MEDICARE ADVANTAGE 2011 DATA SPOTLIGHT

Transcription

1 MEDICARE ADVANTAGE 2011 DATA SPOTLIGHT Plan Availability and Premiums Prepared by Marsha Gld i ; and Gretchen Jacbsn, Anthny Damic, and Tricia Neuman ii OCTOBER 2010 The Centers fr Medicare and Medicaid Services (CMS) recently released infrmatin abut the Medicare Advantage plans that will be available in As f September 2010, 11.8 millin Medicare beneficiaries, nearly ne-quarter f the ttal Medicare ppulatin, are enrlled in a Medicare Advantage plan. This Data Sptlight briefly reviews recent changes made t the Medicare Advantage prgram and examines trends in plan participatin, premiums, and certain benefits. SUMMARY OF FINDINGS Overall, ur analysis f the 2011 Medicare Advantage market finds mdest changes in-stre fr 2011, althugh the experience f enrllees will vary by cunty and acrss plans. Medicare beneficiaries, n average, will be able t chse frm amng 24 Medicare Advantage plans ffered in their cunty, even after a 13 percent decline in the ttal number f Medicare Advantage plans natinwide. 2 This includes, n average, a chice f 10 HMOs, 4 lcal PPOs, 4 PFFS plans, and 5 reginal PPOs. The decline in the ttal number f plans is primarily due t a drp in the number f private fee-fr-service (PFFS) plans and the relatively new CMS rules encuraging cnslidatin f lw enrllment and duplicative plans. These rules were adpted in respnse t cnsumer cncerns abut the ability f beneficiaries t make infrmed chices when large numbers f plans were ffered. Virtually all beneficiaries will cntinue t have access t at least ne Medicare Advantage plan, and the vast majrity will have access t mre than 10 plans in Average unweighted premiums fr Medicare Advantage Prescriptin Drug (MA-PD) plans will be $51 per mnth in 2011 a $5 decrease frm As bserved in previus years, average unweighted premiums will be higher than enrllment-weighted premiums in 2011 ($43 per mnth) assuming enrllees d nt switch plans, because beneficiaries tend t chse lwer premium plans amng thse ffered in their area. Between 2010 and 2011, enrllment-weighted MA-PD premiums will increase by $2, n average, r abut 5 percent, fr plans ffered in bth 2010 and The average increase will be less if, n balance, enrllees switch t lwer premium plans. Either way, the increase in premiums fr 2011 will likely be substantially smaller than the 22 percent increase in weighted MA-PD premiums between 2009 and As we have dcumented in prir years, mnthly premiums will vary acrss plans, plan types, and markets and will be lwer in abslute terms fr HMOs than ther plan types. Because enrllees can shift plans in pen enrllment, histrically average enrllment weighted premiums drp nce these effects are factred in. In 2011, all Medicare Advantage plans will be required t limit beneficiaries ut-f-pcket expenses fr the first time, althugh in many plans, the limits are quite high. As in previus years, abut half f all MA-PDs will ffer sme cverage in the cverage gap, als knwn as the dughnut hle. This year, hwever, enrllees in plans with a gap in drug cverage will receive a 50 percent discunt frm drug manufacturers n brand-name drugs in the gap due t changes made in the health refrm law f Between 2011 and 2020, the dughnut hld will gradually be filled in due t changes enacted in the 2010 health refrm law. Plans will cntinue t vary in terms f premiums, benefits and ther key features presenting beneficiaries with pprtunities and challenges in chsing plans fr RECENT REFORMS IN LAW AND REGULATION The Medicare Advantage prgram has evlved in respnse t a number f changes enacted by Cngress and by changes in rules and requirements established by the Administratin in recent years. The Medicare Imprvements fr Patients and Prviders Act (MIPPA) f 2008, fr example, requires PFFS t have netwrks f prviders in mst cunties beginning in In 2009, CMS began encuraging the cnslidatin f lw-enrllment and duplicative Authr affiliatins: i Mathematica Plicy Research. ii Kaiser Family Fundatin The Henry J. Kaiser Family Fundatin Headquarters: 2400 Sand Hill Rad, Menl Park, CA (650) Fax: (650) Washingtn Offices and Barbara Jrdan Cnference Center: 1330 G Street, NW, Washingtn, DC (202) Fax: (202) Website: The Kaiser Family Fundatin is a nn-prfit private perating fundatin, based in Menl Park, Califrnia, dedicated t prducing and cmmunicating the best pssible analysis and infrmatin n health issues.

2 ( lk alike ) plans, leading t a cnslidatin in plans available in 2010 and CMS als increased its review f hw Medicare Advantage plans structured cst-sharing, with the gal f limiting features that culd adversely affect high-cst beneficiaries and encuraged firms t set limits n ut-f-pcket spending at $3,400 r less. In 2011, CMS established a new requirement that plans limit beneficiaries ut-f-pcket expenditures t n greater than $6,700, amng ther refrms. 5 The Affrdable Care Act (ACA) f 2010 included a number f prvisins that are als expected t affect the Medicare Advantage marketplace, althugh mst f these changes will nt begin t take effect until 2012 r later. The ACA reduces payments t plans ver time, beginning with a freeze in benchmarks (the maximum amunt Medicare pays plans in a given cunty) fr 2011 at 2010 levels. Beginning in 2012, the law phases in a reductin in benchmarks, prvides new quality bnus payments t plans, and reduces the share plans are permitted t keep when bids are belw the benchmark based n quality ratings. 6 Beginning in 2014, the ACA als will require plans t maintain a medical lss rati f at least 85 percent. This Data Sptlight examines the Medicare Advantage marketplace in 2011, in the cntext f these changes. FINDINGS Premiums and Benefits. With numerus Medicare Advantage plans available t beneficiaries thrughut the cuntry in 2011, as in 2010 (see sectin n plan chice belw), beneficiaries will have the pprtunity t cmpare and switch plans during the pen enrllment perid that runs frm Nvember 15 December 31 st. Premiums, benefits and cst-sharing requirements are imprtant plan characteristics fr beneficiaries lking t get the best pssible cverage, at the lwest pssible cst. This analysis examines trends in premiums, the Part D drug benefit and limits n ut-f-pcket spending as published by CMS in late September f 2010; it des nt, hwever, cmpare cstsharing requirements fr individual services, such as daily hspital cpayments, that culd be a majr factr in an enrllees ut-f-pcket expenses because thse data fr 2011 are nt n the data file. Mnthly Premiums. Medicare beneficiaries enrlled in Medicare Advantage plans pay the Part B premium (less any rebate prvided in the Medicare Advantage package) and ften pay an additinal mnthly premium directly t the plan fr supplemental benefits and fr prescriptin drug cverage (Part D). Amng MA-PDs, the average unweighted mnthly plan premium, including the prtin attributable t Part D, will be $51 per mnth in Average unweighted plan premiums capture the premiums beneficiaries have available acrss all plans ffered natinwide. Average premiums weighted fr enrllment are a better indicatr f the amunt beneficiaries actually pay, n average, because they give greater weight t plans with higher enrllment (see belw). Typically, unweighted premiums are higher than weighted nes, reflecting beneficiaries preferences fr lwer premium plans. (Exhibit 1) $56 $52 $51 $40 $35 $36 Exhibit 1 Unweighted Average Mnthly Premiums fr Medicare Advantage Prescriptin Drug Plans, $74 $75 $70 $65 $66 $66 $59 $56 $53 Ttal HMO Lcal PPO PFFS Reginal PPO Overall, average unweighted MA-PD NOTE: Excludes SNPs, emplyer-spnsred (i.e., grup) plans, demnstratins, HCPPs, PACE plans, and plans fr special ppulatins (e.g., Mennnites). Includes nly Medicare Advantage plans that ffer Part D benefits. The ttal includes cst plans, which are nt shwn separately, as well as plans with zer premiums. Includes MA-PDs that nw perate under sanctins that prhibit enrllment f new beneficiaries. premiums will decrease by $5 per mnth, SOURCE: MPR/KFF analysis f CMS s Landscape Files fr r 9 percent. 8 Average unweighted premiums will decline by 6 percent fr lcal PPOs and by 12 percent fr PFFS plans between 2010 and Average unweighted premiums will be lwer fr HMOs ($36 per mnth) than fr ther plan types in 2011, as in previus years. 2

3 In 2011, the average premium, weighted by 2010 enrllment, will be abut $43 per mnth, up frm $41 in 2010 a 5 percent increase fr enrllees in plans available in bth years. In cntrast, premiums increased by 22 percent between 2009 and 2010 (enrllmentweighted). If, during the pen enrllment perid, beneficiaries chse t switch frm their current plan t lwer premium plans fr 2011, enrllment-weighted premiums will likely be smewhat lwer than $43 per mnth. 9 Average weighted premiums in 2010 fr firms remaining in the market in 2011 were substantially lwer than thse departing. (Exhibit 2) Average MA-PD premiums, weighted fr 2010 enrllment, will increase by 15 $41 $43 $34 $36 Exhibit 2 Weighted Average Mnthly Premiums fr Medicare Advantage Prescriptin Drug Plans, Ttal and by Plan Type, (2011 Weighted by 2010 Enrllment; Includes Plans Available in Bth 2010 and 2011) Percent Change, 2010 t (Weighted by 2010 enrllment) $63 $65 $47 $54 $27 $25 Ttal HMOs Lcal PPOs PFFS Reginal PPOs +5% +8% +4% +15% -8% NOTE: Excludes SNPs, emplyer-spnsred (i.e., grup) plans, demnstratins, HCPPs, PACE plans, and plans fr special ppulatins (e.g., Mennnites). Includes nly Medicare Advantage plans that ffer Part D benefits. The ttal includes cst plans, which are nt shwn separately, as well as plans with zer premiums. Weighted mnthly premiums fr 2011 include MA-PDs available in bth 2010 and 2011, based n 2010 enrllment, and assume that enrllees remain in the same plan frm ne year t the next. Calculatins take int accunt plan availability by cunty f residence as well as verall availability and thus reflect service area changes. Includes MA-PDs that nw perate under sanctins that prhibit enrllment f new beneficiaries. SOURCE: MPR/KFF analysis f CMS s Landscape Files fr , CMS s 2011 Part C and D Crsswalk file, and September 2010 Enrllment file. percent fr beneficiaries in PFFS plans wh stay in the same plan, by 8 percent fr HMO enrllees, and by 4 percent fr beneficiaries in lcal PPOs, but will decline fr enrllees wh remain in the same reginal PPOs. Average enrllment weighted premiums will vary by plan type and will be lwest fr reginal PPOs and HMOs, and highest fr cst plans and lcal PPOs. (Table A1) Relative premiums by plan type are hard t interpret in the absence f infrmatin abut plans benefit structure. Fr example, ur analysis f 2010 plans shwed that reginal PPOs typically had lw premiums but higher cst sharing requirements. 10 The share f enrllees in zer-premium plans will increase slightly frm 49 percent in 2010 t 51 percent in 2011, amng plans that will be ffered in bth years, and is much higher share amng HMOs and reginal PPOs enrllees (60 and 61 percent, respectively) than PFFS plan enrllees (9 percent). The vast majrity f Medicare beneficiaries (90 percent) have access t at least ne zer-premium MA-PD, similar t previus years. Mre beneficiaries will have access t zer-premium HMOs (72 percent) than t zer-premium lcal PPOs (40 percent) and reginal PPOs (37 percent). (Exhibit 3) The share f beneficiaries with access t a zer premium PFFS plan will decrease frm 73 percent in 2009 t 26 percent in % 90% 85% 72% 69% 67% Exhibit 3 Share f Beneficiaries with Access t Medicare Advantage Prescriptin Drug Plans with N Additinal Premium, Ttal and by Plan Type, % 73% 33% 27% 26% 26% 37% 33% 29% Ttal HMO Lcal PPO PFFS Reginal PPO NOTE: Excludes SNPs, emplyer-spnsred (i.e., grup) plans, demnstratins, HCPPs, PACE plans, and plans fr special ppulatins (e.g., Mennnites). Includes nly Medicare Advantage plans that ffer Part D benefits. The ttal includes cst plans, which are nt shwn separately. Includes MA-PDs that nw perate under sanctins that prhibit enrllment f new beneficiaries. Calculatins take int accunt plan availability by cunty f residence as well as verall availability and thus reflect service area changes. SOURCE: MPR/KFF analysis f CMS s Landscape and Penetratin Files fr The level f premiums and the extent t which they change frm year t year reflect a number f factrs, accrding t plans and industry bservers, including hw much the plans are paid by Medicare, the csts f delivering care in different areas, and hw firms psitin their Medicare Advantage prducts in the market strategically, taking int accunt their view f beneficiaries preferences and firm market strength. 11 CMS has partially attributed the relatively small verall change in premiums t the new authrity given t the Secretary t negtiate with plans. 12 Such factrs are imprtant t cnsider when interpreting premiums fr ne type f plan relative t anther, and changes frm ne year t the next. Fr example, the increase in PFFS premiums may reflect bth the csts f adding netwrks as well as hw firms are psitining the PFFS prduct in the market. Similarly, firms may be hlding premiums dwn fr reginal PPOs t cmpete fr price sensitive beneficiaries, and may be allwing premiums t rise 3

4 in rder t ffer better benefits in lcal PPOs t cmpete fr the beneficiaries wh want and are willing t pay mre t have a greater chice in prviders. Prescriptin Drug Cverage. Prir t the implementatin f the Medicare drug benefit in 2006, Medicare Advantage plans were attractive t beneficiaries, in part because they prvided sme cverage f prescriptin drugs which were nt therwise cvered under Medicare. Tday, peple n Medicare can get Medicare prescriptin drug cverage either thrugh a stand-alne Part D plan r a Medicare Advantage Prescriptin Drug (MA-PD) plan. Fifty-three percent f all MA-PDs will ffer sme cverage in the cverage gap, als knwn as the Medicare Part D dughnut hle, in Thirty percent will cver generics nly (n brands) and the remaining 23 percent will cver sme brands and generics. Less than 1 percent f the plans ffered in 2011 will cver MA-PDs will ffer n cverage in the gap. (Exhibit 4) Beginning in 2011, enrllees in plans with gap in drug cverage will receive a 50 percent discunt n brand-name drugs due t changes made in the ACA, and additinal cverage f generics that will be phased in ver time. Medicare Advantage plans are smewhat mre likely than stand-alne prescriptin drug plans (PDPs) t ffer cverage in the gap. In 2011, tw-thirds f all PDPs will ffer n cverage in the gap. 13 One reasn fr this is that MA-PDs structure allws them t ffset Part D csts by any savings in Part A and B beneficiaries; such savings likely will be lwer in the future because the ACA limits increase in MA payment benchmarks. Reginal PPOs and cst plans are less likely than ther plan types t have any gap cverage. Nearly tw-thirds f all reginal PPOs have n cverage in the gap, as cmpared t 46 percent f HMOs and 41 percent f PFFS plans. Exhibit 4 Share f Medicare Advantage Prescriptin Drug Plans with Gap Cverage, by Plan Type, % 30% 13% 40% 33% 20% 47% 46% 47% 56% 3% 41% 26% 13% 62% All Plans HMO Lcal PPO PFFS Reginal PPO Sme brands and generics Generics nly N gap cverage NOTE: Excludes SNPs, emplyer-spnsred (i.e., grup) plans, demnstratins, HCPPs, PACE plans, and plans fr special ppulatins (e.g., Mennnites). Includes nly Medicare Advantage plans that ffer Part D benefits. Excludes MA-PDs under sanctin by CMS. Percentages are unweighted by enrllment. Ttals may nt add t 100% due t runding. All plans that cver brand name drugs in the cverage gap als cver generic drugs in the gap. Less than 1% f HMOs, and 0% f lcal PPOs, PFFS plans, and reginal PPOs, cver all brands and generics in the gap. SOURCE: MPR/KFF analysis f CMS s Landscape Files fr % 1% 1% 4% 15% 16% 27% 67% 35% 35% Exhibit 5 Share f Medicare Advantage Prescriptin Drug Plans with Gap Cverage, Share f plans ffering drug cverage 22% 23% 31% 30% 49% 48% 47% 47% % 73% 73% 79% 80% All brands and all generics Sme brands and generics Generics nly N gap cverage NOTE: Excludes SNPs, emplyer-spnsred (i.e., grup) plans, demnstratins, HCPPs, PACE plans, MSAs, and plans fr special ppulatins (e.g., Mennnites). Includes nly Medicare Advantage plans that ffer Part D benefits. Excludes MA-PDs under sanctin by CMS in Percentages are unweighted by enrllment. Ttals may nt add t 100% due t runding. All plans that cver brand name drugs in the cverage gap als cver generic drugs in the gap. Less than 1% f plans in 2010 and 2011 cver all brands and generics in the gap. SOURCE: MPR/KFF analysis f CMS s Landscape Files fr Since 2008, the share f all MA-PDs ffering sme cverage in the gap has remained fairly cnstant at abut 50 percent. (Exhibit 5) Cst Sharing and Limits n Out-f-Pcket Spending. Since the earliest days f the Medicare HMO prgram, private plans (nw knwn as Medicare Advantage plans) have been required t prvide Medicare benefits in a plan design that has cst-sharing that is actuarially equivalent t traditinal fee-fr-service Medicare. In recent years, hwever, there has been cncern that sme plans impse cst-sharing requirements that impse an excess ut-f-pcket burden n high-cst beneficiaries, and in respnse CMS began t scrutinize mre carefully cst-sharing requirements impsed by plans. The 2010 health refrm law included a new prvisin t prhibit Medicare Advantage plans frm having higher cst-sharing than traditinal fee-fr-service Medicare fr chemtherapy, renal dialysis, and skilled nursing care. 4

5 Since 2006 when they were first authrized, reginal PPOs have been required t have a limit n ut-f-pcket spending n cst-sharing fr benefits under Parts A and B. Fr 2010, CMS encuraged all Medicare Advantage plans t incrprate an verall annual ut-f-pcket limit f $3,400 (the 85th percentile f beneficiary spending). In 2011, fr the first time, CMS is requiring all lcal Medicare Advantage plans t include a limit n ut-f-pcket spending that cannt exceed $6,700, a figure calculated t represent the 95th percentile in csts amng beneficiaries in the traditinal fee-fr-service prgram. 14 The traditinal fee-fr-service Medicare prgram des nt include a limit n ut-f-pcket spending fr benefits cvered under Parts A and B. In 2011, all plans will have a limit n ut-fpcket spending, as cmpared t 79 percent f plans in Abut half f all plans will have limits f $3,400 r less, abut the same share as in 2010 (51 percent in 2011 and 48 percent in 2010), but fewer plans will have limits f $2500 r less (5 percent versus 9 percent) and cnsiderably mre will have higher limits. (Exhibit 6) HMOs are mre likely t set lwer limits n utf-pcket spending than ther plan types; 59 percent f HMOs will have a limit f $3,400 r less, as cmpared t 41 percent f reginal PPOs and 23 percent f PFFS plans. PFFS plans are mre likely than ther plan types t have limits in excess f $5,000 in Nearly half f all PFFS plans (46 percent) have limits between $5,001 and $6,700. (Exhibit 7) Plan Availability & Chice Medicare Advantage Plan Availability. Natinwide 2,011 Medicare Advantage plans will be ffered in Of this ttal, 80 percent will be MA-PDs. Between 2009 and 2011, the number f plans ffered natinwide has declined, reversing a steady increase in the number f plans that fllwed the enactment f the MMA in 2003 and intrductin f Part D in Ttal plans available natinwide in 2011 is dwn substantially frm the peak f 2,830 in 2009 but dwn by nly a small number natinwide relative t 2007 (2,011 in 2011 versus 2,098 in 2007). (Exhibit 8) 17 Exhibit 6 Share f Medicare Advantage Plans With Limits n Out-f-Pcket Spending, % 10% 21% 24% 25% 39% 46% 9% 5% N Limit $5001 r Mre $ $5000 $ $3400 $2500 r less NOTE: Excludes SNPs, emplyer-spnsred (i.e., grup) plans, demnstratins, HCPPs, PACE plans, MSAs, and plans fr special ppulatins (e.g., Mennnites). Excludes plans sanctined by CMS. Percentages are unweighted by enrllment. Ttals may nt add t 100% due t runding. SOURCE: MPR/KFF analysis f CMS s Landscape Files fr Exhibit 7 Share f Medicare Advantage Plans by Limits n Out-f-Pcket Spending, by Plan Type, % 22% 25% 46% 19% 53% 17% 33% 43% 5% 6% 7% 46% 31% 23% 24% 36% 41% All Plans HMOs Lcal PPO PFFS Reginal PPO $ $6700 $ $5000 $ $3400 $2500 r less NOTE: Excludes SNPs, emplyer-spnsred (i.e., grup) plans, demnstratins, HCPPs, PACE plans, MSAs, and plans fr special ppulatins (e.g., Mennnites). Excludes plans sanctined by CMS. Percentages are unweighted by enrllment. Ttals may nt add t 100% due t runding. SOURCE: MPR/KFF analysis f CMS s Landscape Files fr Exhibit 8 Distributin f Medicare Advantage Plans by Plan Type, , , ,165 1, , , ,218 1, , , Reginal PPOs PFFS Lcal PPOs HMO Other NOTE: Excludes SNPs, emplyer-spnsred (i.e., grup) plans, demnstratins, HCPPs, PACE plans, and plans fr special ppulatins (e.g., Mennnites). HMOs include Pint f Service (POS) plans. Includes MA-PDs that nw perate under sanctins that prhibit enrllment f new beneficiaries. SOURCE: MPR/KFF analysis f CMS s Landscape Files fr

6 The decline in the ttal number f Medicare Advantage plans appears t be driven in large part by the decline in the number f PFFS plans, frm 801 PFFS plans at their peak in 2008 t 220 PFFS plans in Between 2010 and 2011, the ttal number f PFFS plans will drp nearly in half frm 413 plans t 220 plans, cntinuing the cntractin in this part f the market as firms respnd t market experience and anticipate MIPPA netwrk requirements. (See bx under Market Dynamics) HMOs remain the mst cmmn type f plan in 2011, as in previus years, accunting fr 55 percent f all Medicare Advantage plans. Fewer HMOs will be ffered in 2011 than in 2010 (1,104 versus 1,218). Althugh HMOs share f the ttal Medicare Advantage plan market has fluctuated frm year t year, they have accunted fr arund half f all Medicare Advantage plans since Reginal PPOs cntinue t accunt fr a small share f the ttal Medicare Advantage market, with very little change in the number f plans ffered natinwide ver the past several years. Less than 3 percent f all plans will be reginal PPOs in 2011, as in previus years. By design, hwever, reginal PPOs serve large areas (cmprised f ne r mre states), s reginal PPOs may have mre f a presence in the market than revealed by the abslute numbers f plans (see later discussin). 19 Special Needs Plans. Special Needs Plans (SNPs) are a type f Medicare Advantage plan that is available exclusively t beneficiaries wh meet ne f the fllwing cnditins: (1) are dually eligible fr Medicare and Medicaid, knwn as dual eligibles, (2) require institutinal care, r (3) have specific chrnic cnditins. In 2011, as in previus years, the vast majrity f SNPs are HMOs. SNPs were initially authrized in the MMA with requirements that basically mirrred thse f ther Medicare Advantage plans. Since then, additinal SNP requirements have been intrduced in ways that vary by SNP plan type. 20 Market experience and these changes have led firms t make changes that have influenced the number and type f SNPs available Exhibit 9 Distributin f Special Needs Plans by Plan Type, Institutinal Chrnic r Disabling Cnditin Dual Eligibles NOTE: Excludes emplyer-spnsred (i.e., grup) plans, demnstratins, HCPPs, PACE plans, and plans fr special ppulatins (e.g., Mennnites). SOURCE: MPR/KFF analysis f CMS s Landscape Files fr In 2011, as in previus years, the majrity f SNPs ffered will be fr dual eligibles (63 percent), 22 percent fr beneficiaries with chrnic cnditins (mstly diabetes, chrnic heart failure, r cardivascular disrders), and the remainder fr beneficiaries requiring institutinal care. Fewer institutinal SNPs will be available in 2011 than in any year since (Exhibit 9) The ttal number f SNPs ffered natinwide has declined since 2008, with the largest reductin ccurring between 2009 and 2010, and nly a mdest decline between 2010 and 2011 (418 in 2010 versus 408 in 2011). Despite the verall decline in the number f SNPs, the number f SNPs fr dual eligibles increased frm 201 plans in 2010 t 256 plans in The number f dual SNPs was substantially higher in 2008 and SNPs serving dual eligibles are lcated in cunties in many states, but there are mre SNPs fr dual eligibles in heavily urbanized states where Medicare Advantage is generally is mre ppular, like Califrnia, Arizna, Minnesta, Flrida, Pennsylvania, and New Yrk, as well as Puert Ric (nt shwn). This may be due t a number f factrs, including differences in state Medicaid prgram characteristics and requirements and differences in the market demand fr plans fcusing n the dual eligible ppulatin. Dual SNPs are nt currently required t cntract with State Medicaid agencies but will be required t d s by Cntracts with states shuld help t imprve crdinatin f benefits acrss plans and state Medicaid prgrams. (Exhibit 10) 6

7 Medicare Advantage Plan Chices. Virtually all Medicare beneficiaries will have access t a Medicare Advantage plan as an alternative t the traditinal fee-fr-service Medicare prgram in This means that even if a beneficiary is in a plan that is leaving the market, there likely will be ther plans available t them. 21 (Exhibit 11) 84 percent f all Medicare beneficiaries will have access t ne r mre HMO (93 percent f beneficiaries in urban areas and 53 percent f beneficiaries in rural areas). 78 percent f all Medicare beneficiaries will have access t ne r mre lcal PPOs (82 percent in urban areas and 62 percent in rural areas). Mre than 80 percent f all beneficiaries in urban and rural areas will have access t ne r mre reginal PPOs in Nearly tw-thirds f all beneficiaries will have access t PFFS plans in 2011, despite new requirements fr these plans t have netwrks in mst cunties. Althugh the drp in verall number f Medicare Advantage plans in 2011 means beneficiaries will have fewer plans frm which t chse in 2011, their chice still is extensive. In 2011, Medicare beneficiaries will be able t chse frm amng 24 Medicare Advantage plans, n average (26 plans in urban areas and 16 plans in rural areas). This represents a drp in the average number f plans per beneficiary frm previus years, but still a cnsiderable amunt f plan chice acrss the cuntry. (Exhibit 12) The average beneficiary can chse frm 10 HMOs, 4 lcal PPOs, 4 PFFS plans, and 5 reginal PPOs in 2011 (data nt shwn). 22 Beneficiaries in cunties in which PFFS plans are nt required t have netwrks f prviders can chse frm amng 11 PFFS plans, n average, cmpared t an average f 3 plans in cunties in which PFFS plans are required t have netwrks. Almst all (88 percent) beneficiaries have access t mre than 10 Medicare Advantage plans in 2011 (data nt shwn). 23 N Dual-eligible SNP plans available Exhibit 10 Number f Special Needs Plans Available fr Beneficiaries Dually Eligible fr Medicare and Medicaid, by Cunty, available 2-5 available 6-10 available Mre than 10 available NOTE: Excludes emplyer-spnsred (i.e., grup) plans, demnstratins, HCPPs, PACE plans, and ther plans fr selected ppulatins (e.g., Mennnites). SOURCE: MPR/KFF analysis f CMS s Landscape Files fr Exhibit 11 Share f Medicare Beneficiaries with Access t One r Mre Medicare Advantage Plans, By Plan Type, and Urban/Rural Cunty, % 100% 100% 84% 93% Natinally Urban Rural 53% 82% 78% 62% 62% 60% 73% 89% 86% 87% Ttal HMO Lcal PPO PFFS Reginal PPO NOTE: Excludes SNPs, emplyer-spnsred (i.e., grup) plans, demnstratins, HCPPs, PACE plans, and plans fr special ppulatins (e.g., Mennnites). The ttal includes cst and MSA plans, which are nt shwn separately. HMOs include POS plans. Plans in the territries are included in the ttal, but nt in the urban/rural categries. Includes MA-PDs that nw perate under sanctins that prhibit enrllment f new beneficiaries. SOURCE: MPR/KFF analysis f CMS s Landscape and Penetratin Files fr Exhibit 12 Average Number f Medicare Advantage Plans Available t Beneficiaries, by Urban/Rural Cunty, Natinal Average Urban Areas Rural Areas NOTE: Excludes SNPs, emplyer-spnsred (i.e., grup) plans, demnstratins, HCPPs, PACE plans, and plans fr special ppulatins (e.g., Mennnites). Includes MA-PDs that nw perate under sanctins that prhibit enrllment f new beneficiaries. SOURCE: MPR/KFF analysis f CMS s Landscape and Penetratin Files fr

8 Availability f Plans in Cunties, by Level f Medicare Fee-fr-Service Spending. The 2010 health refrm law reduces benchmarks (maximum payments t plans) beginning in 2012, based n Medicare per capita csts in the feefr-service prgram; hw insurers will respnd t these payment refrms remains t be seen. T prvide a baseline fr analysis, we examined plan availability amng cunties in each f the fur cst quartiles defined by the law. In 2011, cnsistent with ther recent years, cunties with the highest Medicare per capita fee-fr-service csts (tp quartile) have mre Medicare Advantage plans available per beneficiary than cunties in ther quartiles. (Exhibit 13) Exhibit 13 Average Number f Medicare Advantage Plans Available t Beneficiaries, by Quartile f Fee-fr-Service per Capita Csts, Cunties in each quartile have seen a 37 cmparable reductin in the average number f plans available t beneficiaries living in cunties since 2009, with a drp, fr example, frm 53 t 30 plans in cunties in the tp quartile f fee-frservice per capita csts and frm 45 t 18 plans in the lwest per capita cst Lwest cst Secnd quartile Third quartile Highest cst cunties cunties cunties. These changes are unlikely t be NOTE: Excludes SNPs, emplyer-spnsred (i.e., grup) plans, demnstratins, HCPPs, PACE plans, and plans fr special ppulatins (e.g., Mennnites). related t changes t the Medicare Includes MA-PDs that nw perate under sanctins that prhibit enrllment f new beneficiaries. SOURCE: MPR/KFF analysis f CMS s Landscape and Penetratin Files fr Advantage prgram included in the ACA that take effect in 2012, but will be imprtant trends t track as the payment refrms are fully implemented. 53 Market Dynamics While many firms participate in Medicare Advantage, a small number f firms have histrically dminated fferings and this cntinues t be the case in (Table A2) Humana ffers mre plans natinwide (422) than any ther insurer, fllwed by all BlueCrss BlueShield (BCBS) afflilates (236 plans) and then UnitedHealthcare (152 plans). Natinal firms such as Aetna, Universal American and Cventry als ffer 50 plans r mre in Natinwide, Humana and UnitedHealthcare plans are available t 74 percent and 65 percent f beneficiaries respectively in 2011, which cmpares t 83% and 73% respectively in A BCBS affiliated plan will be available t 72 percent f beneficiaries. (Table A3) Histrically, firms have differed substantially in their Medicare Advantage strategy, resulting in firm differences in the types f plans ffered and range f markets in which they are ffered. They als have differed in hw aggressively they have priced their prducts, ver time and acrss markets. (Exhibit 14; Tables A4) Exhibit 14 Distributin f Medicare Advantage Plans in the Firms and Affiliates with the Highest Enrllment, by Plan Type, % 5% 3% 3% 2% 9% 3% 6% 11% 11% 25% 55% Ttal 82% United Healthcare 28% 35% 28% Humana 45% 41% BCBS Affiliates Organizatins with Highest Enrllment 70% NOTE Excludes SNPs, emplyer-spnsred (i.e., grup) plans, demnstratins, HCPPs, PACE plans, MSAs, and plans fr special ppulatins (e.g., Mennnites). Includes MA-PDs that nw perate under sanctins that prhibit enrllment f new beneficiaries. Percentages are unweighted by enrllment. Ttals may nt add t 100% due t runding. BCBS is Blue Crss Blue Shield affiliates and includes Wellpint BCBS plans. SOURCE: MPR / KFF analysis f CMS s Landscape Files fr % Kaiser Permanente Cst Plans Reginal PPOs PFFS Plans Lcal PPOs HMOs 8

9 UnitedHealthcare: Much mre s than sme ther firms, UnitedHealthcare relies n a mix f Medicare Advantage plan types t grw its business, including an extensive set f available HMOs and lcal PPOs, with mre limited and gegraphically targeted reginal PPOs. UnitedHealthcare reduced its PFFS fferings earlier than many ther firms. It was thus less affected by PFFS netwrk requirements than ther firms and has nw limited its PFFS fferings t nly 5 percent f beneficiaries natinwide (frm 35% in 2010). In 2011, UnitedHealthcare s plans will have premiums that are slightly lwer than thse in 2010 fr mst plan types (unweighted fr enrllment). Humana: Humana has cmpeted aggressively using a brad base f PFFS plans and reginal PPOs, cmplemented in select lcales by HMOs and lcal PPOs. In 2010, Humana cntinued with a (smewhat reduced) set f PFFS fferings, maintained reginal PPOs and built up its HMO and lcal PPO fferings in selected markets, s that their plans culd attract enrllees that might be exiting frm PFFS. In 2011, Humana appears t have cntinued with this strategy, gradually reducing its PFFS fferings while expanding ther plans in an effrt t maintain r grw enrllment. Medicare Advantage accunts fr a larger share f revenue fr Humana than fr ther firms. 24 Humana s average unweighted mnthly PFFS premium will increase by abut $10, abut the same amunt as its reginal PPO premiums will decrease. Blue Crss / Blue Shield Affiliates: These plans are perated by a variety f independent cmpanies that share the BCBS trademark. In aggregate, and prbably reflecting their cmmercial insurance base, BCBS cmpanies rely heavily n HMOs and increasingly lcal PPOs in Medicare Advantage. Cllectively, they have scaled back their PFFS fferings. Kaiser Permanente: All f Kaiser Permanente s plans are either HMOs (70 percent) r cst plans. Over time, Kaiser Permanente has had a mre stable set f plans than ther natinal firms. While their plans are gegraphically cncentrated, Kaiser Permanente plans tend t have many enrllees, making it the furth largest Medicare Advantage plan in the natin by enrllment. 25 Understanding Market Respnse t MIPPA s PFFS Netwrk Requirements MIPPA required nn-emplyer PFFS plans t develp frmal arrangements with prviders (netwrks) by 2011 unless they perate in a cunty with fewer than tw netwrk-based plans, including Health Maintenance Organizatins (HMOs), lcal Preferred Prvider Organizatins (PPOs), cst plans, r netwrk-based reginal PPOs r Medical Savings Accunt (MSA) plans. The requirement was enacted in respnse t cncerns that the ease f establishing PFFS plans ffset incentives fr firms t invest in lcal netwrks and care management that culd imprve health utcmes. In 2011, PFFS netwrk requirements apply in 2,537 f the 3,138 cunties natinwide. Cunties withut netwrk requirements are mstly rural (461 f the 601 exempted cunties in 2011). PFFS plans with netwrks will be available in mst rural cunties (78 percent) and urban cunties (87 percent). All but 3.3 millin Medicare beneficiaries natinwide live in a cunty where PFFS plans wuld be required t establish a netwrk (data nt shwn). When a PFFS plan cnverts t a netwrk plan, CMS will rll ver enrllees t the PFFS netwrk plan, unless a beneficiary requests therwise. Of the 220 PFFS plans ffered in 2010, nly 7 (including plans under sanctins) exclusively served cunties exempted frm 2011 netwrk requirements (data nt shwn). This means that almst all firms participating in PFFS in 2011 had t develp netwrks in at least part f their service area. Histrically, PFFS plans have allwed firms t ffer brad natinwide cverage even if they had n netwrks r ther Medicare Advantage fferings. The nly ther way t achieve this was thrugh reginal PPOs with lsely interpreted netwrk adequacy standards. As a result, many firms gegraphic cverage began t diminish as they departed the PFFS market, including Cventry, Health Net and Wellcare in 2010, and Aetna, CIGNA and thers in CIGNA is exiting virtually all f the individual Medicare Advantage market, with a single plan exceptin. See M. Gld Medicare s Private Plans: A Reprt Card n Medicare Advantage. Health Affairs Web Exclusive, Nvember 24, 2008; J. Blum, R. Brwn and M. Frieder An Examinatin f Medicare Private Fee-fr-Service Plans Washingtn DC: Kaiser Family Fundatin, March

10 DISCUSSION The ACA f 2010 includes a number f changes t the Medicare Advantage prgram, but mst f these changes d nt begin t take effect befre The Medicare Advantage marketplace in 2011 thus has predminantly been influenced by MIPPA requirements fr netwrks in PFFS plans, expanded SNP requirements, and new plan requirements frm CMS. After the dramatic increase in plans available t beneficiaries after the MMA, the Medicare Advantage market is cntracting and cnslidating. Yet, Medicare beneficiaries will cntinue t be able t chse frm amng dzens f Medicare Advantage plans in 2011, having, n average, 24 Medicare Advantage plans frm which t chse, as an alternative t traditinal fee-fr-service Medicare. Chsing amng many plans is likely t cntinue t be challenging fr beneficiaries, and effrts t supprt infrmed plan chices cntinue t be imprtant given variatins acrss plans in premiums, cst-sharing, extra benefits and prvider netwrks. The Medicare Advantage market is likely t remain attractive t Medicare beneficiaries in 2011, with lwer mnthly premiums than are generally available in the Medigap market. Enrllees wh chse t stay in the same plan in 2011 will experience mdest premium increases, n average, and a larger share f plans will have zer premiums. Whether due t CMS s negtiatin, the desire amng firms t cmpete aggressively (at least in the shrt run) t retain market share, r the limited time available t make dramatic changes between the signing f the ACA and the submissin f their bids t CMS fr the 2011 year, r ther reasns, premiums remain essentially stable -- despite the freeze in benchmarks used t set rates fr health plans in This situatin is quite different frm 2010 when premiums rse rapidly, thugh plans remained attractive t enrllees and enrllment cntinued t grw. It is encuraging that all plans nw have an ut-f-pcket limit, unlike the traditinal fee-fr-service prgram, but many f these limits are quite high ptentially expsing enrllees t fairly high ut-f-pcket csts, depending n the services they use and the benefit design f their plan. Previus research indicates that cst-sharing under Medicare Advantage plans has grwn cnsiderably. 26 Medicare Advantage generally prvides a lwer-premium alternative t Medigap cverage, but cst-sharing requirements are smetimes higher in Medicare Advantage plans than under traditinal Medicare. Currently, Medicare Advantage plans are mre likely than stand-alne Part D plans t prvide sme cverage in the gap, but these differences in drug cverage between MA-PD and stand-alne drug plans will narrw as gap cverage gradually phases in fr all Part D plans, as required under the ACA. In 2011, enrllees in plans with gap cverage will receive a 50 percent discunt n brand-name drugs frm the drug manufacturers, as required by ACA. Hw the Medicare Advantage market will evlve ver time remains t be seen. The HHS Actuaries predict a decline in enrllment between 2011 and 2019, and an ersin f extra benefits. Hwever, such predictins are difficult, and at the present time, Medicare Advantage appears t remain an imprtant part f the Medicare prgram. Given wide variatins in lcal market cnditins and payment refrms that will vary based n average Medicare csts per cunty, the effects f these changes are likely t vary acrss the cuntry. 1 See Centers fr Medicare and Medicaid Services press release, Medicare Advantage Premiums Fall, Enrllment Rises, Benefits Similar cmpared t 2010, September 21, The ttal includes plans with sanctins that are nt available t new enrllees. Plan cunts and premium calculatins exclude SNPs, demnstratins, Health Care Prepayment Plans (HCPPs), Prgram f All Inclusive Care fr the Elderly (PACE) plans, emplyer-spnsred plans and ther plans fr selected grups (e.g., Mennnites). 3 CMS reprts that average Medicare Advantage premiums will decrease by abut $1 per mnth in Differences in estimates may be due t the scpe f plans included (this analysis excludes plans that d nt ffer prescriptin drugs, SNPs and grup plans) and different assumptins abut enrllment decisins fr See Centers fr Medicare and Medicaid Services press release, Medicare Advantage Premiums Fall, Enrllment Rises, Benefits Similar cmpared t 2010, September 21, See M. Gld, D. Phelps, G. Jacbsn and T. Neuman, Medicare Advantage 2010 Data Sptlight: Plan Enrllment Patterns and Trends. Washingtn, DC: Kaiser Family Fundatin, June Centers fr Medicare and Medicaid Services, Medicare Prgram; Plicy and Technical Changes t the Medicare Advantage and Medicare Prescriptin Drug Benefit Prgrams; Final Rule, 75 Federal Register19677, April 15, In additin, lcal PPOs are n lnger 10

11 permitted t include a pint-f-service-like benefit, and reginal and lcal PPOs, PFFS plans, and medical saving accunts (MSAs) are prhibited frm using prir ntificatin t as a cnditin fr lwer cst-sharing, beginning in Fr mre infrmatin, see Explaining Health Refrm: Key Changes in the Medicare Advantage Prgram, Kaiser Family Fundatin, May Premium calculatins are based n Medicare Advantage plans that prvide Part D benefits, and include zer premium plans. 8 See Centers fr Medicare and Medicaid Services press release, Medicare Advantage Premiums Fall, Enrllment Rises, Benefits Similar cmpared t 2010, September 21, Enrllment is fr September 2010, the mst recent public data available at the time this analysis was cnducted. 10 M. Gld, M. Hudsn, G. Jacbsn and T. Neuman Medicare Advantage 2010 Data Sptlight: Benefits and Cst-Sharing. Washingtn DC: Kaiser Family Fundatin, February M. Gld, E. Fries Taylr, C. Fleming, D. Phelps, M. Cupples Hudsn, and M. Lewenberg, Lking at Medicare Advantage: What Has Happened Since the Launch? What Will Happen in the Future? Final reprt submitted t the U.S. Department f Health and Human Services, Assistant Secretary fr Planning and Evaluatin. Washingtn DC: Mathematica Plicy Research, Nvember See Centers fr Medicare and Medicaid Services press release, Premiums Fall, Enrllment Rises, Benefits Similar Cmpared t 2010, September 21, See J. Hadley, J.Cubanski, E. Hargrave, L. Summer, and T. Neuman, "Medicare Part D Sptlight: Part D Plan Availability in 2011 and Key Changes Since 2006", Kaiser Family Fundatin, Octber 2010; 14 CMS, Medicare Prgram; Plicy and Technical Changes t the Medicare Advantage and Medicare Prescriptin Drug Benefit Prgrams; Final Rule, 75 Federal Register 19677, April 15, Plan cunts exclude grup plans and SNPs since they are nt available t all beneficiaries fr individual enrllment. They als exclude plans with special eligibility r ther requirements including Health Care Prepayment Plans (HCPPs), Prgram fr All Inclusive Care fr the Eldery (PACE) plans, demnstratins, and plans ffered selected grups (such as Mennnites). The ttal includes plans that nw perate under sanctins that prhibit enrllment f new beneficiaries. 16 MMA refers t the Medicare Prescriptin Drug, Imprvement and Mdernizatin Act f 2004, P.L Because f the implementatin challenges f Part D in 2006, sme plan apprvals were delayed and CMS did nt release the same data they have in previus years n plan availability. We therefre shw data nly frm These cunts exclude SNPs, mst f which are HMOs. 19 Other MA plans, s called lcal plans define their service areas by aggregatins f cunties. Thugh sme PFFS plans have histrically served large areas, mst HMOs and lcal PPOs serve mre gegraphically targeted areas, ften defined by subsets f cunties within a single state r metrplitan area. 20 Fr additinal infrmatin n specific SNP requirements, see 21 Accrding t CMS, the nly exceptin is 2,300 beneficiaries in Utah and Clrad wh are currently in a Medicare Advantage plan but will nt have access t ne in Centers fr Medicare and Medicaid Service cnference call, September 21, These numbers are nt additive because the mix f plans differs acrss cunties. 23 Based n the 99 th percentile. 24 CITI Investment and Research Analysis, Humana: It Ain t Bragging If Yu Can D It 2Q10 EPS Analysis, available at 25 M. Gld, D. Phelps, T. Neuman, and G. Jacbsn, Medicare Advantage 2010 Data Sptlight: Plans and Premiums. Washingtn DC: Kaiser Family Fundatin, Nvember M. Gld, L. Achman, J. Mittler, and B. Stevens. Mnitring Medicare+Chice: What Have We Learned? Findings and Operatinal Lessns fr Medicare Advantage. Washingtn, DC: Mathematica Plicy Research, August

12 Table A1. Average Mnthly Premiums fr Medicare Advantage Prescriptin Drug Plans, Weighted by 2010 Enrllment, Average premiums, weighted by 2010 enrllment All plans HMOs Lcal PPOs PFFS Plans Reginal PPOs Cst Plans Premiums fr 2010 plans - all $41.76 $34.03 $63.72 $53.37 $27.08 $ Departing Plans, 2010 $74.98 $55.91 $ $78.36 N/A $33.10 Remaining Plans, 2010 $40.57 $33.77 $63.03 $47.02 $27.08 $ Premiums fr Remaining 2010 Plans $42.74 $36.41 $65.44 $54.14 $25.02 $ Change in premiums fr plans available in bth 2010 and 2011 $2.17 $2.64 $2.41 $7.12 -$2.06 $6.26 Share f plans with n premiums, amng plans available in bth 2010 and % 60% 25% 12% 51% 4% % 60% 21% 9% 61% 3% Change in share f plans with n premiums 2% 0% -4% -3% 11% -1% Average premiums, amng plans with premiums and available in bth 2010 and $79.10 $84.56 $83.69 $53.27 $54.87 $ $86.84 $90.30 $82.95 $59.37 $64.78 $ NOTE: Excludes SNPs, emplyer-spnsred (i.e., grup) plans, demnstratins, HCPPs, PACE plans, plans fr special ppulatins (e.g., Mennnites) and plans that d nt ffer Part D benefits. All reginal PPOs ffered in 2010 will als be ffered in Includes MA-PDs in 2011 that nw perate under sanctins that prhibit enrllment f new beneficiaries. SOURCE: MPR/KFF analysis f CMS s Landscape Files fr 2010 and 2011 and Enrllment file fr September

13 Table A2. Number f Medicare Advantage Plans Available, by Plan Type and Firm, All HMOs Lcal PPOs PFFS Plans Reginal PPOs Cst Plans Number f Plans - Ttal UnitedHealthCare Humana BCBS - Ttal Wellpint BCBS Other BCBS plans Kaiser Permanente Cventry Aetna Health Net Universal American WellCare HealthSpring WellPint (nn-bcbs) Sterling CIGNA Brav Other NOTE: Excludes SNPs, demnstratins, HCPPs, PACE plans, emplyer-spnsred (i.e., grup) plans, and plans fr special ppulatins (e.g., Mennnites). BCBS are BlueCrss BlueShield affiliates, which includes Wellpint BCBS plans. Ttal fr 2011 includes 5 MSAs. Includes MA-PDs in 2011 that nw perate under sanctins that prhibit enrllment f new beneficiaries. SOURCE: MPR/KFF analysis f CMS s Landscape Files fr and CMS s 2011 Part C and D Crsswalk file. 13

14 Table A3. Share f Medicare Beneficiaries with Access t Firms Medicare Advantage Plan Offerings, by Plan Type and Firm, Firm Any Plan HMOs Lcal PPOs PFFS Plans Reginal PPOs Cst Plans UnitedHealthcare 81% 73% 65% 46% 45% 50% 11% 7% 7% 53% 35% 5% 19% 19% 19% 0% 0% 0% Humana 84% 83% 74% 17% 22% 29% 27% 37% 46% 84% 78% 52% 60% 60% 60% 0% 0% 0% BCBS - Ttal 78% 75% 72% 38% 37% 38% 40% 42% 42% 44% 37% 3% 22% 29% 29% 2% 2% 2% Wellpint BCBS plans 32% 32% 30% 18% 16% 17% 12% 11% 12% 17% 17% 2% 18% 18% 18% 0% 0% 0% Other BCBS plans 53% 48% 48% 25% 25% 26% 28% 31% 30% 28% 20% 1% 5% 12% 11% 2% 2% 2% Kaiser Permanente 15% 15% 15% 12% 12% 12% 0% 0% 0% 0% 0% 0% 0% 0% 0% 3% 3% 3% Cventry 85% 16% 17% 10% 11% 11% 11% 10% 11% 85% 0% 0% 0% 0% 0% 0% 0% 0% Aetna 51% 35% 30% 33% 31% 30% 27% 19% 18% 28% 7% 0% 5% 0% 0% 0% 0% 0% Health Net 31% 12% 11% 11% 11% 10% 2% 2% 3% 23% 0% 0% 2% 0% 0% 0% 0% 0% Universal American 97% 97% 30% 3% 4% 4% 5% 11% 11% 97% 97% 28% 0% 0% 0% 0% 0% 0% Wellcare 76% 0% 20% 21% 0% 20% 1% 0% 0% 65% 0% 0% 0% 0% 0% 0% 0% 0% HealthSpring 10% 9% 9% 9% 7% 7% 1% 2% 2% 0% 0% 0% 0% 0% 0% 0% 0% 0% WellPint (nn-bcbs) 48% 48% 2% 0% 0% 0% 0% 0% 0% 48% 48% 2% 0% 0% 0% 0% 0% 0% Sterling 73% 48% 14% 0% 0% 0% 0% 2% 3% 73% 48% 13% 0% 0% 0% 0% 0% 0% CIGNA 54% 54% 1% 1% 1% 1% 0% 0% 0% 54% 52% 0% 0% 0% 0% 0% 0% 0% Brav 9% 8% 8% 6% 7% 8% 1% 5% 2% 6% 4% 0% 0% 0% 0% 0% 0% 0% Others 78% 82% 79% 62% 67% 64% 32% 32% 44% 48% 44% 23% 0% 14% 14% 5% 5% 5% NOTE: Excludes SNPs, demnstratins, HCPPs, PACE plans, emplyer-spnsred (i.e., grup) plans, plans fr special ppulatins (e.g., Mennnites), and plans that d nt ffer Part D benefits. BCBS are Blue Crss / Blue Shield affiliates, which includes Wellpint BCBS plans. Includes MA-PDs in 2011 that nw perate under sanctins that prhibit enrllment f new beneficiaries. SOURCE: MPR/KFF analysis f CMS s Landscape and Penetratin Files fr