TRENDS&ANALYSIS. What s the Best Value? Comparing Medicare HMOs and Supplemental Policies. March 2003

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1 What s the Best Value? Comparing Medicare HMOs and Supplemental Policies Introduction Many California consumers seeking coverage beyond that provided by traditional Medicare have more than one option. When seeking coverage for some of the services not offered by traditional Medicare, consumers throughout the state may choose among different Medicare supplemental (or Medigap ) policies. Additionally, in some locations particularly more populous urban areas consumers may also obtain coverage from Medicare HMOs (also known as Medicare Choice or Medicare managed care plans). A few years ago California Medicare HMOs generally covered a wide range of services and charged very little. In many locations where these plans were available, monthly premiums were low. In some cases consumers paid no monthly premium at all. More recently, however, many Medicare HMOs have increased premiums, reduced coverage (for example, by introducing higher copayments at the time of service or by imposing limits on the services covered), or both. As with all HMOs, Medicare HMOs provide coverage only if services are obtained from a limited network of hospitals and physicians. March 2003 In contrast, Medicare supplemental policies offer benefit packages that are fixed by law and have not changed in recent years. Monthly premiums can be substantial and vary considerably among the ten standardized benefit packages. Even within each identical, standardized benefit package, premiums vary substantially. Consumers covered by Medicare supplemental policies may use any provider, but may incur high out-ofpocket costs. 1 Consumers seeking coverage to augment traditional Medicare may wonder which type of coverage a Medicare HMO or a Medicare supplemental policy is likely to provide them with greater value. To answer this question, in the spring of 2002 the California HealthCare Foundation and the Center for Consumer Health Choices at Consumers Union conducted an analysis comparing the value of Medicare supplemental policies with Medicare HMOs in eight California counties. TRENDS&ANALYSIS

2 Methodology Counties were chosen to represent those with high and low populations of people aged 65 and older; high and low rates of Medicare reimbursement for medical care; and the presence or absence of Medicare HMOs. All Medicare HMO options available in the eight counties were included in the analysis. Only a select number of Medicare supplemental policies were included in the analysis because there are many policies available in most counties. We chose policies offered by companies with large market share which also had premiums close to the average premium for all supplemental policies sold in each county. Among Medicare supplemental policies, we analyzed three standardized benefit packages: Plans C, I, and J. We included Plan C because it represents a popular, basic level of coverage. Plans I and J were included because they provide drug coverage. Plan I pays 50 percent of drug expenses up to $1,250 per year after a $250 deductible. Plan J pays 50 percent of drug expenses up to $3,000 per year after a $250 deductible. Because traditional Medicare does not cover outpatient drugs, access to drug coverage often influences consumers decisions to obtain additional coverage. We were particularly interested in understanding how different approaches to obtaining drug coverage affected overall value. benefits provided. Our value estimate was based on the total value of all services received by a typical consumer (based on Medicare s reimbursement rates) minus the consumer s total out-of-pocket costs (premium plus costs incurred at the time of service). We examined premiums and analyzed value for a 65-year-old man in average health. It is important to note that the relative value of one option compared to another could differ depending on the consumer s age and health status. Our value scores are based on a market basket of services that represent a typical Medicare consumer s use of medical services. A different market basket would produce different results. For example, a person with a chronic illness who sees the doctor frequently would receive more value, in terms of services provided per premium dollar, from either a Medicare HMO or a Medicare supplemental policy than would an individual in average health who uses fewer services. The difference in value to the consumer would depend on the types of services used and the specific cost-sharing requirements (deductibles, copayments, and coinsurance) required under each option. A separate, more detailed analysis of drug coverage, What s the Best Drug Coverage? Comparing Medicare HMOs and Supplemental Policies, is available at For each Medicare HMO and each Medicare supplemental policy, we calculated an index using a mathematical model to determine the value of the 2 CALIFORNIA HEALTHCARE FOUNDATION

3 Findings The results of the analysis are summarized in Tables 1 and 2. The star ratings in the tables represent the value of the policy or managed care plan relative to the value of traditional Medicare benefits alone. A one-star rating, for example, means that the coverage offers no more financial value to consumers than traditional Medicare would provide. A five-star rating means it offers significantly more value. Table 1. Value Index Ratings for Medicare Supplemental Policies Number POLICIES COUNTY Studied 1-Star 2-Star 3-Star 4-Star 5-Star Butte Contra Costa El Dorado Humboldt Los Angeles Madera Monterey San Diego Total Percent 100% 80% 20% 0% 0% 0% Note: Analysis was conducted in spring of 2002 based on premiums for a 65-year-old man in average health. Table 2. Value Index Ratings for Medicare HMOs Number PLANS COUNTY Available 1-Star 2-Star 3-Star 4-Star 5-Star Butte Contra Costa El Dorado Humboldt Los Angeles Madera Monterey San Diego Total Percent 100% 19% 5% 43% 28% 5% Note: Analysis was conducted in spring of 2002 based on premiums for a 65-year-old man in average health. We found that: Only one-fifth of the Medicare supplemental policies we evaluated offered better value than traditional Medicare. All of these received two stars, indicating that the difference in value was slight. The rest of the policies (80 percent) received one star for financial value and offered no better value than traditional Medicare. By contrast, 76 percent of the Medicare HMOs received three, four, or five stars, offering substantially better value than traditional Medicare as well as greater value than the Medicare supplemental policies we analyzed. Nineteen percent of Medicare HMOs received one star and offered no better value than traditional Medicare. Even in 2002, a period of declining HMO benefits and rising premiums, Medicare managed care plans offered consumers in average health better financial value than Medicare supplemental policies. Taking into account both premiums and scope of coverage, managed care plans offered greater value for a 65-year-old man in average health. This finding is generally consistent with recent work funded by The Commonwealth Fund in which researchers Marsha Gold and Lori Achman analyzed national benefits data. Despite recent increases in average out-of-pocket expenditures under Medicare HMO options, they found that annual out-of-pocket expenditures would be $1,787 for an average Medicare HMO enrollee, compared to $2,861 for an average Medicare supplement Plan C enrollee and $3,058 for an average Plan J enrollee. 2 What s the Best Value?: Comparing Medicare HMOs and Supplemental Policies 3

4 In some California locations, especially large urban areas, competitive pressures make it likely that Medicare HMOs will continue to offer relatively comprehensive benefits including prescription drug coverage. In these areas, for consumers in average health, it is likely that HMOs will continue to offer greater value than Medicare supplemental policies in But in other locations, both now and for the foreseeable future, Medicare consumers will have few or no options that provide broad coverage with affordable premiums. Supplemental Policies versus HMOs When both HMOs and Medicare supplemental policies are available, should consumers always choose a Medicare HMO? Even though a Medicare HMO may offer greater financial value, there are many reasons why supplemental policies may be attractive for some consumers. In addition to comparisons of value, Medicare consumers must weigh other factors as they decide between a Medicare HMO plan and a supplemental policy. These include: The attractiveness of different coverage options varies depending on individual circumstances. For example, in some locations individuals who use expensive drugs might prefer to pay a higher premium for a Plan J supplemental policy rather than obtain coverage through a Medicare HMO plan with dollar or formulary limits on prescription drug coverage. Individuals who don t expect to use many drugs might be better off with a Medicare HMO with limited drug coverage and a lower premium. Over time, Medicare supplemental benefits may be more reliable than HMO benefits. The benefits for Medicare supplemental policies are fixed by law and are unlikely to change, whereas HMO benefits change annually and have been declining in recent years. Some consumers may be willing to pay higher premiums for Medicare supplemental policies in order to get predictable benefits through the years. With supplemental policies, consumers may obtain care from any provider and are not limited to a particular provider network. Some consumers may be willing to pay a higher premium or more coinsurance in order to choose any provider. Conclusion In 2002, HMOs offered many consumers better financial value than Medicare supplemental policies. In large metropolitan areas where several HMOs compete (and federal reimbursement rates are relatively high) HMOs offer greater value than Medicare supplemental policies. In other locations, particularly rural areas, there are few or no HMOs available and Medicare consumers do not have many choices. For many of these consumers, none of the options is particularly attractive. 4 CALIFORNIA HEALTHCARE FOUNDATION

5 Acknowledgments Analysis was conducted by the Center for Consumer Health Choices at Consumers Union. Consumers Union is an independent nonprofit testing and information organization serving only consumers. Funding was provided by the California HealthCare Foundation, an independent philanthropy committed to improving California s health care delivery and financing systems. ENDNOTES 1. U.S. General Accounting Office, Medigap insurance: Plans are widely available but have limited benefits and may have high costs, GAO , July Gold, Marsha and Lori Achman, Average out-ofpocket health care costs for Medicare Choice enrollees increase substantially in 2002, Commonwealth Fund Issue Brief, November For detailed information on the value of individual Medicare HMOs, see the 2003 Guide to California Medicare HMOs. The Guide is published annually by Consumers Union and the California HealthCare Foundation and can be found online at What s the Best Value?: Comparing Medicare HMOs and Supplemental Policies 5

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