Hispanic nurse explaining medication senior woman

High-needs eligibility criteria within the Realizing Equity, Access, and Community Health Accountable Care Organization (ACO REACH) program might restrict some beneficiaries from receiving the care they need, according to new research.

The researchers analyzed how more than 600,000 Medicare beneficiaries qualify for high-needs designation under ACO REACH. Currently, qualifications are based on whether a beneficiary has any mobility-impairing conditions or uses the assistance of durable medical equipment. But another way to determine high-needs eligibility is based on the Independence at Home (IAH) qualification, which uses a person’s ability to perform activities of daily living as the measurable factor. Almost 300,000 people qualify for high needs under IAH. And though many of these may still be eligible, ACO REACH could overlook a large population that would qualify under other eligibility standards, according to the study.

“IAH qualifying criteria should be added to the set of [high need] criteria resolving an equity and access issue, including frail, high-need Medicare beneficiaries equally as high needs as those currently included,” the researchers advised.

The program is slated for changes in 2024, and high-needs eligibility criteria are set to be modified. Next year, beneficiaries with at least 90 days of home health service utilization within a given year will qualify for high needs. Still, these new criteria do not consider beneficiaries’ ability to perform activities of daily living. About a quarter of people who qualify for high needs under IAH will still not be eligible under these new criteria, according to the study.

Lawmakers also have shared health equity-related concerns regarding REACH. Last year, Sen. Elizabeth Warren (D-MA) and Rep. Pramila Jayapal (D-WA) urged the Centers for Medicare & Medicaid Services to scrap the program entirely, or at least act to address fraud and waste concerns held by program stakeholders.

The study was published in the Journal of the American Geriatrics Society.