AARP Public Policy Institute INSIGHT on the Issues An Illustrative Analysis of Medicare Options Compare: What’s There and What’s Not? Marsha Gold, ScD Mathematica Policy Research This Insight on the Issues assesses Medicare Options Compare, a Web site maintained by the Centers for Medicare & Medicaid Services (CMS) to help beneficiaries choose among available Medicare Advantage (MA) plans. The findings show that the site helps beneficiaries identify the health plan choices specifically available in their zip code, and provides them with an extensive amount of information on these choices. But beneficiaries also could likely have trouble interpreting or be misled by some of the information. Though the site limitations partly reflect the complexity of the program, CMS could enhance the usefulness of the site by restructuring some of the information to better support beneficiary choice. SUMMARY narrow down the choices before consulting Medicare Options Compare This issue brief presents findings from may find it difficult to do so via the Web an assessment of Medicare Options site. Compare, a Web site maintained by the Centers for Medicare & Medicaid To a great extent, the site’s limitations Services (CMS) to help beneficiaries reflect both the complexity of the choose among the Medicare Advantage Medicare Modernization Act of 2003 (MA) plans available to them. The brief (MMA) and the large number of identifies both the site’s contributions companies that offered plans in response and the ways in which it might be to that legislation. Medicare is designed improved. so that the basic choice facing beneficiaries who have no other The findings on Medicare Options subsidized sources of medical insurance Compare are mixed. On the one hand, supplements is comparing a single MA the site helps beneficiaries identify the plan to a combination of traditional fee- health plan choices specifically available for-service Medicare, a freestanding in their zip code, and provides them with private prescription drug plan (PDP), an extensive amount of information on and potentially a Medigap plan.1 In these choices. On the other hand, it is contrast to Medigap plans, the benefit likely that beneficiaries could have designs of MA plans are not trouble interpreting or be misled by standardized, and numerous different some of the information. In particular, types of plans are available (e.g., health beneficiaries who have not been able to maintenance organization or HMO, local An Illustrative Analysis of Medicare Options Compare: What’s There and What’s Not? or regional preferred provider also looked at the different information a organization or PPO, private fee-for- beneficiary might learn from the site if service or PFFS). However, within that he or she reported being in “excellent” context, CMS could enhance the site’s or “poor” health. The site allows value by restructuring the information on beneficiaries to limit the choices shown plan features, such as benefits, and the to them according to various criteria potential financial risks of each type of (maximum premium, an ability to use plan, such as out-of-pocket costs and any doctor, inclusion of Part D, plans other financial risks beneficiaries assume designed as a Medicare medical savings by enrolling. Information on new drug account, specific chronic conditions or coverage also could be better integrated disabilities, and so on). However, we into the site. This would help asked to see all choices for the purpose beneficiaries to choose between of the analysis. We used the site’s traditional Medicare (with or without “default” setting for ordering choices by Medigap and a private, freestanding estimated out-of-pocket costs (within the PDP) and the MA plans available to chosen age/health status group) versus them. alternatives for ordering based on plan names, premium amounts, coverage of DATA SOURCES AND ANALYSIS drugs, vision or dental coverage, and scores on quality ratings.4 Our data source for this brief consisted essentially of our personal experience Appendix A summarizes what the site with Medicare Options Compare. We offered our hypothetical beneficiary at went to www.medicare.gov just as a three levels of analysis: beneficiary (or someone helping them) might do. For a point of departure, we 1. An overview of what the site shows assumed that we were a beneficiary about the MA plans available in living in President Obama’s former 2009 (table A.1). neighborhood—the Hyde Park section of 2. A more detailed look at what the site Chicago, zip code 60637—seeking to shows beneficiaries about how their understand the MA (called “health plan” top three choices compare. We did on the site and here henceforth) choices this once for coordinated care plans available in 2009.2 Plans in this zip code (table A.2) and again for PFFS plans generally are offered at least throughout (table A.3). all of Cook County, Illinois. To simplify the task, we assumed that our 3. An assessment of what beneficiaries beneficiary neither qualified for the low- might learn about choosing MA income subsidy nor had preexisting or versus traditional Medicare (with or employment-based supplemental without Medigap) (table A.4). coverage.3 We did not examine how the site The site prompts the beneficiary for age supports a comparison of specific and health status so that it can provide coverage offered in Part D because to do estimates of out-of-pocket costs based so would entail another level of on average service use for an average potentially complex review. Because our beneficiary with those characteristics. analysis is based on a single locale, We assumed our beneficiary was 65 to readers also should not assume the 69 years old—a common age for specific plan details we show apply someone choosing an MA plan for the nationwide.5 first time. Although we assumed that our beneficiary was in “good” health, we 2 An Illustrative Analysis of Medicare Options Compare: What’s There and What’s Not? FINDINGS requirements. (This is called a point-of- service [POS] option with an HMO.)10 Medicare Options Compare lists 37 Six PPO plans and 10 PFFS plans are health plan options in 2009 for the Hyde offered as well. The Web site shows Park zip code, one of which is Original each PPO as providing access to “any Medicare.6 Only 30 of the MA plans doctor,” presumably because out-of- (along with Original Medicare) would be network benefits are available. But relevant to our beneficiary, because four beneficiaries are not warned here that are special needs plans (SNPs), and two their costs will be higher for using an are offered by the Mennonite Mutual out-of-network doctor than if they stay Aide Association (see table A.1) (the within the network. Most PFFS plans are remaining choice is original shown as having access to “any willing Medicare).7,8 The latter six plans have doctor.” Two plans (Today’s Options specific eligibility requirements that we Value and Today’s Options Premier) assumed our beneficiary would not meet. indicate that there is access to “any Though the Web site shows these doctor,” and the distinction between choices, it does not allow beneficiaries “any willing doctor” and “any doctor” is to choose them online, instead indicating not apparent. It takes a more targeted that interested beneficiaries should search for beneficiaries to access contact these plans by phone to information on the number of physicians determine whether they would be affiliated with a plan or on out-of-pocket eligible. We do not know if the typical costs for out-of-network care. Even then, beneficiary would find the inclusion, the information has its limitations, as particularly of the Mennonite plans, discussed later. confusing.9 Firm Affiliation. Beneficiaries who Narrowing Down the Choices prefer certain firms that sponsor health plans can substantially narrow down Medicare Options Compare is structured their choices, a feature that probably such that beneficiaries get certain types gives sponsors an incentive to “brand” of information on each plan. Additional their offerings. Though there are 30 information for a specific plan or to health plans available to our beneficiary compare up to three plans at a time is in Hyde Park, six firms account for all of available on request via a mouse click. them because it is common for a The general information provided by the company to offer more than one type of site is described below, along with an plan and several plans of each type with explanation of what beneficiaries would differing benefits. The six companies are learn from the site to help them choose a Humana (traditional HMO, local and plan. regional PPO, and PFFS); Aetna Plan Type and Provider Access. As (traditional HMO, PPO, PFFS); beneficiaries begin the selection process, WellCare (HMO with a POS option); they can use Medicare Options Compare HealthSpring (traditional HMO as well to make relatively gross distinctions as an HMO with a POS option); between types of plans available based AARP/Secure Horizons (HMO with a on the way the plan is structured and POS option); and Today’s authorizes access to providers. For Options/Universal American (PFFS). example, our Hyde Park beneficiary has Plan Names. The plan names show the 14 HMO choices, 6 of which limit sponsor but do not necessarily help coverage to “plan doctors” and 8 of beneficiaries narrow their choices based which make “some exceptions” to those on the type of plan or scope of benefits. 3 An Illustrative Analysis of Medicare Options Compare: What’s There and What’s Not? For example, among HMOs, presentation is misleading.11 All MA HealthSpring’s Healthy Advantage is an plans include the very limited benefits HMO with neither a POS option nor Medicare provides for these services, drug coverage, but its Healthy often substituting a fixed copay for the Advantage Basic Rx and Premier Rx are 20 percent Medicare cost sharing. Fifty- HMOs with both features. Its Healthy seven percent of MA plans provide some Living Premier Rx appears identical (see preventive benefit in 2009 (up from 36 table A.1) to the Healthy Advantage percent in 2008), but none provide Premier Rx, but the Healthy Living additional coverage for restorative product has a higher monthly premium services (e.g., fillings, crowns). Virtually ($37 versus $0) and higher estimated all plans provide coverage for eye exams out-of-pocket costs ($2,800 versus and eyeglasses in 2009, but they $2,600). Today’s Options Value from typically limit the frequency for exams Universal American is a PFFS plan or new glasses and the amount they will without a drug benefit, but WellCare pay for the glasses. Value is an HMO with a POS option and a drug benefit. Summary Rating of Quality. Medicare Options Compare uses a five-star rating Monthly Plan Premium. The Web site system to summarize the quality of care clearly shows the differences in monthly and other features of the performance premiums from one plan to the next, delivered by the health plans and drug perhaps making this portion of the site plans. The ratings are based on more transparent than the rest. As aggregate measures constructed by CMS discussed later, however, premiums from individual measures of care account for a variable share of out-of- developed from survey, claims, and pocket costs, so beneficiaries could be administrative data. The stars represent misled if they rely too heavily on summary measures that combine, in an premiums in selecting a plan. The fact unspecified way, ratings of staying that premiums are expressed on a healthy, getting timely care, managing monthly basis while total estimated out- chronic (long-lasting) conditions, health of-pocket spending is expressed in plan responsiveness, and handling annual terms could also be confusing. appeals well and quickly. Ratings for the drug plans are based on customer Part D Coverage. Beneficiaries who service, member complaints and know they want Part D can eliminate 8 turnover, member experience, and drug of the 30 plans and still have a pricing and safety. Plans can get from substantial number of choices, including one to five stars, with five being the 11 HMOs, 5 PPOs, and 6 PFFS plans. highest. The site does not show the Many beneficiaries know whether or not weights used to generate star ratings they want Part D when they look at MA from individual ratings (whether some options, so having readily accessible ratings are more important than others) information on whether Part D is nor the specific data elements used to included in the plan is important. compile the individual ratings (what the individual rating is based on). Dental and Vision Coverage. The Web site indicates whether dental and vision Health plan ratings are not available for services are covered, not covered, or, in 16 of the 30 plans in the site, including a few cases, covered for an additional all but 2 of the PFFS plans. Of the plans cost. However, our nationwide analysis that are rated, almost all received 2.5 of MA coverage of these benefits in stars, and the rest got only 2, making it 2009 suggests that this simplified difficult for a beneficiary to differentiate 4 An Illustrative Analysis of Medicare Options Compare: What’s There and What’s Not? between the quality of one plan versus without Part D benefits and three plans another. The drug plan ratings are more with Part D—a Value, Standard, and complete, but even so, they vary only a Premier plan; the premiums differ from bit more than the health plans (from 2.5 one to the next, but CMS’s out-of-pocket to 3.5 stars). Those findings could mean cost estimates for a beneficiary differ by plans have similar performance that the only $200 annually from low to high. ratings are not sufficient to detect real differences. Regrettably, the documentation on the site is not clear on how overall costs are Plans that are not rated have missing defined and what they include. In data because (1) survey and other data particular, the user note does not indicate are not available for new plans or for clearly that estimates include Part B and those with only a year or two of plan premiums as well as estimated out- experience, and (2) reporting of quality- of-pocket costs for services. As we based measures is voluntary for PFFS discuss later, CMS could make better plans (until 2010). In addition, because use of the available data to help the ratings are developed at the contract beneficiaries understand both predictable level, all plans offered by that contract costs (premiums) and more uncertain serving that zip code will have the same costs (costs related to their use of health rating, a fact that limits variation in services). The distinction could be ratings across plans.12,13 important because all these health plans have an insurance component to provide Estimated Out-of-Pocket Cost. These some degree of financial protection to estimates, based on 2003–2004 beneficiaries. Each plan must provide at Medicare claims data, are the main least actuarially equivalent coverage to vehicle through which beneficiaries can that offered by traditional Medicare, but see how their total spending could vary almost all change Medicare’s cost- from one plan to another.14 The sharing structure in ways that could estimates combine premiums (for Part B increase or decrease the financial and MA) with expected average out-of- protection beneficiaries would pocket costs for inpatient care, outpatient experience compared to each other or to prescription drugs, dental, and other traditional Medicare. services. Digging Deeper Beneficiaries are given an idea of their potential out-of-pocket cost by estimates Beneficiaries can dig deeper for that show what the average cost would information on specific plans they are be for someone in their age group with interested in or to compare plans. Tables the same perceived health status. In this A.2 and A.3, respectively, provide our specific zip code, for example, the site summary of this information for three tells a beneficiary that HMOs will tend, lower-cost coordinated care plans and on average, to have lower out-of-pocket for three PFFS plans in zip code 60637, costs, that PFFS plans will have higher excluding, for simplicity, the detailed out-of-pocket costs, and that their costs description of Part D benefits and some could vary by as much as $1,000 within others. each plan type—more if they are in Estimated Out-of-Pocket Costs. The poorer health and less if they are in plan profile repeats information on the excellent health. Some differences, summary sheet about total estimated however, are much smaller. For annual out-of-pocket costs, but example, Aetna’s Golden Medicare beneficiaries are given the option to ask HMO plans include a basic option for more information. When they do, the 5 An Illustrative Analysis of Medicare Options Compare: What’s There and What’s Not? Web site breaks down the estimate by beneficiaries whose health status varies, category of expense on a monthly basis: because estimated spending on dental Part B premium, plan premium, inpatient services, unlike other services, is lower care, outpatient prescription drugs, for those in worse health (see box 1). dental services, and all other services. Premiums are the same regardless of a Provider Networks. Though research beneficiary’s health status, but the other shows that beneficiaries care a great deal costs differ with plan design. In table about which providers are in their plan, A.2 we examined these figures for one the Web site does not have information of the plans and found that, for someone on this topic. This is not surprising and in excellent health, out-of-pocket costs reflects a lack of uniformity in data beyond the premium account for only 40 collection and tracking of provider percent of the estimated total out-of- networks across the industry and the pocket spending, but these costs are potential speed with which this kind much higher for those whose health is information changes. For coordinated poor (or becomes so after enrollment) care plans, the site shows the number of (see box 1). Out-of-pocket spending for providers affiliated with the plan within those in poor health was more than categories (e.g., 501–1000, 2,001–2,500) double that for those in excellent health. (see table A.2). Counts are for the service area of the plan, which may In our chosen plan in box 1, 73 percent differ from one plan to another in the of out-of-pocket costs for an enrollee in counties it includes. Thus, plans with good health occur when the enrollee uses larger service areas may appear to have services rather than through payment of more provider choice even if some of monthly premiums for Medicare or these providers are relatively distant MA.15 Drug costs account for only 26 from the beneficiary. In addition, percent of these costs; the remainder provider counts do not show anything reflect spending for hospital, physician, about the characteristics of the network and other health services. Yet by design (e.g., criteria for selection; inclusion of of the included PDP tool, the Web site certain large, dominant practices). For steers beneficiaries toward considering this information, beneficiaries would likely drug costs rather than toward these have to consult individual plans, for other costs. By combining dental costs which the site provides links and contact with cost sharing associated with Parts A information. Beneficiaries thus cannot and B benefits, the site may also mute find out from Medicare Options differences in health plans for Compare which providers are affiliated Box 1 Illustration: Point-of-Service Cost Sharing Accounts for a Higher Share of Out-of-Pocket Costs for Sicker Beneficiaries Out-of-Pocket Components Excellent Health Good Health Poor Health Total (Monthly) $161.40 $206.40 $363.40 Part B Premium 96.40 96.40 96.40 Monthly Plan Premium 0.00 0.00 0.00 Inpatient Care 2.00 19.00 85.00 Outpatient Prescription Drugs 19.00 40.00 94.00 Dental Services 30.00 24.00 16.00 All Other Services 14.00 27.00 72.00 Source: Medicare Options Compare 2009 estimates for WellCare Value Plan (HMO-POS) in zip code 60637; beneficiaries ages 65–69 by self-reported health status. 6 An Illustrative Analysis of Medicare Options Compare: What’s There and What’s Not? with the plan. show this level of detail in the appendix tables.) Benefit Specifications. The Web site provides details on how each plan Detailed Performance Ratings. handles limits and cost sharing for Beneficiaries delving deeper into the Medicare Parts A and B services. Such Web site can find five-star ratings for features may differ substantially across each of the components used to construct plans. Among coordinated care plans, the previously discussed summary for example, WellCare Value charges a performance scores for health plans and $50 copay for hospital days one through for PDPs. A plan that has no summary five, Humana Gold Plus charges $550 rating may have sufficient data to per stay with a $3,500 limit, and Aetna’s provide a star rating for a specific Golden Choice Standard PPO charges component of the summary rating. In $500 per stay in network and 30 percent this zip code, there is more of charges out of network. It may be differentiation across plans in challenging for beneficiaries to compare component ratings than in the summary plans that differ on so many dimensions ratings. Separate ratings for health plans for each benefit. Beneficiaries also may and the drug plan they offer are not fully appreciate the financial risk to consistent with the split in traditional them of different benefit features (e.g., Medicare between Parts A, B, and D. the high cost of hospital care and However, separate ratings are not as difference between hospital charges and applicable to MA plans, in which all MA payment rates) and how that might Medicare benefits are integrated into a add to their costs in using out-of- single package. network providers. Why Enrollees Leave the Plan. This In some instances, the descriptions of the information may be of considerable benefits also are not specific enough to interest to beneficiaries, but it is not give beneficiaries a clear sense of what easily identifiable or retrievable on the is and is not covered, and at what price. site, and the information is very dated For example, the site shows that (2004–2005). Users see reference to this Humana Gold Plus HMO pays anywhere information only if they request detailed from $0 to $50 for many ancillary information on the out-of-pocket costs in services (e.g., clinical laboratory tests), a plan and notice (and click on) a and coordinated care plans may require separate tab for “Why People Leave.” authorization to pay for durable medical This tab contains information on the equipment (see table A.2). It could also percentage of members who leave, how be challenging to compare coinsurance the reasons for leaving break down (e.g., 20 percent, as in traditional between “health care or services” or Medicare) with what most plans, using “benefits and costs,” and additional fixed dollar copayments, would charge detail on some specific reasons. But unless beneficiaries are familiar with users who want that information must Medicare payment rules. (Most probably first read a lengthy text of explanation are not.) The Web site also makes and proactively request that data be standard distinctions between in- and shown. (The default appears to leave it out-of-network cost sharing for PFFS hidden.) They then get national and state plans, though such distinctions are not averages and, if available, information relevant to PFFS plans. Including this for that contract (which may include kind of information could confuse multiple plans). Because the data are so beneficiaries. (For simplicity, we do not old, they are often missing. Thus, it is not clear how valuable the information 7 An Illustrative Analysis of Medicare Options Compare: What’s There and What’s Not? provided on this topic would be to a Medicare, with or without a Medigap beneficiary. option. This is because the out-of-pocket cost estimates for the traditional Deciding between Traditional Medicare program on the site exclude Medicare and Medicare Advantage any PDP or Medigap coverage. By going The Web site appears to be most limited to a different part of the site that allows in its ability to help beneficiaries choose Medigap policies to be compared, between traditional Medicare (with or beneficiaries can get information on without a PDP or Medigap plan) and benefits and expected out-of-pocket MA plans. The site preceded Part D. costs for traditional Medicare and each After the MMA, CMS appears to have of the standardized Medigap options (see built on the site to emphasize helping table A.4). These, too, exclude drug beneficiaries decide which freestanding benefits, while such benefits do PDPs or MA plans provide the best influence estimates provided for MA. coverage for the particular drugs they take. However, that may not be the most This structure has some problems. First, important information to beneficiaries it implicitly steers beneficiaries away concerned about how their health plan from traditional Medicare because the choice could influence total out-of- out-of-pocket spending estimates do not pocket spending. As shown in box 2, account for PDP enrollment, even CMS’s estimates of out-of-pocket though PDPs are popular with spending show that hospital, physician, beneficiaries who have no other source and other services account for a majority of drug coverage. Second, the patchwork of out-of-pocket costs under traditional of information could be confusing to Medicare—not prescription drugs, even beneficiaries, because if they choose the without Part D. Further, the way traditional Medicare program, their Medicare Options Compare is expected out-of-pocket costs are not structured, a beneficiary could be misled what the site shows for Medicare alone, about the relative out-of-pocket costs for but for a combined total reflecting the MA health plans and traditional decisions they make about Medigap and Box 2 Illustration: Common Medigap Plans in Hyde Park have Lower Expected Cost Sharing Than Medicare Alone and May Compare Favorably to PFFs MA-PDs Today’s Aetna Traditional Option Value Medicare Out-of-Pocket Medicare Medicare + Medicare + With Rx Open Basic Components A/B Only Medigap C Medigap F PFFS With RX Total (Monthly) $331.40 $ 349.00 $ 349.65 $346.10 $375.00 Part B Premium 96.40 96.40 96.40 96.40 96.40 Monthly Plan 0.00 118.60 119.25 86.70 112.00 Premium Inpatient Care 42.00 0.00 0.00 31.00 34.00 Outpatient 95.00 95.00 95.00 44.00 59.00 Prescription Drugs Dental Services 39.00 39.00 39.00 39.00 39.00 All Other Services 59.00 0.00 0.00 49.00 35.00 Source: Medicare Options Compare 2009 estimates for traditional Medicare and Medicare/Medigap Plans C and F in zip code 60637; beneficiaries ages 65–69 by self-reported good health (assumes no PDP coverage). The PDPs shown are the least expensive ones listed with Part D coverage. 8 An Illustrative Analysis of Medicare Options Compare: What’s There and What’s Not? also Part D. Congress’s decision to operate Part D apart from traditional Medicare Parts A Perhaps even more critical, the focus on and B make for some very complex aggregate estimates of out-of-pocket choices. It is not clear that any one tool costs may discourage beneficiaries from can adequately simplify the decision giving due consideration to their between one plan and another for tolerance for risk and to the potential beneficiaries or their advisors. If MA trade-offs they wish to make (or can health plan benefits were standardized afford to make) between fixed and (as they are for Medigap), it could be predictable premiums and less simpler for beneficiaries to compare predictable cost sharing at the point of health plans. Standardization of plan service. As box 2 shows, the most names also could make it easier for the popular Medigap options (C and F) site to display, and beneficiaries to typically eliminate out-of-pocket costs compare, their health plan choices.16 for hospital and physician services. The estimated total of a beneficiary’s out-of- Second, the Web site could be modified pocket costs for these plans in Hyde to offer beneficiaries a better Park actually are lower and more understanding of how the choice of one predictable than the same costs for those plan over another translates into their in the least expensive PFFS plans probable out-of-pocket spending and offered in that locale, even though the financial risk. The basis for this latter include prescription drugs. While improvement already exists within the the specific facts are likely to vary site itself, as it already contains data that across markets, it is important that can be used to look separately at the beneficiaries have access to information different types of out-of-pocket that can help them make these kinds of spending. Beneficiaries might be able to assessments. compare plans more easily if such costs were clearly broken down into four CONCLUSIONS categories: (1) premiums that are fixed Though CMS has made a considerable and predictable; (2) inpatient and other investment in Medicare Options medical services, whose costs vary with Compare to help beneficiaries (and their health status and are less predictable advisors) make a choice of Part D plans over time; (3) outpatient prescription and navigate the overall Medicare drugs, whose costs vary with Part D environment, our analysis suggests that decisions and coverage; and (4) dental substantially more can be done to make and other services not included in the Medicare Options Compare valuable to traditional Medicare package. With a bit beneficiaries choosing a health plan more work and the same data, CMS also under the MMA. The site covers a lot of should be able to provide beneficiaries ground, but it could be challenging for with potentially useful information to beneficiaries to use. While our analysis assess the uncertainty of the estimates. reflects only our own experience on the The raw data, for example, could support site and does not provide feedback on analysis for each health status and age what beneficiaries actually experience, group to show beneficiaries not just the results have three implications. average out-of-pocket costs, but also how common it might be for a First, CMS’s efforts to help beneficiaries beneficiary like them to encounter choose among the plans authorized by substantially higher out-of-pocket costs. the MMA drive home the magnitude of Dental benefits could also be labeled the task posed by the legislation. Both more accurately so that beneficiaries the range of options allowed in MA and know that the extra dental benefits they 9 An Illustrative Analysis of Medicare Options Compare: What’s There and What’s Not? might receive relate solely to preventive coverage. The fundamental choice is services. whether to go with traditional Medicare (with or without Part D and/or Medigap) Third, CMS should probably review the or with an integrated MA plan. The site’s focus on Part D relative to the utility of the site as it now stands has information on the overall choice facing been adversely affected by CMS’s need beneficiaries. The current structure of to revise it quickly to support the new the Web site makes it too easy for Part D option launched in 2006. A beneficiaries to base decisions on the reexamination of its form is now monthly premium and prescription drug overdue. 10 What’s There and What’s Not? An Illustrative Analysis of Medicare Options Compare: Table A.1 Medicare Advantage Plans Available for General Enrollment, 2009 Zip Code 60637 (Hyde Park, IL) Monthly Estimated Out-of-Pocket Cost Plans (by type, as sorted by Medicare Options Premium Star Rating (of 5) Ages 65–69a Compare on estimated out-of-pocket cost for (excluding Any Any Health Excellent Good beneficiaries in good health) Part B) Part D Vision Dental Plan Rx Health Health Poor Health HMO (no POS option) Humana Gold Plus $0 Yes Yes No 2.5 3.5 $2,150 $2,550 $4,500 Health Spring Healthy Advantage $0 No Yes Yes 2 -- $1,600 $2,600 $5,700 Aetna Golden – Medicare Standard $38 Yes Yes (for Extra) NA 3.5 $2,650 $3,250 $5,200 Aetna Golden – Medicare Value Plan $0 Yes Yes (for Extra) NA 3.5 $2,400 $3,300 $6,100 Aetna Golden – Medicare Premier $73 Yes Yes (for Extra) NA 3.5 $2,950 $3,450 $4,950 Aetna Golden – Medicare Basic $0 No Yes (for Extra) NA -- $2,500 $3,550 $7,000 HMO (POS option) WellCare Value $0 Yes Yes Yes 2.5 3 $1,950 $2,500 $4,350 WellCare Choice $0 Yes Yes Yes 2.5 3 $1,950 $2,550 $4,700 Health Spring Healthy Advantage Premier Rx POS $0 Yes Yes Yes 2 3 $2,000 $2,600 $4,550 11 WellCare Rx $24 Yes Yes Yes 2.5 3 $2,550 $2,750 $4,700 Health Spring Healthy Advantage Basic Rx POS $13 Yes Yes Yes 2 3 $2,200 $2,800 $4,950 Health Spring Healthy Living, Premier Rx POS $37 Yes Yes Yes 2 3 $2,250 $2,800 $4,600 AARP Medicare Complete Plus Plan 1 $0 Yes Yes (for Extra) NA 3 $2,250 $2,950 $5,450 AARP Medicare Complete Plus Plan 2 $0 No Yes (for Extra) NA -- $2,450 $3,550 $7,000 PPO Humana Choice PPO $0 No No Yes 2.5 -- $2,100 $3,200 $6,700 Aetna Golden Choice Standard $53 Yes Yes (for Extra) NA NA $3,550 $3,450 $5,600 Humana Choice PPO (regional) $91 Yes No Yes 2.5 2.5 $2,950 $3,950 $6,600 Humana Choice PPO (local) $78 Yes No Yes 2.5 3.5 $2,950 $3,600 $5,950 Humana Choice PPO (regional) $97 Yes No Yes 2.5 2.5 $3,200 $3,900 $6,300 Aetna Golden Choice Premier $134 Yes Yes (for Extra) NA NA $3,700 $4,200 $5,700 What’s There and What’s Not? An Illustrative Analysis of Medicare Options Compare: Table A.1 (continued) Monthly Estimated Out-of-Pocket Cost Plans (by type, as sorted by Medicare Premium Star Rating (of 5) Ages 65–69a Options Compare on estimated out-of-pocket (excluding Any Any Health Excellent Good cost for beneficiaries in good health) Part B) Part D Vision Dental Plan Rx Health Health Poor Health PFFS Today’s Options Value Powered by CCRx $87 Yes Yes No NA 2.5 $3,350 $4,150 $7,000 Aetna Medicare Open Basic Plan with Rx $112 Yes Yes No NA 3.5 $3,700 $4,500 $4,150 Today’s Option Value $65 No Yes No NA -- $3,400 $4,500 $7,850 Today’s Option Premier $99 No Yes No NA -- $3,600 $4,600 $7,850 Today’s Option Premier Powered by CCRx $154 Yes Yes No NA 2.5 $4,050 $4,600 $6,600 Aetna Medicare Open Basic Plan $90 No Yes No NA -- $3,550 $4,650 $7,200 Humana Gold Choice PFFS $148 Yes No No 2.5 3 $4,050 $4,700 $7,250 Humana Gold Choice PFFS $134 Yes No No 2.5 3 $4,100 $4,750 $7,750 Aetna Medicare Open Standard with Rx $199 Yes Yes No NA 3.5 $4,300 $4,950 $6,400 Aetna Open Standard Plan $167 No Yes No NA -- $4,500 $5,200 $7,850 Source: Author’s construction from information on www.Medicare.gov, January 7, 2009. 12 NA = Not available, usually because the plan is of a type not required to submit it or is too new to have such data. Note: Excludes four SNPs from Health Spring (Chronic Care, Institutional), Evercare (Chronic Care, Institutional), two PFFS plans offered by the Mennonite Mutual Aide Association (not available for online enrollees), and Original Medicare. a Based on CMS analysis applied to benefits design in 2009 bids. Includes out-of-pocket costs associated with Part B premium, health plan premium, inpatient care, prescription drugs, dental, and skilled nursing care, whether or not they are Medicare covered, as well as a variety of Medicare-covered benefits. For MA-PDs, prescription drug costs are based on the Part D plan. (This differs from traditional Medicare and Medigap, which assumes no such coverage.) From www.Medicare.gov/MPPF/Include/DataSection/OOPC/OOPCCalculations.asp. -- = Does not offer Rx. An Illustrative Analysis of Medicare Options Compare: What’s There and What’s Not? Table A.2 Comparison of Lowest-Premium Coordinated Care Plans (with Part D coverage) of Each type, Selected Information Abstracted from Medicare Options Compare, 2009 Aetna Golden WellCare Value Humana Gold Choice Standard (HMO with POS) Plus HMO (PPO) Estimated Out-of-Pocket Costs for Ages 65–69 in Good Health $2,500 $2,550 $3,450 Service Area Cook and Will Co. Cook and Will Co. Cook Co. Provider Network 2,001–2,500 501–1,000 1,001–1,500 Ratings Staying healthy 2* 2* Not enough data Timely care 2* 2* Not enough data Managed home care 3* 3* Not enough data Health plan response 2* 3* Not enough data Appeal speed 5* 5* Not enough data Drug plan services 4* 3* 5* Member complaints Rx plan 2* 4* Not enough data Member experience Rx plan 2* 3* Not enough data Drug pricing/safety 4* 4* 5* Premium (Monthly) $0 $0 $53 Out-of-Pocket Limit $1,500 (in network) None $5,000 (in network) Some services (Same out-of-pocket network, but $500 deductible.) Inpatient Care $50/day (1–5) $550/stay $500/stay $0 after/No day limit $3,500 out-of-pocket No day limit Prior notification limit annually (30% out-of network) (except emergency) No day limit Doctor’s Visit No copay for primary No copay for 20% in network/ care visits primary care visits 30% out of network $25 urgent care $30 for specialist $30 specialist visits Durable Medicare Equipment 20% (authorization 20% (authorization 20% in network/ may be required) may be required) 30% out of network authorization Ancillary Services (in network) Lab $0 $0–$50 $0 Diagnostic procedures $30–$50 $0–$50 $0 X-ray $0 $0–$50 $3 Diagnostic radiology $50 $0–$110 $175 Therapeutic radiology $30 $0–$50 $30 (30% non-network) Part B Drugs General 20% 20% $45 Chemotherapy 20% 20% $45 Source: Author’s construction from information on Medicare Options Compare, January 7, 2009, zip code 60637. * = Star rating. 13 An Illustrative Analysis of Medicare Options Compare: What’s There and What’s Not? Table A.3 Comparison of Lowest-Premium PFFS Plans (with Rx), Selected Characteristics Abstracted from Medicare Options Compare, 2009 Universal American Aetna Medicare Universal American Today’s Options Open Basic Plan Today’s Option with CCRx with Rx Premier with CCRx Estimated Out-of-Pocket Costs for Those Age 65–69 in Good Health $4,150 $4,500 $4,600 Service Area NE/Midwest/South 6 Selected counties West/Midwest/South 6 in 5 states Provider Network Not available Not available Not available Ratings Staying healthy 2* 4* 2* Timely care 4* 4* 2* Managed chronic care Not enough data Not enough data Not enough data Health plan response 3* 3* 3* Appeal speed Not enough data 5* Not enough data Drug plan services 3* 4* 3* Member complaints Rx plan 1* 2* 1* Member experience Rx plan 1* 3* 1* Drug pricing/safety 3* 4* 3* Premium (Monthly) $86.70 $112 $153.50 Out-of-Pocket Limit $3,000 $4,000 $2,500 (in and out of network (in and out of network) combination) Inpatient Care $195/day (1–5) $400/day (1–7) $350/stay $0 copay other days $0 copay other days $0 copay other days No limit days No limit days $875 annual out-of- pocket limit Doctor’s Visit $20–$25 for primary $20 for primary care $10–$35 for primary care care, $35 for and for specialists $25 for specialists specialists Durable Medicare Equipment 20% 20% 20% Ancillary Services (in network) Lab $0 $20 $0 Diagnostic procedures $0 $20 $0 X-ray 20% $20 10% Diagnostic radiology 20% $150 10% Therapeutic radiology 20% $20 10% Part B Drugs General 20% $45 20% Chemotherapy 20% $45 20% Source: Author’s construction from information on Medicare Options Compare, January 7, 2009, zip code 60637. * = Star rating. 14 An Illustrative Analysis of Medicare Options Compare: What’s There and What’s Not? Table A.4 CMS’s Estimates of Out-of-Pocket Costs for Alternatives to Medicare Advantage, by Health Status, 2009 (Zip Code 60637) Estimated Annual Costs Ages 65–69 Monthly Premium by Self-Reported Health Statusb a Range Excellent Good Poor Medicare Only $0 $2,700 $4,000 $8,250 Medicare + Medigap C $109–$318 $3,600 $4,200 $5,900 Medicare + Medigap F $102–$294 $3,600 $4,200 $5,900 Medicare + Medigap K $53–$94 $3,450 $4,550 $8,200 Source: CMS’s Medicare Options Compare, accessed January 8, 2009, on www.Medicare.gov. a Excludes the regular Part B premium all beneficiaries pay. b Based on CMS-provided analysis applied to standardized benefit design. Includes out-of-pocket costs associated with inpatient care, prescription drugs, dental, and skilled nursing care, whether or not Medicare covers them, as well as a variety of Medicare- covered services (assumes no Part D coverage purchased separately). From www.Medicare.gov/MPPF/Include/DataSection/OOPC/ OOPCCalculations.asp, accessed January 7, 2009. encourages them to talk to their former employer before making an MA choice. 1 Beneficiaries who are eligible for Medicaid and 4 While the ability to customize is useful, it also related public coverage or group-based retiree could result in frustration for beneficiaries benefits are exceptions because their eligibility because if a user leaves the site and begins again for these subsidies modifies the choices they are later, the site may display different plans, plans likely to consider. In 2006, 35 percent of ordered in different ways, or other differences. beneficiaries had employer-sponsored coverage, 5 and 16 percent had Medicaid as a source of The plans we show typically have service areas supplemental coverage. Of the remainder, 19 that include Cook County (Chicago) and perhaps percent were enrolled in MA, 18 percent in proximate counties, though service areas for Medigap plans, and 11 percent in traditional regional PPOs and many PFFS plans will be Medicare only (Kaiser Family Foundation, broader. Readers seeking information on MA Medicare: A Primer 2009, Washington, DC: benefits and premiums nationwide can find them January 2009). in companion issue briefs available from AARP 2 (see M. Gold and M Hudson, A First Look at This portion of the site preexisted the MMA How Medicare Advantage Benefits and and the Part D expansion and focuses on helping Premiums in Individual Enrollment Plans Are beneficiaries choose an MA plan or Medigap Changing from 2008 to 2009 and M. Gold and plan, depending on which they want. The site M. Hudson, Medicare Advantage Benefit was modified after Part D was enacted to reflect Design: What Does It Provide, What Doesn’t It, changes in Medicare drug benefits. A separate and Should Standards Apply? Washington DC: channel on the site, added after the MMA, AARP Public Policy Institute, March 2009]). focuses on Medicare PDPs and assists 6 beneficiaries seeking to learn how coverage of This number of choices is somewhat below the specific drugs they use varies across the average nationally. In 2008, the average formularies and benefit designs of available beneficiary had 44 plan choices (excluding special freestanding PDPs and MA options that needs plans), with 35 choices available in the incorporate drug coverage. average county. See Marsha Gold, “Medicare’s 3 Private Plans: A Report Card on Medicare Choices for beneficiaries eligible for the low- Advantage,” Health Affairs Web Exclusive, income subsidy are influenced by the fact that November 24, 2008 (www.healthaffairs.org) their Part D coverage is subsidized. Beneficiaries 7 with group-based coverage may find that SNPs are coordinated care plans designed to enrolling in an MA plan voids their group-based serve enrollees with certain special needs: dual coverage; thus, Medicare Options Compare eligible (Medicare-Medicaid), those who are institutionalized or eligible for institutionalization, 15 An Illustrative Analysis of Medicare Options Compare: What’s There and What’s Not? and those with serious chronic or disabling CMS Web site (“CY 2009 Medicare Options conditions. Compare Cohort Selection and Out-of-Pocket 8 Cost Estimates Methodology,” by Fu Associates, Table 1 lists the choices and the information October 17, 2008). shown for each plan as ordered by the sort (for 15 those in good health). The one exception is that Though these figures are for a single plan we sort plans into four categories of provider within the zip code, CMS’s estimates of out-of- INSIGHT on the Issues choice (HMO with and without point-of-service pocket costs reflect national estimates of use option, PPO, and PFFS). (The Web site names based on the Medicare Current Beneficiary the plan model (e.g., HMO) and describes doctor Survey for individuals in a given age and health choice separately and doesn’t sort by this under status group, applied to the specific plan’s the default option.) benefits. Thus, while plan and location choice 9 will influence the benefit package, it should not Because of the way the MMA is structured, influence the use assumptions. This fact means SNP choices exist in most markets and seem that there is likely to be a reasonable consistency necessary to include, although only a subset of to the patterns reflected in estimates for different beneficiaries may be eligible. plans and locales. CMS does not make public the 10 Also referred to as “open-ended HMOs” in the data behind the estimates in an analytical file, so past, such options provide some coverage when we cannot provide market or national estimates selected out-of-network services are used (often on these topics. with higher cost sharing). 16 Additional analysis of this issue is included in 11 See M. Gold and M. Hudson, Medicare a companion AARP report by M. Gold and M. Advantage Benefit Design: What Does It Hudson, Medicare Advantage Benefit Design: Provide, What Doesn’t It, and What Standards What Does It Provide, What Doesn’t It, and Should Apply? (Washington DC: AARP Public What Standards Should Apply? (Washington Policy Institute, March 2009). DC: AARP Public Policy Institute, March 2009); 12 and also in E. O’Brien and J. Hoadley, Medicare CMS makes certain exceptions for contracts Advantage: Options for Standardizing Benefits with a wide geographical scope (e.g., some PFFS and Information to Improve Consumer Choice plans are offered under contracts that cover much (New York: The Commonwealth Fund, April of the United States). 2008). 13 A contract is for a particular type of plan (e.g., an HMO) from a sponsor and typically is for a defined service area. However, multiple plans with different benefits may be offered under the Insight on the Issues I 27, April, 2009 same contract, and other distinctions also are allowed across plans under a single contract Written by Marsha Gold, Mathematica (e.g., HMOs with and without a POS option). Policy Research, for the 14 Additional detail on how costs are calculated AARP Public Policy Institute, are provided directly on the site at 601 E Street, NW, Washington, DC 20049 www.medicare.gov/MPPF/Include/ DataSection?OOPC/OOPCCalculations.asp www.aarp.org/ppi (accessed January 7, 2009) and through a link 202-434- , ppi@aarp.org provided from that site to a document on the © 2009, AARP. Reprinting with permission only. 16