1,370 (91)f 2,884 (92)f 13,540 (94)f 3.7 ▼ Oral exam 637 (86) 1,320 (88) 2,883 (92) 13,530 (94) 6.1 ▼ Prophylaxis (cleaning) 630 (85) 1,270 (84) 2,883 (92) 13,530 (94) 7.0 ▼ Fluoride treatment 432 (58) 990 (66) 2,096 (67) 9,740 (67) 8.6 ▼ Dental X-rays 629 (84) 1,310 (87) 2,852 (91) 13,430 (93) 6.2 ▼ Non-routine services 443 (59) 1,080 (72) 1,823 (58) 7,920 (55) 1.6 ▲ Diagnostic services 464 (62) 1,060 (70) 2,077 (66) 10,000 (69) 3.7 ▼ Restorative services 590 (79) 1,340 (89) 2,280 (72) 10,390 (72) 6.8 ▲ Endodontics 542 (73) 1,230 (82) 1,924 (61) 8,560 (59) 11.6 ▲ Periodontics 565 (76) 1,280 (85) 2,098 (67) 10,020 (69) 9.2 ▲ Extractions 557 (75) 1,220 (81) 2,162 (69) 10,100 (70) 6.1 ▲ Prosthodontics 567 (76) 1,240 (82) 2,071 (66) 9,620 (66) 10.3 ▲ Any vision 712 (96)f 1,440 (96)f 3,089 (98)f 14,400 (99)f 2.6 ▼ Routine eye exams 688 (92) 1,360 (90) 3,083 (98) 14,390 (99) 5.6 ▼ Other eye exam 26 (3) 30 (2) 580 (18) 2,150 (15) 14.9 ▼ Contact lenses 676 (91) 1,380 (91) 2,875 (91) 13,420 (93) 0.6 ▼ Page 35 GAO-23-105527 Medicare Advantage Supplemental Benefits Appendix II: Supplemental Benefits Offered by Medicare Advantage Special Needs Plans (SNP) and Non-SNPs GAO Reviewed SNPs that offered benefit Non-SNPs that offered benefit Enrollment in Enrollment in April 2022 in Number of April 2022 in Percentage Number of thousandsa non-SNPs thousandsa point difference SNPs (percent) (percent) (percent) (percent) in plans that Supplemental benefit (N=745) (N=1,510) (N=3,148) (N=14,470) offered benefitb Eyeglasses (frames and lenses) 636 (85) 1,320 (88) 2,653 (84) 12,730 (88) 1.1 ▲ Eyeglass lenses 504 (68) 870 (58) 2,059 (65) 7,780 (54) 2.2 ▲ Eyeglass frames 508 (68) 890 (59) 2,059 (65) 7,780 (54) 2.8 ▲ Eyewear upgrades 374 (50) 820 (55) 1,511 (48) 5,150 (36) 2.2 ▲ Any hearing 674 (90)f 1,250 (83)f 2,994 (95)f 13,420 (93)f 4.6 ▼ Routine hearing exams 661 (89) 1,240 (83) 2,970 (94) 13,280 (92) 5.6 ▼ Fitting/evaluation for hearing aids 548 (74) 990 (66) 2,275 (72) 8,560 (59) 1.3 ▲ Hearing aids (all types) 644 (86) 1,230 (82) 2,858 (91) 12,930 (89) 4.3 ▼ Hearing aids - inner ear 18 (2) 10 (1) 10 (<1) <10 (<1) 2.1 ▲ Hearing aids - outer ear 18 (2) 10 (1) 10 (<1) <10 (<1) 2.1 ▲ Hearing aids - over the ear 18 (2) 10 (1) 10 (<1) <10 (<1) 2.1 ▲ Any of the 47 traditional 744 (>99)f 1,500 (>99)f 3,148 (100)f 14,470 (100)f <1.0 ■ supplemental benefits GAO reviewed Expanded primarily health-related supplemental benefitsg Therapeutic massage 34 (5) 50 (3) 147 (5) 430 (3) <1.0 ■ Adult day health services 41 (6) 20 (1) 32 (1) 90 (1) 4.5 ▲ Home-based palliative care 7 (1) 50 (3) 121 (4) 560 (4) 2.9 ▼ In-home support services (e.g., to 235 (32) 440 (29) 437 (14) 2,160 (15) 17.7 ▲ assist individuals in performing activities such as dressing, eating, and housework) Support for caregivers of enrollees 70 (9) 130 (9) 163 (5) 810 (6) 4.2 ▲ Any of the five expanded primarily 257 (34)f 510 (34)f 674 (21)f 3,050 (21)f 13.1 ▲ health-related supplemental benefits GAO reviewed Special Supplemental Benefits for the Chronically Ill (SSBCI)h Food and produce (e.g., frozen foods, 240 (32) 680 (45) 331 (11) 1,310 (9) 21.7 ▲ canned goods, and produce to assist enrollees in meeting nutritional needs) Meals beyond a limited basis 78 (10) 110 (7) 179 (6) 930 (6) 4.8 ▲ Pest control 66 (9) 110 (7) 125 (4) 690 (5) 4.9 ▲ Any transportation for non-medical 107 (14) 280 (19) 129 (4) 770 (5) 10.3 ▲ needs (e.g., to a grocery store or a bank) Page 36 GAO-23-105527 Medicare Advantage Supplemental Benefits Appendix II: Supplemental Benefits Offered by Medicare Advantage Special Needs Plans (SNP) and Non-SNPs GAO Reviewed SNPs that offered benefit Non-SNPs that offered benefit Enrollment in Enrollment in April 2022 in Number of April 2022 in Percentage Number of thousandsa non-SNPs thousandsa point difference SNPs (percent) (percent) (percent) (percent) in plans that Supplemental benefit (N=745) (N=1,510) (N=3,148) (N=14,470) offered benefitb Indoor air quality equipment and 32 (4) 70 (5) 37 (1) 150 (1) 3.1 ▲ services Social needs benefit (e.g., access to 61 (8) 130 (8) 143 (5) 330 (2) 3.6 ▲ community or plan-sponsored programs and events to address enrollee isolation) Complementary therapies (therapies 16 (2) <10 (<1) 14 (<1) 60 (<1) 1.7 ▲ offered alongside traditional medical treatment) Services supporting self-direction 22 (3) 10 (1) 30 (1) 120 (1) 2.0 ▲ (e.g., interpreter services for encounters with health care providers, financial literacy classes, or other services that help enrollees to be responsible for managing their care) Structural home modifications (e.g., 17 (2) 40 (2) 36 (1) 110 (1) 1.1 ▲ permanent mobility ramps or widening of hallways) General supports for living (e.g., 87 (12) 230 (15) 106 (3) 260 (2) 8.3 ▲ subsidies for rent or utilities) Other SSBCIs not defined by CMSi 52 (7) 100 (6) 145 (5) 680 (5) 2.4 ▲ Any of the 11 SSBCIs GAO 337 (45)f 830 (55)f 514 (16)f 1,930 (13)f 28.9 ▲ reviewed Legend ▲: A higher percentage of SNPs than non-SNPs offered the benefit ■: A similar percentage of SNPs and non-SNPs offered the benefit ▼: A lower percentage of SNPs than non-SNPs offered the benefit Source: GAO analysis of CMS data. | GAO-23-105527 Note: GAO uses "plan" to refer to each unique set of benefits submitted by a Medicare Advantage organization for a specific geographic region. GAO excluded certain plans, including plans outside the 50 states and District of Columbia, Medicare-Medicaid plans, Cost plans, plans that did not offer prescription drug benefits, plans participating in the Value-Based Insurance Design Model (which includes most SNP enrollees), and employer plans. The benefits are listed in the same order as the benefit information plans submit to CMS. a Enrollment numbers are rounded to the nearest ten thousand. b This is the absolute difference between the percentage of SNPs and non-SNPs that offered at least one benefit. The difference shown may not equal the difference in percentages for SNPs versus non- SNPs due to rounding. c Traditional supplemental benefits have a primary purpose of preventing, curing, or diminishing an illness or injury. d Plans can submit up to three other traditional supplemental benefits not defined by CMS. For example, in 2022, some plans listed compression socks or face masks as a traditional supplemental benefit. The count of plans reflect any plans that offered at least one other benefit. Page 37 GAO-23-105527 Medicare Advantage Supplemental Benefits Appendix II: Supplemental Benefits Offered by Medicare Advantage Special Needs Plans (SNP) and Non-SNPs GAO Reviewed e In general, Original Medicare covers an initial preventive physical exam within the enrollee's first 12 months of Medicare enrollment. It also covers an annual wellness visit that includes a health risk assessment. However, it does not cover a routine physical exam that is not related to treating or diagnosing a specific illness, symptom, complaint, or injury. f The number and percentage of plans for a group of benefits or a given type of benefit do not equal the sum of the related rows because plans could offer more than one of these benefits. g Expanded primarily health-related benefits act to ameliorate the functional/psychological effect of injuries or health conditions or reduce avoidable emergency and health care utilization, among other things. h SSBCIs do not have to be primarily health related, but must have a reasonable expectation of improving or maintaining the health or overall function of chronically ill enrollees. When determining and designing benefits to be offered, plans may consider social determinants of health, such as socioeconomic status, as secondary criteria. i Plans can submit up to five other SSBCIs not defined by CMS. For example, in 2022, some plans listed support for service animals as an SSBCI. The count of plans reflect any plans that offered at least one other benefit. Page 38 GAO-23-105527 Medicare Advantage Supplemental Benefits Appendix III: Supplemental Benefits Offered Appendix III: Supplemental Benefits Offered by Medicare Advantage Plans GAO Reviewed in by Medicare Advantage Plans GAO the Value-Based Insurance Design Model Reviewed in the Value-Based Insurance Design Model The Centers for Medicare & Medicaid Services (CMS) began the Value- Based Insurance Design (VBID) Model in January 2017, and it is scheduled to run until December 2024. The VBID Model tests different ways to deliver and pay for services in Medicare Advantage (MA). For example, in 2022, the VBID Model allowed plans unique flexibilities for targeting supplemental benefits to subgroups of enrollees. Unlike non- VBID plans, they could target supplemental benefits at subgroups of enrollees based on the enrollees' (1) chronic condition or conditions or (2) socioeconomic status, as identified by eligibility for Medicare's Low Income Subsidy that assists with costs associated with the prescription drug benefit program. 1 For example, a plan could offer certain supplemental benefits only to enrollees who were eligible for the Low Income Subsidy and who have chronic obstructive pulmonary disease. To describe the supplemental benefits offered by VBID plans, we analyzed the plan benefit data submitted to CMS for 2022. 2 We analyzed data for 957 VBID plans-410 special needs plans (SNP) and 547 non- SNPs-that were in the 50 states and District of Columbia and offered prescription drug benefits. 3 In April 2022, the VBID plans reviewed had total enrollment of approximately 6.58 million, including approximately 2.95 million SNP enrollees and 3.63 million non-SNP enrollees. We found that VBID plans we reviewed offered an array of supplemental benefits in 2022 with some benefits offered only to targeted subgroups of enrollees. • Traditional supplemental benefits. All VBID plans reviewed offered at least one of these benefits, which have a primary purpose of 1Ifa plan offers a benefit only to targeted subgroups of enrollees, it must offer the benefit in a non-discriminatory manner-that is, to all enrollees who meet the criteria established by the MA plan. 2We analyzed the second quarter Plan Benefit Package data for 2022, which is the first version that contains information on the full range of supplemental benefits offered by each plan, as approved by CMS. We use "plan" to refer to each unique set of benefits submitted by an MA organization (the legal entity that has a contract with the Medicare program to provide coverage) for a specific geographic region. A plan can offer a specific benefit to all enrollees or targeted subgroups of enrollees, but each plan was only counted once when determining the number of plans that offered a specific benefit. 3Medicare beneficiaries can enroll in a SNP if they are dually eligible for Medicare and Medicaid, require an institutional level of care, or have a severe or chronic condition. Page 39 GAO-23-105527 Medicare Advantage Supplemental Benefits Appendix III: Supplemental Benefits Offered by Medicare Advantage Plans GAO Reviewed in the Value-Based Insurance Design Model preventing, curing, or diminishing an illness or injury. The most common benefits offered were fitness, vision, over-the-counter items (such as non-prescription pain relievers), hearing, annual/routine physical exams, meals for a limited period (e.g., after an inpatient hospital stay), and dental. In general, most VBID plans offered the traditional supplemental benefits uniformly. However, for a subset of these benefits, plans more commonly targeted them to enrollees based on their socioeconomic status or chronic condition, or to chronically ill enrollees. These benefits included the alternative therapies, weight management, and home and bathroom safety devices and modifications. • Expanded primarily health-related supplemental benefits. About one-fourth of VBID plans reviewed offered at least one of these benefits, which act to ameliorate the functional/psychological effect of injuries or health conditions or reduce avoidable emergency and health care utilization, among other things. The most common such benefit offered by VBID plans was in-home support services (e.g., to assist individuals in performing activities such as dressing, eating, and housework). The VBID plans generally targeted some of the expanded primarily health-related benefits-support for caregivers, therapeutic massage, and adult day health services-at chronically ill enrollees. Plans more commonly offered the other two expanded benefits-in-home support services and home-based palliative care-uniformly to all enrollees. In addition, plans rarely targeted the expanded benefits to enrollees based on socioeconomic status. For example, 2 percent of VBID plans reviewed that offered in-home support services did so based solely on socioeconomic status, and the plans did not target any other expanded benefits based solely on socioeconomic status. • Non-primarily health-related supplemental benefits. About one- third of VBID plans reviewed offered at least one of these benefits, which must have a reasonable expectation of improving or maintaining the health or overall function of the enrollee. 4 The most commonly offered non-primarily health-related benefits were food and produce (e.g., frozen foods, canned goods, and produce to assist enrollees in meeting nutritional needs), meals beyond a limited basis, 4These non-primarily health-related supplemental benefits are of the same type and scope as Special Supplemental Benefits for the Chronically Ill, which can be offered to only chronically ill enrollees. In the VBID Model, these benefits can also be offered to subgroups of enrollees based on the enrollees' (1) chronic condition or conditions or (2) socioeconomic status, as identified by eligibility for Medicare's Low Income Subsidy. Page 40 GAO-23-105527 Medicare Advantage Supplemental Benefits Appendix III: Supplemental Benefits Offered by Medicare Advantage Plans GAO Reviewed in the Value-Based Insurance Design Model and transportation for non-medical needs (e.g., to a grocery store or a bank). Among VBID plans that offered these types of benefits, varying percentages targeted the benefits based solely on socioeconomic status. For example, around 40 percent of plans that offered food and produce and around 30 percent of plans that offered meals beyond a limited basis did so based solely on socioeconomic status. Finally, we found that, among VBID plans reviewed, a higher percentage of SNPs offered certain benefits compared to non-SNPs. These included traditional supplemental benefits such as transportation for medical needs (e.g., to a doctor's office), personal emergency response systems, and remote access technology (e.g., nurse hotlines). They also included in- home support services (e.g., to assist individuals in performing activities such as dressing, eating, and housework), which is an expanded primarily health-related supplemental benefit. Finally, all but one of the non- primarily health-related benefits was offered by a higher percentage of SNPs we reviewed compared to non-SNPs. See table 9 for additional information on the supplemental benefits offered by VBID plans. Table 9: Examples of Supplemental Benefits Offered by Medicare Advantage Plans in the Value-Based Insurance Design Model, Including Special Needs Plans (SNP) and Non-SNPs, 2022 Non-SNPs that offered SNPs that offered benefit benefit Total number of Percentage plans that Number of Number of point difference offered benefit SNPs Percent of non-SNPs Percent of in plans that Supplemental benefit (percent) (N=957) (N=410) SNPs (N=547) non-SNPs offered benefita Traditional supplemental benefitsb Fitness 932 (97) 390 95 542 99 4▼ Visionc 922 (96) 399 97 523 96 2▲ Over-the-counter items (e.g., 916 (96) 406 99 510 93 6▲ nonprescription pain relievers) Hearingc 910 (95) 398 97 512 94 4▲ Annual/routine physical examd 904 (94) 370 90 534 98 7▼ Meals for a limited period (e.g., 892 (93) 368 90 524 96 6▼ after an inpatient hospital stay) Dentalc 885 (92) 401 98 484 88 9▲ Other supplemental services not 737 (77) 281 69 456 83 15 ▼ defined by the Centers for Medicare & Medicaid Services (CMS)e Page 41 GAO-23-105527 Medicare Advantage Supplemental Benefits Appendix III: Supplemental Benefits Offered by Medicare Advantage Plans GAO Reviewed in the Value-Based Insurance Design Model Non-SNPs that offered SNPs that offered benefit benefit Total number of Percentage plans that Number of Number of point difference offered benefit SNPs Percent of non-SNPs Percent of in plans that Supplemental benefit (percent) (N=957) (N=410) SNPs (N=547) non-SNPs offered benefita Acupuncture 662 (69) 214 52 448 82 30 ▼ Transportation for medical needs 648 (68) 379 92 269 49 43 ▲ (e.g., to a doctor's office) Personal emergency response 469 (49) 310 76 159 29 47 ▲ system Remote access technology (e.g., 343 (36) 267 65 76 14 51 ▲ nurse hotlines) Home and bathroom safety 272 (28) 179 44 93 17 27 ▲ devices and modifications Smoking and tobacco cessation 238 (25) 173 42 65 12 30 ▲ counseling Health education 203 (21) 119 29 84 15 14 ▲ Wigs for hair loss related to 197 (21) 131 32 66 12 20 ▲ chemotherapy Any of the 47 traditional 957 (100)g 410g 100g 547g 100g 0■ supplemental benefits GAO reviewedf Expanded primarily health-related supplemental benefitsh In-home support services (e.g., to 219 (23) 143 35 76 14 21 ▲ assist individuals in performing activities such as dressing, eating, and housework) Therapeutic massage 100 (10) 56 14 44 8 6▲ Adult day health services 96 (10) 58 14 38 7 7▲ Support for caregivers of enrollees 96 (10) 57 14 39 7 7▲ Home-based palliative care 22 (2) 1 0 21 4 4▼ Any of the five expanded 240 (25)g 149g 36g 91g 17g 20 ▲ primarily health-related supplemental benefits GAO reviewed Non-primarily health-related supplemental benefitsi Food and produce (e.g., frozen 262 (27) 208 51 54 10 41 ▲ foods, canned goods, and produce to assist enrollees in meeting nutritional needs) Other non-primarily health-related 158 (17) 92 22 66 12 10 ▲ supplemental benefits not defined by CMSj Meals beyond a limited basis 149 (16) 97 24 52 10 14 ▲ Page 42 GAO-23-105527 Medicare Advantage Supplemental Benefits Appendix III: Supplemental Benefits Offered by Medicare Advantage Plans GAO Reviewed in the Value-Based Insurance Design Model Non-SNPs that offered SNPs that offered benefit benefit Total number of Percentage plans that Number of Number of point difference offered benefit SNPs Percent of non-SNPs Percent of in plans that Supplemental benefit (percent) (N=957) (N=410) SNPs (N=547) non-SNPs offered benefita Transportation for non-medical 144 (15) 98 24 46 8 16 ▲ needs (e.g., to a grocery store or a bank) Pest control 132 (14) 94 23 38 7 16 ▲ General supports for living (e.g., 97 (10) 59 14 38 7 7▲ subsidies for rent or utilities) Services supporting self-direction 96 (10) 53 13 43 8 5▲ (e.g., interpreter services for encounters with health care providers, financial literacy classes, or other services that help enrollees to be responsible for managing their care) Indoor air quality equipment and 92 (10) 54 13 38 7 6▲ services Complementary therapies 91 (10) 53 13 38 7 6▲ (therapies offered alongside traditional medical treatment) Social needs benefit (e.g., access 36 (4) 24 6 12 2 4▲ to community or plan-sponsored programs and events to address enrollee isolation) Structural home modifications 13 (1) 5 1 8 1 <1 ■ (e.g., permanent mobility ramps or widening of hallways) Any of the 11 non-primarily 308 (32)g 211g 51g 97g 18g 34 ▲ health-related supplemental benefits GAO reviewed Legend: ▲: A higher percentage of SNPs than non-SNPs offered the benefit ■: A similar percentage of SNPs and non-SNPs offered the benefit ▼: A lower percentage of SNPs than non-SNPs offered the benefit Source: GAO analysis of CMS data. | GAO-23-105527 Note: The Value-Based Insurance Design (VBID) Model is designed to test a broad array of alternative ways to deliver and pay for services in Medicare Advantage. GAO uses "plan" to refer to each unique set of benefits submitted by a Medicare Advantage organization in a specific geographic region. GAO excluded plans outside the 50 states and District of Columbia and plans that did not offer prescription drug benefits. a This is the absolute difference between the percentage of SNPs and non-SNPs that offered at least one benefit. b Traditional supplemental benefits have a primary purpose of preventing, curing, or diminishing an illness or injury. Only the most commonly offered traditional supplemental benefits are listed. Page 43 GAO-23-105527 Medicare Advantage Supplemental Benefits Appendix III: Supplemental Benefits Offered by Medicare Advantage Plans GAO Reviewed in the Value-Based Insurance Design Model c There are multiple vision, hearing, and dental benefits. For example, specific dental benefits include oral exams, cleaning, fluoride, and X-rays. A plan is counted as offering the benefit if it offers at least one such specific benefit. d In general, Original Medicare covers an initial preventive physical exam within the enrollee's first 12 months of Medicare enrollment. It also covers an annual wellness visit that includes a health risk assessment. However, it does not cover a routine physical exam that is not related to treating or diagnosing a specific illness, symptom, complaint, or injury. e Plans can submit up to three other traditional supplemental benefits not defined by CMS. For example, in 2022, some VBID plans offered a monthly allowance that members could spend on certain healthy foods as a traditional supplemental benefit. The count of plans reflect any plans that offered at least one other benefit. Plans report to CMS whether they offer each of 46 traditional supplemental benefits defined by CMS. f Plans can also report up to three other traditional supplemental benefits not in the defined list-which GAO collapsed into and counted as a single benefit. g The number and percentage do not equal the sum of the previous rows because plans could offer more than one of these benefits. In addition, for traditional supplemental benefits, not all benefits are listed. h Expanded primarily health-related supplemental benefits act to ameliorate the functional/psychological effect of injuries or health conditions or reduce avoidable emergency and health care utilization, among other things. i Non-primarily health-related supplemental benefits must have a reasonable expectation of improving or maintaining the health or overall function of the enrollee. These benefits are of the same type and scope as Special Supplemental Benefits for the Chronically Ill, which can be offered to only chronically ill enrollees. In the VBID Model, these benefits can also be offered to subgroups of enrollees based on the enrollees' (1) chronic condition or conditions or (2) socioeconomic status, as identified by eligibility for Medicare's Low Income Subsidy. j Plans can submit up to five other non-primarily health-related supplemental benefits not listed elsewhere. For example, in 2022, some VBID plans listed pet care assistance as a non-primarily health-related supplemental benefit. The count of plans reflect any plans that offered at least one other benefit. Page 44 GAO-23-105527 Medicare Advantage Supplemental Benefits Appendix IV: Comments from the Appendix IV: Comments from the Department of Health and Human Services Department of Health and Human Services Page 45 GAO-23-105527 Medicare Advantage Supplemental Benefits Appendix IV: Comments from the Department of Health and Human Services Page 46 GAO-23-105527 Medicare Advantage Supplemental Benefits Appendix IV: Comments from the Department of Health and Human Services Page 47 GAO-23-105527 Medicare Advantage Supplemental Benefits Appendix V: GAO Contact and Staff Appendix V: GAO Contact and Staff Acknowledgments Acknowledgments Michelle B. Rosenberg, (202) 512-7114 or RosenbergM@gao.gov GAO Contact In addition to the contact named above, Iola D'Souza (Assistant Director), Staff Corissa Kiyan-Fukumoto (Analyst-in-Charge), and Elizabeth Flow- Acknowledgments Delwiche made key contributions to this report. Sam Amrhein, Todd Anderson, Zhi Boon, Sonia Chakrabarty, and Ying Hu also made important contributions. (105527) Page 48 GAO-23-105527 Medicare Advantage Supplemental Benefits The Government Accountability Office, the audit, evaluation, and investigative GAO's Mission arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. GAO examines the use of public funds; evaluates federal programs and policies; and provides analyses, recommendations, and other assistance to help Congress make informed oversight, policy, and funding decisions. GAO's commitment to good government is reflected in its core values of accountability, integrity, and reliability. The fastest and easiest way to obtain copies of GAO documents at no cost is Obtaining Copies of through our website. 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