Medicare Cost Sharing and Supplemental Coverage

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1 Medicare Cost Sharing and Supplemental Coverage

2 Topics to be Discussed Medicare costs to beneficiaries Review Medicare premiums and cost sharing Background on Medicare beneficiary income Current role of supplemental coverage Concerns about impact of supplemental coverage on Medicare program spending Policy options

3 Medicare Premiums and Cost Sharing: Background

4 Medicare Premiums, 2015 Coverage Part A Most beneficiaries Part A Beneficiaries lacking 40 quarters FICA contributions Part B standard Income-related premium may also apply Part D Income-related premium may also apply Medicare Advantage Monthly Premium $0 $ $ varies by plan choice varies by plan choice* Notes: A late enrollment penalty applies to the premium for beneficiaries who do not enroll when first eligible. Assistance in paying premiums is available to certain low-income beneficiaries. *The weighted average premium (assuming no plan switching from 2014) for MA plans that also cover Part D benefits is $41. See Kaiser Family Foundation, Medicare Advantage 2015 Data Spotlight: Overview of Plan Changes, December data-spotlight-overview-of-plan-changes/ 4

5 Income-Related Part B Premium, 2015 File individual tax return Annual income for 2013 File joint tax return File joint tax return Monthly Part B in 2015 % of standard premium % of Part B costs $85,000 or less $170,000 or less $ % 25% above $85,000 up to $107,000 above $170,000 up to $214,000 $ % 35% above $107,000 up to $160,000 above $214,000 up to $320,000 $ % 50% above $160,000 up to $214,000 above $320,000 up to $428,000 $ % 65% above $214,000 above $428,000 $ % 80% Separate thresholds, not shown here, apply to married individuals filing separate returns. Less than 5% of beneficiaries currently pay an income-related premium. Income related premiums began in 2007; original thresholds were indexed to the CPI. The Affordable Care Act eliminated indexing for

6 Medicare Part A Cost Sharing, 2015 Services Hospital Skilled Nursing Facility Home Health Hospice Beneficiary liability $1,260 deductible per benefit period $0 for the first 60 days of each benefit period $315 per day for days of each benefit period $630 per "lifetime reserve day" after day 90 of each benefit period (up to a maximum of 60 days over a lifetime $0 for the first 20 days each benefit period $ per day for days each benefit period Full costs after day 100 in a benefit period $0 for Medicare-approved services 20% of the Medicare-approved amount for durable medical equipment $0 for hospice care Up to $5 per prescription for outpatient prescription drugs for pain and symptom management 5% of the Medicare-approved amount for inpatient respite care Source: Medicare.gov

7 Medicare Part B Cost Sharing, 2015 Services Deductible Medical & most other services, (incudes mental health services and Part B drugs provided in physician s office) Outpatient Hospital (includes Part B drugs provided in outpatient hospital setting) Home Health Clinical Lab Beneficiary liability $147 per year 20% of the Medicare-approved amount Coinsurance (for doctor services) or a copayment amount for most outpatient hospital services that varies by service to phase down to 20% over time. The copayment for a single service can't be more than the amount of the inpatient hospital deductible. $0 for Medicare-approved services $0 for Medicare-approved services Source: Medicare.gov

8 Cost Sharing in MA and Part D Plans Cost sharing varies by plan MA plans must include an out-of-pocket limit of no more than $6,700 for Parts A and B benefits Part D plans must also include a separate out-of-pocket limit (up to $4,700 for 2015) For 2015, out-of-pocket limits for MA plans that also cover Part D benefits average $5,037; 9 percent of plans have a limit of $3,400 or less; half have limits above $5,000* *Kaiser Family Foundation, Medicare Advantage 2015 Data Spotlight: Overview of Plan Changes, December

9 Cost-Sharing Liability for Medicare Fee-for- Service Beneficiaries, 2008 $5,000 to $9,999, 4% $10,000 or more, 2% $2,000 to $4,999, 16% $1 to $499, 42% $500 to $1,999, 36% Note: The amounts reflect Medicare beneficiaries liability but do not reflect what Medicare beneficiaries actually paid out of pocket because most beneficiaries have supplemental coverage that covers all or some of their Medicare cost sharing. Source: Medicare Payment Advisory Commission, Report to the Congress: Aligning Incentives in Medicare, June 2010, p. 54, 9 available at

10 Background: Income and Health Expenditures of Medicare Beneficiaries

11 Household Income of the Elderly US Median Household Income, 2013, by Age All Households Age <65 years Age 65 years and older $51,939 $58,448 $35,611 Source: US Census Bureau, Income, and Poverty in the United States, 2013, September 2014, Table 1. Income distribution of the population age 65 and older, as percent of poverty, % 9.0% 34.0% 25.6% 34.6% < 200% Percent of poverty: <100% % % 400% Source: Federal Interagency Forum on Aging- Related Statistics, Older Americans 2012: Key Indicators of Well-Being, June 2012, Table 8a.

12 Source: Federal Interagency Forum on Aging-Related Statistics, Older Americans 2012: Key Indicators of Well- Being, June 2012, p. 15

13 Analyses of Medicare Beneficiary Income Note: For married couples, per capita income is estimated by equally diving household income. Source: Kaiser Family Foundation/Urban Institute analysis, For interactive charts, see

14 Median Out-of-Pocket Health Care Spending As a Percent of Income Among Medicare Beneficiaries, by Demographic Characteristics, % 21.4% 20.2% 17.5% 19.6% 17.9% 15.3% 12.7% 13.6% 11.8% 14.8% 15.7% 15.2% 8.0% OVERALL MEDIAN < Excellent Very good Age Good Fair Poor <100% % Health Status % 400%+ % of Federal Poverty Level NOTES: Includes Medicare Advantage enrollees, and includes institutionalized and non-institutionalized beneficiaries. The 2009 poverty guidelines were $10,830/individual and $14,570/couple. Out-of-pocket spending includes premiums. SOURCE: Kaiser Family Foundation analysis of CMS Medicare Current Beneficiary Survey Cost and Use File, 2009.

15

16 Supplemental Coverage

17 Sources of supplemental coverage among noninstitutionalized Medicare beneficiaries, 2010 None, 10.4% Medigap, 21.6% Medicare managed care, 23.8% Employer sponsored, 29.4% Other public, 1.0% Medicaid, 13.8% For more information on Medicaid assistance to low income beneficiaries for premiums and cost sharing see Medicare Savings Programs Source: MedPAC analysis of Medicare Current Beneficiary Survey, Cost and Use file, From: A Data Book: Health Care Spending and the Medicare Program, June 2014, Chart 3-1.

18 What is Medigap? Optional private health insurance available for purchase by individual beneficiaries (or groups) to cover some or all Medicare cost sharing Federal law requires plans to meet standards set by the National Association of Insurance Commissioners (NAIC) under model state law Beneficiaries may choose among 10 standardized benefit plans Other standards include: 6-month guaranteed issue period at age 65 Minimum medical loss ratio of 65% for individual coverage/75% group For overview of Medigap, including history of federal legislation see Congressional Research Service, Medigap: A Primer. January 3, 2014 version available at green-book/chapter-2-medicare/medicare-congressional-research-service-crs-reports

19 Currently Available Standardized Medigap Plans Plan F has 53% of Medigap enrollees; another 13% in Plan C Benefits A B C D F* G K L M N Part A Coinsurance Part B Coinsurance 50% 75% ** Blood 50% 75% Part A Hospice 50% 75% SNF Coinsurance 50% 75% Part A Deductible 50% 75% 50% Part B Deductible Part B Excess Charges Foreign Travel Emergency * Plan F also offers a high-deductible plan. If a beneficiary chooses this option, she must pay for Medicare-covered costs (coinsurance, copayments, deductibles) up to the deductible amount of $2,180 in 2015 before the Medigap policy pays anything. **Plan N pays 100 percent of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that do not result in an inpatient admission. *** Plans K and L have out-of-pocket limits for 2015 of $4,940 and $2,470 respectively. Sources: Center for Medicare & Medicaid Services, Medicare & You 2015, Section 6, available at Enrollment distribution from America s Health Insurance Plans, data for Medigap-Coverage-Enroll

20 Exhibit 20 Distribution of Monthly Medigap Premiums, Plans A J, th percentile $169 $177 $187 $175 $181 $169 $186 $196 $195 National average premium $ th percentile A B C D E F G H I J 10 th percentile $89 $130 $161 $149 $145 $155 $140 $149 $151 $ th percentile $168 $198 $213 $205 $206 $197 $195 $208 $215 $211 NOTE: Analysis excludes California, as the majority of health insurers do not report their data to the NAIC. Analysis includes standardized plans A-J; excludes plans K-L because of the small number of policyholders enrolled in these plans; excludes policies existing prior to federal standardization; excludes plans in Massachusetts, Minnesota, and Wisconsin; excludes plans that identified as Medicare Select; excludes plans where number of covered lives was less than 20. SOURCE: K. Desmond, T. Rice, and Kaiser Family Foundation analysis of National Association of Insurance Commissioners (NAIC) Medicare Supplement data. See Medigap Reform: Setting the Context for understanding Recent Proposals, January 2014, available at

21 Does First-Dollar Supplemental Coverage Affect Medicare Spending? Concern that prevalence of first-dollar Medigap coverage contributes to higher Medicare spending View that beneficiaries with no skin in the game are insensitive to cost of care and may over-use services Is higher spending due to Medigap ( insurance effect ) or are individuals with higher health needs more likely to obtain Medigap ( selection effect )? Literature shows that imposing cost sharing lowers use of services, but disagreement as to health effects Some individuals may forgo needed care Lower-income individuals more sensitive to cost sharing MedPAC summary of literature (June 2012 report) 21

22 Total = $15,971 Total = $9,263 22

23 Medigap in the Affordable Care Act Secretary directed to request that NAIC update the standards for Plans C and F to include nominal cost sharing for physician services based on peer reviewed literature and experience with integrated health plans In December 2012 response, NAIC recommends no change to these plans Cites lack of directly relevant literature, concern about discouraging use of needed care, and availability of new plans M and N 23

24 Policy Options for Limiting First-Dollar Coverage/Modifying Medicare Cost-Sharing Source Change to Medigap Change to Medicare Savings (over 10 yrs) National Commission on Fiscal Responsibility and Reform (Simpson-Bowles) December 2010 CBO Options November 2014 The President s Budget for FY 2016 MedPAC June th Congress: S. 11 (Corker/Alexander) No coverage for the first $500 Maximum 50% coverage of the next $5,000 (Effective $3,000 out-of-pocket maximum) No coverage for the first $650 Maximum 50% coverage of the next $5,850 (Effective $3,575 out-of-pocket maximum) Unchanged Additional charge on supplemental insurance No new Medigap enrollees after 2016; prohibit Medigap coverage of certain out-ofpocket expenses (deductible, 50% cost sharing) Replace existing cost-sharing rules with universal deductible, single coinsurance rate, and catastrophic cap for Medicare Part A and Part B. None in this estimate, but could be paired with options to restructure Medicare cost sharing for greater savings ($111 billion total) Surcharge (~30% of Part B premium) on new enrollees who purchase Medigap with particularly low cost sharing, beginning in Redesign Medicare to include out-of-pocket cap; Parts A/B deductible(s); copayments that may vary by type of service/ provider; give Secretary authority to link cost sharing to evidence of service value. Simplify Medicare cost-sharing to combine Parts A and B deductibles and add catastrophic cap $38 Billion $53 billion $4 billion Not available Not available 24

25 Considerations in Limiting Medigap Are Medigap changes in context of broader Medicare cost-sharing restructuring, e.g., adding out-of-pocket cap? Would changes apply to new beneficiaries (less savings) or extend to everyone? What happens to retiree health plans? What are implications for beneficiaries of less predictable health care spending? What are distributional effects on beneficiaries? (health status, income) 25

26 Questions? 26

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