Combo benefits: Understanding the landscape of this innovative Medicare Advantage benefit in 2022

A 2023 update to this article is available here.

The 2022 benefit landscape in the Medicare Advantage (MA) market includes an increase in the number of beneficiaries covered by plans offering combined benefits under a specific maximum plan benefit amount—known as a Combined Benefit Limit or a “combo” benefit. Within the highly competitive 2022 supplemental benefit landscape, there are many different combinations of benefits being offered under this relatively new benefit option. This article provides a summary of 2022 combo benefits observed in the MA market.

Executive summary

Using the Milliman MACVAT®, a tool providing a comprehensive benefit summary of individual MA plans, we analyzed all 2022 individual MA plans to determine the breadth of combo offerings available to beneficiaries, drilling down to the service category in each plan benefit package (PBP). We specifically focused on each of the benefits contained in the combo benefit, as there are multiple ways an MA organization can combine specific PBP categories into a combo benefit.

The combo benefit allows plans to combine supplemental benefits into groups with a maximum plan benefit amount. One popular example is offering a combined maximum benefit limit for both preventive and comprehensive dental. Another example is a plan offering a combined visit limit across chiropractic and acupuncture services. The maximum plan benefit amount can be a total dollar limit, a total visit limit, or varying maximums by benefit included in the package. Plans are required to designate whether the enrollee must select from one or more of the benefits (as opposed to having access to all of the benefits in the package). In 2022, MA rules allow plans to cover up to three packages of combo benefits.

Key takeaways from this analysis include:

• We estimated nearly 69% of beneficiaries enrolled in MA are enrolled in plans offering a combo benefit. This percentage largely consists of beneficiaries enrolled in plans offering dental-only combo benefits.
• About 19% of MA beneficiaries are enrolled in plans offering a combo benefit other than dental coverage.
• About 6% of MA beneficiaries were enrolled in plans offering a combo benefit in 2021 exclusive of dental; thus, the prevalence of non-dental combo benefits grew significantly from 6% of beneficiaries in 2021 to 19% of beneficiaries in 2022.
• In dual eligible special needs plans (D-SNPs), about 79% of beneficiaries have a combo benefit. Additionally, D-SNPs offer demonstration program or over-the-counter (OTC) benefit coverage under combo benefits more than any other type; about 45% of D-SNP beneficiaries have access to each of these benefit types, relative to less than 5% under other enrollment types.
• National organizations offer combo benefits to about 74% of beneficiaries enrolled in their plans, significantly more than regional organizations at about 52%.

Overall and dental benefit coverage in combined benefit packages

Plans are able to include any allowable supplemental benefit in their combo benefit. Figure 1 shows the percentage of beneficiaries by varying plan/carrier characteristics with combo benefit coverage in 2022.¹

About 77% of beneficiaries enrolled in preferred provider organizations (PPOs)—including local PPOs (LPPOs), regional PPOs (RPPOs), and health maintenance organizations with added point-of-service benefits (HMO-POS plans)—are covered by combo benefits, while 63% of beneficiaries in HMOs have combo benefit coverage. Beneficiaries enrolled in D-SNPs are the most likely to be covered by combo benefits (about 79% coverage) relative to beneficiaries in general enrollment plans and chronic condition special needs plans (C-SNPs), about 64% coverage). General enrollment plans with zero-dollar premiums offer combo benefits to a higher percentage of beneficiaries than plans with non-zero premiums; the same holds true for national versus regional organizations.

Combined dental limits are the most commonly offered combo benefit package, covering about 58% of total MA enrollment. Some MA plans have offered combined limits across preventive and comprehensive dental services for many years. Starting in 2022, the Centers for Medicare and Medicaid Services (CMS) requires plans offering this benefit structure to identify combined preventive and comprehensive dental limits formally as combo benefits in the PBP. While rarely done in 2022, it is possible to include other benefits alongside dental within the same package; about 0.4% of beneficiaries are covered by a combo benefit that includes dental along with other services within the same package. Figure 2 shows the percentage of beneficiaries by plan characteristic with combo benefit coverage including dental in 2022.

A comparison of Figures 1 and 2 shows that, in total, about 85% of beneficiaries with combo benefits receive dental coverage under a combo benefit. Dental combo benefits are the least common in regional organizations, where 29% of beneficiaries have a combo dental benefit while 52% of regional beneficiaries have any type of combo benefit; this is in part because regional organizations tend to offer separate preventive and comprehensive dental limits more frequently than national organizations. Additionally, PPOs are the most likely to include dental in a combo benefit, as only about 5% of beneficiaries in PPOs have a combo benefit that does not include dental (77% of beneficiaries have access to a combo benefit while 72% have access to a combo benefit including dental).

For plans with a dental combo benefit, the maximum benefit value varies widely. Figure 3 shows the enrollment-weighted average dental combo limit by plan characteristic, rounded to the nearest $100.

The average dental combo benefit for HMO plan types is larger than those offered under HMO-POS and PPO plan types, at about $1,900 annually versus about $1,400 and $1,500 annually, respectively. The average D-SNP dental combo benefit limit is about twice that of the average general enrollment plan’s combo dental benefit limit (about $2,900 annually versus about $1,400 annually).

The interactive graphic in Figure 4 demonstrates the percentage of beneficiaries with coverage within a combo benefit package for each high-level PBP service category. This graphic allows the user to include or exclude dental coverage from the interactive graphic, which is generally significantly more prevalent than other benefit offerings. The categories are ranked by the percentage of membership covered for each category across the total market. Aside from dental, demonstration programs are offered most frequently in combo benefits, with about 12% of membership covered. This includes Value-Based Insurance Design (VBID), Uniformity Flexibility (UF), and Special Supplemental Benefits for the Chronically Ill (SSBCI), which are all offered non-uniformly to beneficiaries based on individual eligibility. Demonstration programs are closely followed by OTC benefits, with about 10% of membership covered. Other benefits with more than 5% of membership covered across the entire market are fitness, home and bathroom safety devices and modifications, health education, worldwide emergency coverage, and acupuncture.

Combo benefit offerings by SNP type

We reviewed the data categorized by SNP type. We note very few I-SNPs offer non-dental combo benefits, and so they are not included in this graphic.

• Around 46% of beneficiaries in D-SNPs are covered by combo benefits that include either demonstration programs or OTC benefits, significantly higher than the coverage of these services under a combo benefit for any other enrollment type.
• C-SNPs are the most likely to offer acupuncture or chiropractic services under a combo benefit, covering about 11% and 10% of beneficiaries, respectively.
• Each non-dental service is offered in a combo benefit by general enrollment plans to about 6% of beneficiaries or less.

While not summarized directly in the interactive graphic, D-SNPs are by far the most prevalent enrollment type offering non-dental combo benefits, with about 54% of enrollment in D-SNP plans with access to a non-dental combo benefit. This is relative to about 11% of general enrollment plans and about 18% of C-SNP plans.

Combo benefit offerings by plan type

We summarized combo benefit coverage data by broad plan type: HMO, HMO-POS, and PPO, including both local PPOs (LPPOs) and regional PPOs (RPPOs). Private fee-for-service (PFFS) plans are excluded due to the limited enrollment in this plan type and subsequent limited offering of combo benefits.

• Beneficiaries in HMO plans are the most likely to have coverage of non-dental benefit categories in a combo benefit, with a few exceptions. Demonstration programs and OTC benefit coverage in a combo benefit are the most commonly offered by HMOs, covering about 14% and 11% of HMO membership, respectively.
• HMO-POS plans provide the highest percentage of health education, worldwide emergency coverage, and alternative therapy services in combo benefits to their beneficiaries of the three plan types.
• While PPOs offer access to demonstration programs and OTC benefit coverage to about 8% each of beneficiaries, coverage of all other non-dental benefits is relatively low. As seen in Figures 1 and 2 above, the vast majority of PPO combo benefits are dental.

Combo benefit offerings by organization type

We summarized combo benefit coverage data by national and regional organizations. We classified the following organizations as national: Anthem, Centene/WellCare, CIGNA, CVS Health/Aetna, Humana, Kaiser, and UnitedHealth, with the remainder of plans being identified as regional.

• As displayed in Figures 1 and 2 above, a significant portion of combo benefit coverage by regional organizations includes non-dental benefits. Thus, the interactive graphic shows multiple benefit categories covered for over 10% of regional organization beneficiaries, the highest being combo benefits including acupuncture offered to about 17% of beneficiaries in regional organizations. Health education and worldwide emergency coverage are both offered to about 14% of regional organization beneficiaries.
• About 13% of beneficiaries in national organizations are covered by combo benefits that include demonstration programs. The next most common are OTC benefits (9%) and home and bathroom safety devices (6%).

While not summarized directly in the interactive graphic, regional organizations are about two times more likely to offer a non-dental combo benefit than national plans. About 29% of beneficiaries enrolled in regional organizations are covered by a non-dental combo benefit, while about 15% of beneficiaries enrolled in national organizations are covered by a non-dental combo benefit.

Combo benefit offerings by plan premium for general enrollment plans

Finally, we summarized combo benefit coverage data by 2022 beneficiary premiums (Part C plus Part D premiums), distinguishing between general enrollment plans that have zero-dollar premiums and non-zero-dollar premiums. General enrollment plans tend to focus on zero-dollar premium plan offerings more than other plan types; D-SNPs, for example, generally target a premium equal to the low-income benchmark (LIB).

• In general, plans with zero-dollar premiums cover a higher percentage of beneficiaries with combo benefits than plans with non-zero-dollar premiums. Only a few non-dental benefits are covered in a combo benefit for more than 5% of beneficiaries in zero-dollar plans; these are fitness, acupuncture, home and bathroom safety, nutritional/dietary benefits, and worldwide urgent coverage.
• The non-dental benefit offered to the most beneficiaries in plans with non-zero-dollar premiums is acupuncture, at about 8% coverage. Other benefits with combo benefit membership coverage by non-zero-dollar plans at or above 5% are health education, worldwide emergency coverage, and routine chiropractic care.

Conclusion

The majority of beneficiaries are enrolled in a plan design that includes a combo benefit, and the majority of these plans include combined preventive and comprehensive dental limits. However, the nearly 15% growth in non-dental combo benefits across the market from 2021 to 2022, and the high prevalence of D-SNP plans offering non-dental combo benefits, suggest plans are thinking strategically about how combo benefits support plan competitiveness and enrollment growth.

Methodology and assumptions

To perform these analyses, we relied on detailed information on MA plan combo benefit offerings for 2022. We also used publicly available MA enrollment information from January 2022 to develop enrollment-weighted averages by the groupings noted above. The various groupings we analyzed include:

• Special needs plan type
• Plan type
• $0 premium plans vs. non-$0 premium plans
• Regional vs. national organizations

The values presented reflect plans available in 2022. The information released by CMS includes detailed cost-sharing information by PBP service category, enrollee premium, and enrollment by plan. We used the 2022 Milliman MACVAT® (which summarizes the previously mentioned information released by CMS).

We included all individual plans, e.g., non-employer group waiver plan (non-EGWP) MA prescription drug (MAPD) plans. We excluded standalone prescription drug plans (PDPs), medical savings account (MSA) plans, Medicare-Medicaid plans (MMPs), Program for All-Inclusive Care of the Elderly (PACE) plans, Part B-only plans, and Cost plans.

Caveats, limitations, and qualifications

Julia M. Friedman and Mary G. Yeh are consulting actuaries for Milliman, members of the American Academy of Actuaries, and meet the qualification standards of the Academy to render the actuarial opinion contained herein. To the best of their knowledge and belief, this report is complete and accurate and has been prepared in accordance with generally recognized and accepted actuarial principles and practices.

The material in this report represents the opinion of the authors and is not representative of the view of Milliman. As such, Milliman is not advocating for, or endorsing, any specific views contained in this report related to the Medicare Advantage program.

The information in this report is designed to provide an overview of the 2022 Medicare Advantage combo benefit offerings. This information may not be appropriate, and should not be used, for other purposes. We do not intend this information to benefit any third party that receives this work product. Any third-party recipient of this report that desires professional guidance should not rely upon Milliman’s work product, but should engage qualified professionals for advice appropriate to its specific needs. Any releases of this report to a third party should be in its entirety.

The credibility of certain comparisons provided in this report may be limited, particularly where the number of plans in certain groupings is low. Some metrics may also be distorted by premium and benefit changes in a few plans with particularly high enrollment.

In preparing our analysis, we relied upon public information from CMS, which we accepted without audit. However, we did review it for general reasonableness. If this information is inaccurate or incomplete, conclusions drawn from it may change.

¹ This paper excludes institutional special needs plans (I-SNPs) and private fee-for-service (PFFS) plans. I-SNPs offer very limited non-dental combo benefits in 2022. PFFS plans have limited enrollment and subsequent limited offering of combo benefits.