Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. 2. High-Risk Seniors Require Care from Providers Not Covered by Medicare


Medicare plays a primary role in addressing medical conditions and impairments but a smaller role in dealing with limitations in functioning and disability. Therefore, it does not address the full range of needs of high-risk seniors. In both fee-for-service and managed care systems, Medicare covers medical treatments, limited preventive care, and interventions to address impairments. It also covers some services to maintain improve functioning, although those are generally limited to services deemed “medically necessary.” This limitation creates problems for many high-risk seniors who may require care to maintain their functioning or quality of life or to prevent additional complications. Furthermore, many services used by high-risk seniors are intended to address nonmedical issues associated with helping them maintain independence and functioning. These services may fail to meet strict medical-necessity criteria, particularly given the lack of evidence of the effectiveness of many interventions aimed at prevention and functional support.

Results in Table III.6 show that many high-risk seniors in the three surveyed MCOs receive home- and community-based services beyond those included in the Medicare fee-for-service home health benefit. For example, 10 percent of our sample receive home-delivered meals, and 12 percent receive transportation to medical appointments. In addition, 29 percent of the high-risk seniors in our sample receive home health services, but our survey does not indicate whether these services are covered by Medicare or by the MCO.

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