Restructuring Medicare Cost Sharing: Options and Implications
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1 Restructuring Medicare Cost Sharing: Options and Implications Alliance for Health Reform Washington, D.C. Juliette Cubanski, Ph.D. Associate Director, Program on Medicare Policy Kaiser Family Foundation July 22, 2013 Exhibit 1 Recent proposals include three main approaches to changing Medicare cost sharing 1) Revise the cost sharing features of traditional Medicare Simplify deductibles and cost sharing Add an out of pocket spending maximum 2) Restrict and/or discourage supplemental coverage (Medigap and/or employer sponsored retiree plans) Prohibit first dollar Medigap coverage Supplemental coverage premium surcharge 3) Restructure Medicare cost sharing AND prohibit/restrict supplemental coverage 1
2 Exhibit 2 Two examples of restructured Medicare cost sharing CBO (March 2011) Unified $550 Part A and B deductible 20% coinsurance on all Medicare services $5,500 out of pocket (OOP) spending maximum MedPAC (June 2012) Unified Part A and B deductible Copayments that vary by service and provider; e.g., $20 for primary care visit; $40 for specialist visit; $750 copay per hospital admission Out of pocket spending maximum Gives HHS Secretary authority to make value based changes to the benefit design Exhibit 3 Under the CBO design, a small share of Medicare beneficiaries would pay less than under current law; most would face higher costs CBO Design: $550 deductible, 20% coinsurance for all services, $5,500 out of pocket maximum in 2013 reduction 5% No/ nominal change Increase 71% Traditional Medicare beneficiaries, 2013: 40.8 million About 2 million beneficiaries (5%) would see savings ($1,570 on average) About 29 million beneficiaries (71%) would see costs increase ($180 on average) For those using physician services but no inpatient care, the deductible would more than triple compared to current law ($147 to $550) NOTES: Out of pocket costs includes premiums and cost sharing requirements. No/nominal change group includes beneficiaries with changes in spending no more than ±$25. SOURCE: Kaiser Family Foundation, Restructuring Medicare s Benefit Design: Implications for Beneficiaries and, November
3 Exhibit 4 A small share would reach a $5,000 OOP maximum in any given year, but a larger share would reach the limit over a longer period of time Liabilities above OOP maximum one or more times 11% 14% 17% 25% 27% 30% 32% 7% Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 NOTES: Cohort includes beneficiaries who died during the 10 year period. Analysis assumed current cost sharing requirements and no changes in supplemental coverage. The $5,000 maximum is expressed in 2009 dollars and indexed for projected growth in average spending per traditional Medicare beneficiary. SOURCE: Actuarial Research Corporation analysis for MedPAC and the Kaiser Family Foundation, June Exhibit 5 Under the CBO design, Medicare spending would decrease, but costs would be shifted onto beneficiaries and other payers CBO Design: $550 deductible, 20% coinsurance for all services, $5,500 out of pocket maximum in 2013 SPENDING Federal DECREASES $4.2 $0.1 Total = $4.3 billion decrease Medicare Medicaid (Federal and State) SPENDING Other INCREASES $2.3 Beneficiaries $1.3 Employers and other supplemental insurers Total = $3.6 billion increase NET CHANGE Net $0.7 Total = $0.7 billion decrease NOTES: Other supplemental insurers includes Veterans Administration, Indian Health Service and other federal sources; other state and local sources; worker s compensation; and other unclassified sources. SOURCE: Kaiser Family Foundation, Restructuring Medicare s Benefit Design: Implications for Beneficiaries and, November
4 Exhibit 6 Approaches to prohibiting and/or discouraging supplemental coverage CBO (March 2011) Prohibits first dollar Medigap coverage: Medigap policies not allowed to cover first $550 in cost sharing for Part A/B services and limited to covering half of the next $4,950, but would cover any remaining cost sharing liability MedPAC (June 2012) Imposes an additional charge on the premiums of supplemental insurance policies both Medigap and employer sponsored retiree plans President s FY2014 Budget Imposes a Part B premium surcharge for new Medicare beneficiaries with firstdollar or near first dollar Medigap coverage, beginning in 2017 Exhibit 7 Prohibiting first dollar Medigap coverage would reduce costs for many Medigap enrollees, but one in five expected to pay more Plans not allowed to cover first $550 in cost sharing for Part A/B services and limited to covering half of the next $4,950, but would cover any remaining obligations Share of Medigap policyholders expected to see costs decline (due to lower Medigap premiums) Share of Medigap policyholders expected to see costs rise (because cost sharing increases would be greater than expected premium reductions) 79% Includes a disproportionate share of those in relatively poor health and those with modest incomes SOURCE: Kaiser Family Foundation, Medigap Reforms: Potential Effects of Benefit Restrictions on Medicare and Beneficiary Costs, July
5 Exhibit 8 Medigap restrictions would have different geographic implications Percent of Medicare Beneficiaries with Medigap by State, All Plans, % National Average = 23% 35% 30% 51% 16% 26% 12% 50% 38% 49% 27% 47% 13% 33% 15% 29% 17% 17% N/A 46% 27% 25% 16% 13% 29% 25% 25% 20% 17% 2% 28% 30% 20% 27% 26% DC 9% 0% 15% (6 states, DC) 16% 20% (12 states) 25% (13 states) 26% 30% (10 states) 31% 40% More than 40% (3 states) (5 states) NOTES: Analysis excludes California, as the majority of health insurers do not report their data to the NAIC. Analysis includes standardized plans A N, policies existing prior to federal standardization, plans in Massachusetts, Minnesota, and Wisconsin that are not part of the federal standardization program, and plans that identified as Medicare Select; excludes plans where number of covered lives was less than 20. Number of Medigap policyholders as of December 31, 2010, as reported in the NAIC data. SOURCE: K. Desmond, T. Rice, and Kaiser Family Foundation analysis of 2010 National Association of Insurance Commissioners (NAIC) Medicare Supplement data. Kaiser Family foundation and Mathematica Policy Research analysis of CMS State/County Market Penetration Files. Exhibit 9 A surcharge on Medigap and retiree coverage could affect 6 out of 10 beneficiaries in traditional Medicare Employer Sponsored 41% Medicare Advantage 25% Traditional Medicare 75% Medigap Medicaid Other No Supplemental Coverage, 17% Public/Private 1% Total Number of Beneficiaries, 2009: 47.2 Million Beneficiaries with Traditional Medicare, 2009: 35.4 Million NOTES: Numbers do not sum due to rounding. Some Medicare beneficiaries have more than once source of coverage during the year; for example, 2% of all Medicare beneficiaries had both Medicare Advantage and Medigap in Supplemental Coverage was assigned in the following order: 1) Medicare Advantage, 2) Medicaid, 3) Employer, 4) Medigap, 5) Other public/private coverage, 6) No supplemental coverage; individuals with more than one source of coverage were assigned to the category that appears highest in the ordering. SOURCE: Kaiser Family Foundation analysis of the Centers for Medicare & Medicaid Services Medicare Current Beneficiary 2009 Cost and Use file. 5
6 Exhibit 10 Most recent proposals combine restructured cost sharing with changes to supplemental coverage CBO (March 2011) Combines restructured cost sharing with a prohibition on first dollar Medigap coverage MedPAC (June 2012) Combines restructured cost sharing with a premium surcharge on supplemental coverage (both Medigap and employer sponsored retiree plans) New(er) features Value based cost sharing Income related cost sharing amounts (e.g., higher out of pocket maximum for higher income beneficiaries) Enhanced financial protections for low income beneficiaries Exhibit 11 Under the CBO design, about a quarter of beneficiaries would spend less, but half would spend more Medicare: $550 deductible, 20% coinsurance for all services, $5,500 out of pocket maximum Medigap: Plans prohibited from covering the deductible and more than half of the 20% coinsurance No/ nominal change 26% reduction Increase 50% Traditional Medicare beneficiaries, 2013: 40.8 million Nearly a quarter expected to see costs decline More than under restructured cost sharing alone, due in part to drop in Medigap and Part B premiums Half of beneficiaries expected to see cost increases, including an estimated six million beneficiaries who would see costs increase by $250 or more Fewer than under restructured cost sharing alone, but Medigap restrictions would expose them to more cost sharing NOTES: Out of pocket costs includes premiums and cost sharing requirements. No/nominal change group includes beneficiaries with changes in spending no more than ±$25. SOURCE: Actuarial Research Corporation analysis for the Kaiser Family Foundation. 6
7 Exhibit 12 Key Takeaways Not all Medicare cost sharing restructuring/supplemental coverage proposals are alike; effects would vary depending on design details If designed to achieve Medicare savings, cost sharing restructuring proposals would create winners and losers among Medicare beneficiaries in any given year Restructured cost sharing: Most beneficiaries would pay more with a unified deductible and uniform coinsurance than they would under current law A small share would benefit from the out of pocket spending maximum in any given year; a larger share over a multiple year period Supplemental coverage restrictions: Achieves Medicare savings by increasing enrollees exposure to Medicare cost sharing obligations and/or by collecting premium surcharges Increased exposure to cost sharing may lead to reduced use of both necessary and unnecessary care producing efficiency gains from the latter, but potential health complications and additional costs from the former Attention is needed to avoid shifting excessive costs onto beneficiaries with modest incomes 7
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