Medicare Cost Sharing and Supplemental Coverage Lisa Potetz, MPP Health Policy Alternatives, Inc. National Health Policy Forum Friday, February 8, 2013
Topics to be Discussed Medicare costs to beneficiaries Review Medicare premiums and cost sharing Background on Medicare beneficiary income Health care costs as share of beneficiary income Current role of supplemental coverage Concerns about impact of supplemental coverage on health costs Policy options under discussion
Medicare Premiums and Cost Sharing: Background
Medicare Premiums, 2013 Coverage Part A Most beneficiaries Part A Beneficiaries lacking 40 quarters FICA contributions Part B standard Excludes income-related premium Part D Monthly Premium $0 $441.00 $104.90 varies by plan choice 4
Income-Related Part B Premium File individual tax return Annual income for 2011 File joint tax return File joint tax return Monthly Part B in 2013 % of standard premium % of Part B costs $85,000 or less $170,000 or less $104.90 100% 25% above $85,000 up to $107,000 above $170,000 up to $214,000 $146.90 140% 35% above $107,000 up to $160,000 above $214,000 up to $320,000 $209.80 200% 50% above $160,000 up to $214,000 above $320,000 up to $428,000 $272.70 260% 65% above $214,000 above $428,000 $335.70 320% 80% Income related premiums began in 2007; original thresholds were indexed to the CPI. The Affordable Care Act eliminated indexing for 2011-2019. In 2010, 5% of beneficiaries paid an income-related premium; projected to grow to 14% by 2019. (From Kaiser Family Foundation, Income-Relating Medicare Part B and Part D Premiums: How Many Medicare Beneficiaries Will Be Affected? December 2010) 5
Medicare Part A Cost Sharing, 2013 Services Hospital Skilled Nursing Facility Home Health Durable Medical Equipment Hospice Beneficiary liability $1,184 deductible per benefit period $0 for the first 60 days of each benefit period $296 per day for days 61 90 of each benefit period $592 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 $148 per day for days 21 100 each benefit period Full costs after day 100 in a benefit period $0 for Medicare-approved services 20% of the Medicare-approved amount $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, Medicare costsu.s. Department of Health and Human Services, available at www.medicare.gov/cost/. 6
Medicare Part B Cost Sharing, 2013 Services Deductible Medical & other services, (incudes Part B drugs provided in physician s office) Outpatient Hospital (includes Part B drugs provided in outpatient hospital setting) Mental Health Home Health Durable Medical Equipment 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. 40% of the Medicare-approved amount for most outpatient mental health care $0 for Medicare-approved services 20% of the Medicare-approved amount $0 for Medicare-approved services Source: Medicare.gov, "2012 Medicare Costs," U.S. Department of Health and Human Services, available at www.medicare.gov/cost/. 7
Cost-Sharing Liability for Medicare Feefor-Service Beneficiaries, 2008 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, 8 available at www.medpac.gov/ chapters/jun10_ch02.pdf.
Income of Medicare Beneficiaries: Background
Distribution of Medicare Beneficiaries by Income Level, 2012 5% had incomes above $88,900 50% had incomes below $22,500 25% had incomes below $14,000 NOTE: Figures are not household income. Total household income for couples is split equally between husbands and wives to estimate income for married beneficiaries. SOURCE: Urban Institute analysis of DYNASIM for the Kaiser Family Foundation, Income-Relating Medicare Part B and Part D Premiums Under Current Law and Recent Proposals: What are the Implications for Beneficiaries? February 2012.
Household Income and the Elderly US Median Household Income, by Age 2010 2011 Income distribution of the population age 65 and older, as percent of poverty, 2010 All Households $50,831 $50,054 9.0% 34.6% < 200% Age <65 years Age 65 years and older $56,850 $55,640 $32,454 $33,118 Source: US Census Bureau, Income, Poverty, and Health Insurance Coverage in the United States, 2011, September 2012, Table 5. 31.4% 34.0% 25.6% Percent of poverty: <100% 100-199% 200-399% 400% Source: Federal Interagency Forum on Aging- Related Statistics, Older Americans 2012: Key Indicators of Well-Being, June 2012, Table 8a.
Source: Federal Interagency Forum on Aging-Related Statistics, Older Americans 2012: Key Indicators of Well-Being, June 2012.
Median Out-of-Pocket Health Care Spending As a Percent of Income Among Medicare Beneficiaries, by Demographic Characteristics, 2009 Age Health Status % 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.
Supplemental Coverage
Sources of supplemental coverage among noninstitutionalized Medicare beneficiaries, 2009 Source: MedPAC analysis of Medicare Current Beneficiary Survey, Cost and Use file, 2009. From: Data Book: Health spending and the Medicare Program, June 2012.
Distribution of Income of Medicare Beneficiaries, by Source of Supplemental Coverage, 2007 SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost and Use File, 2007, Medigap Reform: Setting the Context, September 2011.
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 NAIC standards include: 6-month guaranteed issue period at age 65 Minimum medical loss ratio of 65% for individual coverage/75% group
Currently Available Standardized Medigap Plans Plan F has 44% of Medigap enrollees; another 15% 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 $2,000 in 2011 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. Source: Center for Medicare & Medicaid Services, Medicare & You 2012, p. 67, available at ww.medicare.gov/publications/pubs/pdf/10050.pdf. 18
2010 Monthly Medigap Premiums, National Average, State High and Low Source: Kaiser Family Foundation Program on Medicare Policy, Medigap Reform: Setting the Context, September 2011, Available at http://www.kff.org/medicare/upload/8235-2.pdf 19
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) 20
Total = $13,414 Total = $10,068 21
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 Cite lack of directly relevant literature, concern about discouraging use of needed care, and availability of new plans M and N 22
Recent Proposals to Limit First-Dollar Coverage/Modify 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 March 2011 The President s Budget for FY 2013 MedPAC June 2012 Senator Hatch January 2013 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 $550 Maximum 50% coverage of the next $4,950 (Effective $3,025 out of pocket maximum) Unchanged Additional charge on supplemental insurance Limit Medigap coverage of initial out-of-pocket expenses 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 ($93 billion total) 30% Part B premium surcharge on new enrollees who purchase near first dollar Medigap policies, including C and F, beginning in 2017. 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 $2.5 billion Not available Not available 23
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) 24
Questions? 25