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Companion Care
Payer Brief — MA SSBCI · Medicaid MCO · PACE · AAA

The Payer Case
for Companion Care.

One page. Everything your compliance, clinical, and contracting teams need to evaluate a supplemental benefit contract with Boojee Companion Care.

Request a Plan Briefing ↓ View Outcome Dashboard →
Socially isolated older adults cost Medicare an estimated $6.7 billion more per year — approximately $1,608 in extra spend per beneficiary, driven largely by avoidable hospital and skilled-nursing use (AARP Public Policy Institute / Stanford analysis, publicly reported). A companion program that reduces isolation and closes care gaps pays for itself against even a fraction of that avoidable spend — at a PMPM that is a rounding error on your medical loss ratio.

Reimbursement Pathways

Three routes to payment.
One is ready now.

Insurance does not pay for a "loneliness program" via a magic CPT code. The money flows two primary ways — here is an honest ranking of which is achievable, how, and what each requires of the plan or provider.

Most Achievable — Start Here

Pathway 1

Health-Plan Vendor Contract, Paid PMPM

Medicare Advantage supplemental benefit (SSBCI / standard) or Medicaid MCO contract. The plan pays a monthly per-member fee. This is the Papa and Pyx Health model — both contract with 70–100+ plans respectively on this basis. No CPT codes. No billing department. One contract.

  • SSBCI or supplemental benefit authorization in the plan's Evidence of Coverage
  • CY2025 SSBCI evidence bibliography (we build this with you)
  • UCLA-3 + PHQ-2/9 baseline and tracking data for the bid file
  • Care-gap closure hooks: AWV, HRA, covered screenings
  • 24/7 human escalation + crisis protocol (988)
  • HIPAA BAA + SOC 2 (in progress; BAA available)
  • General-wellness posture memo for compliance team

Sources: KFF Health News (Papa plan contracts); Pyx Health (MA / Medicaid MCO page); CMS CMS-4205-F (CY2025 SSBCI rule).

Proven for Companion Tech

Pathway 2

Medicaid HCBS / State Aging-Services Line-Item

State Medicaid waivers (1915(c)/(i)), Area Agency on Aging programs, and PACE (capitated) organizations. ElliQ operates at scale via this channel — Washington State authorized a Medicaid reimbursement code for it; NYSOFA placed 800+ units via a state-funded AAA program. PACE programs can simply include a companion under their all-inclusive capitation.

  • State-by-state approval (non-repeatable across states)
  • Alignment to a waiver service definition or aging-services grant
  • Device/service provisioning + member support
  • Outcome reporting to the state agency or AAA
  • PACE: capitation covers it — no separate code needed

Sources: Fierce Healthcare (WA Medicaid ElliQ code); NYSOFA ElliQ initiative (800+ placement); CMS PACE capitation overview. ElliQ figures are vendor/program impact-survey data, not peer-reviewed RCTs.

Phase 2 — Clinical Partner

Pathway 3

Clinician-Billed RTM / CCM Codes

A physician or QHP bills — we are the data-capture and engagement layer. RTM 98978 (CBT/adherence monitoring, 30-day device supply) or CCM 99490 (chronic care management time) are the closest fits. We do NOT bill these ourselves. This is a partnership with a provider group willing to treat our monitoring module as part of their documented care management.

  • Physician/QHP order + patient consent
  • Clinician documents time against our check-in / screening data
  • RTM: ≥16 days of data per 30 days for device-supply codes
  • CCM: 2+ chronic conditions, 20 min/month clinician time documented
  • RPM does NOT fit — loneliness is not physiologic data
  • Z60.2 / SDOH Z-codes support but do not pay on their own

Sources: ThoroughCare (RTM 2025 codes); CMS RPM rules; APTA RTM advisory. RTM device status for a general-wellness companion is unsettled — pursue via a clinical partner willing to own the billing side.

What We Deliver

The artifacts your plan's
bid file actually needs.

We do not sell a vague "wellness engagement program." We deliver specific evidence artifacts that map to specific requirements in the SSBCI rule and the Stars/HEDIS quality story.

1
Validated Loneliness + Mood Screening (Pre/Post Delta)
UCLA-3 at intake and on rolling schedule (the same instrument Pyx Health uses at onboarding). PHQ-2 → PHQ-9 and GAD-7 paired in every outcome cycle. Pre/post deltas computed per member and reported to the plan in the format the CMS SSBCI evidence bibliography requires. All instruments are public domain — no license fees that inflate your per-member cost.
SSBCI Evidence
2
Care-Gap Closure — AWV / HRA / Covered Screenings
Proactive nudges to members for Annual Wellness Visit, Health Risk Assessment, and preventive screenings — with completion tracking reported back to the plan. This is the core mechanism Papa uses to justify its plan contracts and Star rating story. We build the same lever into every engagement cycle.
Stars / HEDIS
3
Engagement Telemetry — Activation, Frequency, Retention
Activation rate, sustained daily/weekly check-in rate, and retention metrics — the engagement proof your plan's value-based contract requires. Companion-initiated daily check-ins maintain high interaction frequency (the ElliQ NYSOFA program reported ~30 interactions/day, 6 days/week as its engagement benchmark — cited as program impact-survey data, not our result).
Engagement Proof
4
24/7 Human Escalation + Crisis Protocol (988)
The hard payer procurement requirement that many vendors fail. Any conversation containing risk language, or a PHQ-9 item 9 score above zero, triggers immediate escalation to a human and delivery of 988 Suicide & Crisis Lifeline resources. Every escalation is documented with timestamp, severity, reason, and resolution — the audit trail your compliance team will ask for.
Crisis Protocol
5
SDOH / Z-Code Capture (Z60.2 + Z55–Z65)
Structured detection of social-determinant risk — living alone, food insecurity, transport barriers, housing — surfaced in conversation and passed to the plan for clinician documentation. Z60.2 ("Problems related to living alone") and the Z55–Z65 family enriches your risk capture and HEDIS picture. Z-codes support claims but are not a payment source on their own; they are captured here as a plan intelligence asset.
SDOH Risk Intel
6
Monthly / Quarterly Outcome Report — Payer Format
The standing deliverable: members enrolled and retained, UCLA-3 and PHQ-9 pre/post deltas, care-gap actions triggered and completed, escalations raised and resolved, SDOH flags captured. Formatted as the exhibit you attach to your SSBCI evidence bibliography and quarterly plan review. The caregiver dashboard shows a live version of this artifact.
Payer Report

Compliance Posture

What we have, what's in
progress, and what's not.

We are a pilot-stage program. We tell you exactly where we are on every compliance item — because your contracts team will ask and fabricating readiness is worse than being honest about the roadmap.

HIPAA-Eligible Infrastructure

Lambda, DynamoDB, Polly, and Bedrock are AWS HIPAA-eligible services covered under Amazon's BAA program. We say "HIPAA-eligible" not "HIPAA compliant" — compliance is a program, not a product feature. A signed AWS BAA must be executed before real PHI is stored; we have not done this for production yet. BAA available on health-plan contracts.

Infrastructure ready — BAA to execute

Crisis Protocol — 988 + Human Escalation

PHQ-9 item 9 above zero or risk language in conversation triggers immediate escalation: 988 Suicide & Crisis Lifeline delivered to the member, CRISIS-severity alert raised to the caregiver/plan dashboard, full audit log entry created. This is a hard design requirement, not a configurable option.

Live in care engine

Consent-First Architecture

The API gate refuses all health data writes without an explicit consent record on file. Consent is timestamped, scoped, and revocable. A right-to-erasure / purge workflow is on the production roadmap (consent withdrawal currently records the withdrawal but does not retroactively delete prior data).

Live — purge workflow roadmap

SOC 2 Type I

SOC 2 Type I is on our roadmap for the first payer contract. We do not have it yet. Our AWS architecture — scoped IAM roles, DynamoDB encryption at rest, append-only audit logging, HIPAA-eligible services — is designed to pass Type I controls. We will obtain Type I before going live with real member data at plan scale.

Roadmap — before plan scale

FDA General-Wellness / Non-Device Posture

We operate in the FDA general-wellness lane per the agency's January 6, 2026 guidance. We screen, track, engage, and route to humans — we do not diagnose, treat, or name conditions as findings. This keeps us non-device and satisfies the payer's crisis-escalation requirement simultaneously. A general-wellness posture memo is available for your compliance team on request.

Posture memo available on request

Clinical Governance (Named Advisor)

A named clinical advisor (MD or LCSW) governing screening thresholds, escalation rules, and outcome report methodology is a hard payer procurement requirement. We are actively recruiting this role. We will not claim it is filled until it is. This is the one item your compliance team will rightfully flag as a gap today — it is in progress.

In recruitment — required before plan contract
Honesty note on evidence: We cite sector evidence (AARP $6.7B / $1,608 isolation cost; ElliQ 95%/80% self-reported improvement; Pyx Health 2.5:1 claims ROI) as vendor/program impact-survey data and publicly reported estimates — not peer-reviewed RCTs and not our results. We do not yet have enrolled members. Our first pilot will generate the first real outcome data for this program. This is exactly the honesty posture CMS's SSBCI evidence rule rewards — plans get in trouble when they fabricate outcomes, not when they accurately describe what their evidence demonstrates.

Request a Plan Briefing

Let's build the PMPM case
for your plan's population.

We'll walk your contracting and clinical teams through the SSBCI evidence package, PMPM model, compliance posture, and outcome reporting cadence. Preparation time for a first call: two business days.

Request a Plan Briefing

For Medicare Advantage plans, Medicaid MCOs, AAAs, and PACE programs. Tell us about your population and we will come prepared.

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View the caregiver dashboard: Outcome Dashboard →

Full compliance & evidence status: Trust & Evidence Center →