Perspectives on Health-Related Social Needs for Medicare Advantage Beneficiaries

ABSTRACT

Objectives: We sought to characterize current approaches to address health-related social needs that arise for Medicare Advantage (MA) members in the context of postacute home health care.

Study Design: Qualitative study.

Methods: From March 2023 to June 2024, we interviewed 18 representatives from 14 MA organizations representing more than 62.4% of the MA market and 5 representatives from 5 postacute care management companies (CMCs) about approaches to health-related social needs. Interviews were audio recorded, transcribed, and analyzed using content analysis to identify themes.

Results: Three themes were identified related to health-related social needs: motivations, approaches, and lessons learned and aspirations. Motivations included fulfilling organizational missions, meeting individual or community member needs, and differentiating from other MA plans to improve enrollment and retention. Approaches varied and leveraged internal teams, CMCs, and/or community partnerships to screen and connect members to resources. Lessons learned focused on rightsizing staffing while managing program costs. Aspirations centered on expanding how MA organizations and Medicare might broaden allowable supplemental benefit coverage for health-related social needs.

Conclusions: The motivations and approaches that MA organizations and CMCs use to address members’ social needs vary widely. Notable innovative approaches included partnerships with local community organizations with the intent to differentiate and grow plans as well as an emerging role for CMCs in identifying and addressing social needs during postacute care transitions.

Am J Manag Care. 2026;32(10):566-574

doi:10.37765/ajmc.2026.90028

Takeaway Points

Qualitative interviews with 18 representatives from 14 Medicare Advantage organizations and 5 care management companies examined how health-related social needs are addressed during postacute home health care and beyond, with 3 major themes revealing wide variation in how plans translate social needs into practice.

• Motivations: Plans were driven by mission alignment, addressing the needs of individuals and community members, and differentiating to attract and retain enrollees.
• Approaches: Strategies varied, including screening, internal or care management company–led referrals, and partnerships with community-based organizations.
• Lessons and aspirations: Plans emphasized balancing staffing and costs while seeking expanded guidelines and definitions for supplemental social need benefits.

Health-related social needs, such as food insecurity, lack of transportation, and housing insecurity, are important contributors to overall health outcomes and costs.^1-7 In recent years, identifying and addressing patients’ social needs has become a high priority for clinicians, health systems, and payers. For Medicare Advantage (MA) enrollees, benefits to address social needs prior to 2018 were limited to those that were considered “primarily health-related” services, such as dental, vision, hearing, limited meal provision, and rides to medical appointments.⁸

To expand coverage for Medicare beneficiaries, the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act was signed into law in 2018. This legislation allowed MA plans to introduce 2 distinct types of expanded supplemental benefits. Starting in 2019, plans could offer expanded “primarily health-related benefits,” such as caregiver support, more generous meal and transportation services, and in-home help. By 2020, coverage further expanded to include Special Supplemental Benefits for the Chronically Ill (SSBCI), which introduced purely nonmedical social supports such as extended home-delivered meals, nonmedical transportation, and pest control.⁹

MA leaders interviewed in 2018 after the CHRONIC Care Act was passed but before implementation described the value of addressing members’ social needs, although their perspectives differed on whether MA organizations should directly address these needs and how to do so. Some described intentions to design new MA benefits or develop partnerships with community organizations, but others reported that it was outside their scope to address social needs. Overall, participants reported that more evidence, infrastructure, and guidance from CMS were needed to guide their decision-making.¹⁰

Early adoption of SSBCIs was limited: Only 4.6% of MA plans offered new SSBCIs in 2020.¹¹ This increased to 16% in 2025 but declined to 12% in 2026.^12-14 Infrastructure for social needs benefits can be supported by rebates from CMS, which represent the difference between the CMS benchmark and the amount an MA plan bids to provide care in a county, and by quality bonus payments received by MA plans with CMS Star Ratings of at least 4 (based on plan performance in chronic condition management, member experience, hospital readmissions, and other domains).¹⁵ Overall, MA organizations are guided by multiple factors in their decisions to invest in infrastructure for SSBCIs or other social needs programs because the policy and payment landscape continues to shift and MA enrollment continues to surge.¹⁶

Medicare beneficiaries who need additional support through home health care nursing and/or therapies after hospital discharge are at high risk for hospital readmissions and mortality.^17-19 This transition from hospital to home health care can be an opportune time to screen for and address health-related social needs with the goal of improving clinical outcomes after hospitalization.²⁰ Postacute care management companies (CMCs) are increasingly being contracted by MA organizations to handle care coordination, referrals, and utilization management for MA members during the postacute care period. Given this context, we sought to understand current motivations and approaches to benefits related to social needs for MA beneficiaries during care transitions from hospital to home health care from the perspective of leaders at MA organizations and CMCs.

METHODS

Context, Sample, and Recruitment

This research was conducted as part of a larger mixed-methods project examining the role of MA organizations, CMCs, and home health agencies in beneficiaries’ postacute care decision-making. This paper focuses on insights from MA representatives and CMCs regarding approaches to identify and address health-related social needs among their members. Our approach to defining the sample and recruiting from the larger project has been published previously.²¹ Briefly, we identified 6 health care markets in the US with moderate to high MA penetration based on hospital referral regions (HRRs), defined as HRRs above the median MA penetration percentage. Candidate HRRs also had at least 3 MA plans serving 10% or more of MA beneficiaries and at least 2 acute care hospitals. We used purposive and snowball sampling to identify and recruit participants. We conducted semistructured interviews with representatives of MA organizations (ie, the companies contracted with Medicare that managed 1 to several MA plans), CMCs, and home health agencies. We recruited and interviewed participants until we reached our recruitment goal of at least 2 MA organizations per market and 5 CMCs.

Interview Procedures

Two semistructured interview guides were developed and piloted as previously described.²¹ The full interview guide (eAppendix 1 [eAppendix available at ajmc.com]) asked about postacute care benefits; home health benefit design, administration, processes, and outcomes; and other topics. This analysis focuses on the questions related to participant approaches to address beneficiaries’ social needs. Interviews were conducted by telephone or video conference (per participant preference) from March 2023 through June 2024. Interviews were recorded with participants’ consent and lasted an average of 1 hour. This project did not require institutional review board approval, as it was deemed not to involve human subjects research.

Qualitative Analysis

Interview transcripts were qualitatively analyzed using a modified content analysis approach to identify overarching concepts and themes.^22-24 The full approach to coding and analysis has been described previously.²¹ Briefly, preliminary codes were developed and iteratively refined; at least 2 team members coded each transcript, which was then reconciled and summarized for each interview. The analysis for this paper focuses on codes and themes related to health-related social needs. NVivo 12 (formerly QSR International, now Lumivero) was used for coding, data management, and the generation of coding reports. Coding reports were reviewed by the entire study team to identify themes and guide discussions aimed at reconciling any discrepancies. A comprehensive audit trail recorded team decisions about codes and themes.^22,23,25-27

RESULTS

MA Organizational Characteristics

The characteristics of the 14 MA organizations represented in this study varied in size (< 100,000 to > 5 million members), Medicare quality star ratings (2.5-5 stars), and geographic scope, consisting of 4 national plans and 10 regional plans. The MA organizations we interviewed enrolled more than 20 million MA members in 2023, which was more than 62.4% of the total MA market (eAppendix Table 1). Overall, 18 individuals from 14 MA organizations and 5 individuals from 5 CMCs were interviewed. Participants’ positions included chief executive officers, chief medical officers, chief development officers, chief operating officers, and vice presidents.

All participants described investing in pathways to address social needs and indicated the importance of this to their organization. Although social needs questions were asked as part of a larger study about approaches to postacute home health care, most participants described organizational approaches to social needs for all members, rather than just those receiving home health care. Three major themes and related subthemes were identified from interviews, as shown in Table 1, with representative quotes in Tables 2, 3, and 4.

Theme 1: Plans’ Motivation for Addressing Social Needs

Almost all participants from MA organizations identified a clear motivation for addressing members’ social needs, which fell into several key subthemes.

Subtheme 1a: Mission Driven. Participants from MA organizations and a CMC described addressing members’ social needs as core to their organization’s mission and values. The organizational mission was frequently described in the context of serving a community, specific region, or state (MA 4). The organizational mission to meet members’ social needs also emerged in interviews with participants who had prior experience meeting social needs in other Medicaid or Dual Eligible Special Needs Plans (D-SNPs) and applying those learnings to MA members (CMC 1).

Subtheme 1b: Meeting Members’ Needs. Participants described identifying members’ health-related social needs to improve overall member health, noted that nonmedical needs often drive health outcomes, and expressed a desire to remove social barriers to care. Participants from MA organizations frequently described “value-added benefits” or social needs supplemental benefits tailored to the needs of the communities they serve. Goals included providing care in their members’ languages and providing culturally tailored supplemental benefits such as “cupping and reflexology, herbal medications” (MA 14). One participant described how meeting members’ needs as they transition from hospital to home could help to avoid readmissions after hospital discharge (MA 1).

Subtheme 1c: Enrollment and Retention. One participant described retaining members and acquiring their spouses, nursing home hall mates, and others due to high member satisfaction with the provision of meals, transportation, Wi-Fi, and “tangible things” when a member has a hip fracture and undergoes rehabilitation at home (MA 5). Another MA participant more broadly discussed how they consider supplemental benefits, such as flexible spending credit cards and dental coverage, to drive enrollment (MA 6).

Theme 2: Plans’ Approaches to Address Social Needs

Participants described varying approaches to screening and addressing members’ health-related social needs, including internal teams of case managers, contracts with CMCs, and partnerships with community members and congregations, as noted below in subthemes. As in the themes for motivations, some approaches were informed by prior experience with Medicaid and D-SNPs.

Subtheme 2a: Approaches to Identifying Social Needs. Participants described using an assessment tool or screener to identify social risk factors. Some mentioned completing assessments for all members at enrollment, and others described gathering this information through community health workers (MA 3) or through case managers when evaluating “high-risk utilizers” (MA 10).

Subtheme 2b: Approaches to Connecting Members to Resources Using Internal Teams. Specific approaches that used infrastructure within MA organizations included community specialist teams, care management teams, and call centers to connect members with community resources. One plan described having storefronts where members could access resources, classes, and even nurse case managers to help address members’ needs (MA 4).

Subtheme 2c: Postacute CMC’s Role.Participants interviewed from CMCs described their roles in both screening and addressing social needs as a service for MA organizations and their members during postacute care transitions. One participant described using data collected by home health clinicians in the Outcome and Assessment Information Set (OASIS) for patients receiving home health care to identify patients with social needs (CMC 1). Another described a telephone-based coaching program that reaches out to patients after discharge from hospitals or postacute facilities to ensure they have follow-up appointments and transportation and that their other needs are being met (CMC 2). A third CMC participant described acquiring a company doing telephone-based outreach after hospitalization to talk with patients, identify their needs, and connect them with resources (CMC 3).

Subtheme 2d: Strategic Partnerships for Social Needs.Several participants described strategic partnerships with community-based organizations to address social needs. For one MA organization, these included local farms, transportation services, congregations, translators, and babysitters (MA 5). Others included community paramedics, community health workers, and volunteers to help with tasks such as grocery shopping (MA 1 and 2).

Theme 3: Lessons Learned and Aspirations

Subtheme 3a: Lessons Learned. Participants described lessons learned about scalability and sustainability, including the need for adequate staffing and for managing program scope to stay high yield. For example, one participant noted that a limited number of staff were focused on responding to members who indicated they needed help, with plans to redistribute that workload given the volume of requests (MA 7). One CMC participant described managing the cost of their telephone-based program—which could require many calls to resolve each member’s issues—as well as payers’ expectations for return on investment (CMC 3).

Subtheme 3b: Aspirations.Related to the lessons learned, aspirations for future work to address health-related social needs included expanding how MA organizations and Medicare guidelines define what can be approved through benefits. Examples included providing support for members without plumbing or electricity (MA 10) and for those living in rural areas with limited resources (MA 12) and covering medication-related expenses for members who cannot afford them (MA 11).

DISCUSSION

MA organization and CMC leaders described their motivations, approaches, lessons learned, and aspirations to address health-related social needs among members receiving home health care. Primary motivators were related to fulfilling the organizational mission, meeting members’ needs, and enrolling and retaining new members. The variability was most pronounced in the approaches used to connect members to resources, including building internal teams, establishing CMCs, and partnering with community-based organizations to address social needs.

This analysis provides unique insights into the role of CMCs and innovative programs developed to identify and address social needs. Given their focus on postacute care, CMCs described various resources to identify social needs during that period, including information collected by home health clinicians during patient assessments (eg, OASIS) and telephone outreach to members to ask about their social needs and connect them with resources. The emergence of CMCs to address social needs on behalf of MA organizations is a novel finding, suggesting a growing role for CMCs in this work as part of managing postacute care for MA members. To our knowledge, prior research has not focused on the role of CMCs in screening for and addressing health-related social needs. Given our findings, future work could further define the size, scale, and roles of CMCs, since data are not yet available for CMCs as they are for MA organizations.

It was also notable that some MA representatives had prior experience managing Medicaid or D-SNPs, which informed how they addressed social needs among their MA members. Consistent with prior research,²⁸ participants described building internal teams or partnering with community-based organizations as approaches to address social needs. Although many participants expressed a desire to expand their programs, they also noted limitations on what they could provide while still meeting Medicare guidelines for supplemental benefits as well as the challenge of managing program costs.

Our findings highlight how MA organizations and CMCs have navigated shifting policies since the CHRONIC Care Act was signed into law in 2018. In prior interviews with MA representatives preparing for the act’s implementation, participants acknowledged that social needs influenced their members’ health but did not uniformly believe that the health plan’s role was to directly address these needs.¹⁰ Interestingly, in the present study, ambivalence regarding the role of MA organizations in addressing members’ social needs was not discussed. This suggests that MA and CMC leaders have moved from considering whether social needs are in scope to actively addressing them for members.

This shift is noteworthy and coincides with other policy changes related to social needs, including the fact that, in 2024, Medicare began reimbursing clinicians who performed health-related social needs risk assessments during annual wellness visits.²⁹ The use of this billing code for social determinants of health risk assessment (Healthcare Common Procedure Coding System code G0136) was limited in 2024 to fewer than 10% of traditional Medicare beneficiaries (235,974 assessments), and 27% of submitted services were denied payment for unclear reasons.³⁰ However, the introduction and use of these billing codes indicate that social needs are increasingly considered part of overall health by both clinicians and payers.

As noted in prior research related to social needs and SSBCIs,³¹ participants in the present study described the need to weigh both the cost and effectiveness of programs when making investment decisions. Although our study was framed in the context of postacute home health care, participants described motivations to retain and attract members in broader terms,including spouses, nursing home hall mates, and other members beyond those receiving home health care directly. Even though it did not emerge from our interviews, it is possible that MA organizations may be hesitant to invest in social needs benefits that would potentially attract members in need of costly postacute care. Participants described anticipated benefits of their social needs programs primarily in terms of avoiding readmissions (MA 1, Table 2; CMC 2, Table 3) while also noting that the return on investment for readmissions can be challenging to achieve (CMC 3, Table 4).

Our findings also provide insight at a time when recent CMS policy changes have shifted the landscape related to social needs. One example of this is the MA Value-Based Insurance Design (VBID) Model, which began in 2017 and was terminated at the end of 2025, through which CMS tested MA innovations with participating MA plans.³² Within the VBID model, MA organizations could further target benefit design based on health conditions, low-income subsidy eligibility, and area deprivation index of their neighborhood, among others, to provide additional tailored supplemental benefits (eg, lower medication costs, grocery assistance, transportation).³²

Termination of the VBID model, without a successor model to sustain or expand its innovations, has narrowed options for MA innovative benefit design. This coincides with changes in MA plan payment rates and CMS benchmarks used to calculate rebates, which have reduced payments to MA organizations nationally, thereby reducing revenue that has historically been used to offer meals, transportation, and other social needs.¹⁵ This convergence of factors likely contributed to fewer MA plans offering meals, transportation, and other social needs benefits in 2026.¹³ Overall, the future directions of MA benefits to support social needs remain uncertain.

Limitations

A limitation of this study is that, given the primary study objectives, our sample was designed to represent MA organizations broadly and nationally, rather than purposively targeting plans known to offer specific SSBCIs. Within that broader strategy, we purposively selected markets with substantial MA penetration and plans that varied in size and quality star ratings, together representing more than 62.4% of the MA market. Yet representatives from participating plans may have differed from nonparticipants in important ways. In addition, although this study asked questions about how MA organizations and CMCs approached postacute home health care, responses to questions about social needs often described broad organizational approaches rather than those specifically used for members receiving home health care. Finally, given that this was a qualitative study, our results are not intended
to be generalizable.

CONCLUSIONS

MA organizations and CMCs described widely varying motivations and approaches to addressing health-related social needs, with CMCs emerging as a novel partner in identifying and addressing these needs during postacute care. As MA continues to grow and policies shift, innovative, high-value approaches will be needed to sustain this work. Our findings can inform plan and policy makers as they consider future approaches to address health-related social needs and how they can be scaled to improve outcomes for the growing number of MA beneficiaries.

Author Affiliations: Institute for Health Research, Kaiser Permanente Colorado (CDJ), Aurora, CO; Colorado Permanente Medical Group (CDJ), Aurora, CO; Department of Medicine, University of Colorado School of Medicine (CDJ, MD), Aurora, CO; Department of Health Services, Policy and Practice, Brown University School of Public Health (EAG), Providence, RI; School of Nursing, Johns Hopkins University (JNB, KST), Baltimore, MD; Jack and Nancy Dwyer School of Nursing, Widener University (JMS), Chester, PA.

Source of Funding: This work was supported by The Commonwealth Fund.

Author Disclosures: Dr Jones reports consulting for the Carelon Home Health Panel to develop home health clinical guidelines and reports employment at Kaiser Permanente Colorado. The remaining authors report no relationships or financial interests with any entity that would pose a conflict of interest regarding the subject matter of this article.

Authorship Information: Concept and design (CDJ, MD, EAG, KST); acquisition of data (CDJ, MD, EAG); analysis and interpretation of data (CDJ, MD, EAG, JNB, JMS, KST); drafting of the manuscript (CDJ, JMS); critical revision of the manuscript for important intellectual content (CDJ, MD, EAG, JNB, JMS, KST); provision of patients or study materials (JNB); obtaining funding (EAG, KST); and administrative, technical, or logistic support (JNB).

Address Correspondence to: Christine D. Jones, MD, MSc, Kaiser Permanente Colorado Institute for Health Research, 16601 East Centretech Parkway, Aurora, CO 80011. Email: Christine.d.jones@kp.org.

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