RUPRI Center for Rural Health Policy Analysis

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Brief No. 2021-6 May 2021 http://www. public-health, uiowa,edu/rupri/

 

Medicare Advantage Enrollment Update 2020

Redwan Bin Abdul Baten, MPH; Fred Ulirich, BA; and Keith Mueller, PhD

Background and Purpose

This policy brief continues the RUPRI Center's annual series of Medicare Advantage (MA)
enrollment updates. In addition to tracking overall and nonmetropolitan/metropolitan
enrollment, this brief also reports on changes in enrollment in types of MA plans. The
Center's ongoing line of inquiry also considers policy changes from previous years that may
have impacted MA plan enrollment.

Key Findings

e Overall MA enrollment increased by 9.4 percent (2.1 million) from 2019 to 2020; in
nonmetropolitan counties, the increase was 13.8 percent.

e Between 2019 and 2020, the proportion of nonmetropolitan MA enrollees in Health
Maintenance Organization (HMO) plans increased from 32.7 percent to 35.2 percent,
but decreased in metropolitan counties from 65.0 percent to 64.3 percent.

e Local Preferred Provider Organization (PPO) enrollment increased in both
nonmetropolitan (from 45.2 percent to 46.6 percent) and metropolitan (from 29.0
percent to 30.7 percent) areas.

Methods

Monthly MA enrollment data for March 2020 were downloaded from Centers for Medicare &
Medicaid Services (CMS) web sites [1]. March enrollment data are used in this series of
annual updates because it is the first month after open enrollment closes each year and
reflects net enrollment each year. Nonmetropolitan/metropolitan designations (based on
Urban Influence Code) were used because data were reported by county. The terms rura/ and
nonmetropolitan are used interchangeably in this brief.

Results / Findings

As of March 2020, 24.1 million beneficiaries were enrolled in MA plans, which is 36.1 percent
of all Medicare beneficiaries (Figure 1). The total number of MA beneficiaries increased by 9.4
percent (2.1 million) between 2019 and 2020. While nonmetropolitan counties had a lower
rate of participation than metropolitan counties (38.0 percent compared to 27.5 percent), the
rate of enrollment growth was higher (13.8 percent compared to 8.7 percent).

The patterns of enrollment in type of MA plan varied between nonmetropolitan and
metropolitan areas (Tables la, 1b, 1c). Between 2019 and 2020, HMO enrollment in
nonmetropolitan areas increased from 32.7 percent to 35.2 percent, whereas in metropolitan

rusoril

Rural Health Research
& Policy Centers RURAL POLICY RESEARCH INSTITUTE
Funded by the Federal Office of Rural Health Policy

www.rurathealthresearch.org RUPRI Center for Rural Health Policy Analysis,

University of Iowa College of Public Health,

This project was supported by the Federal Office of Rural Health Policy (FORHP), Depart t of Health M t and Poli
Health Resources and Services Administration (HRSA), U.S. Department of Health and 145 Riverside Dr Towa City, IA 52242-2007"
Human Services (HHS) under cooperative agreement/grant 1U1GRH07633. The (319) 384-3830 i ' '
information, conclusions and opinions expressed in this policy brief are those of the http://www. public-health. uiowa.edu/rupri

 

authors and no endorsement by FORHP, HRSA, or HHS is intended or should be E-mail: cph-rupri-inquiries@uiowa.edu
areas, HMO enrollment decreased from 65.0 percent to 64.3 percent. Local PPO enrollment
increased in both nonmetropolitan (from 45.2 percent to 46.6 percent) and metropolitan
(from 29.0 percent to 30.7 percent) areas. On the other hand, regional PPO enrollment
continued to decrease in both nonmetropolitan (from 14.6 percent to 12.1 percent) and
metropolitan (from 4.3 percent to 3.6 percent) areas. In keeping with the trends of the past
few years, enrollment in Private Fee-For-Service (PFFS) and other types of plan continued to
decline in 2020.

National and state-specific maps and tables of MA enrollment can be found at
http: //ruprihealth.org/maupdates/nstablesmaps.html

Figure 1. Medicare Advantage Enrollment, March 2009-March 2020

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

 

Nonmet./ Count Pct.

Year Metro. (x1,000) | Enroll.
Nonmet. 3,272 | 27.5%

2020 | Metro. 20,860 | 38.0% © 3.3M ees 2 200Mien S | 38.0%
Total 24,131 | 36.1% 36.1%
Nonmet. 2,874 | 25.6% || '

2019 | Metro. 19,190 | 37.0% ; 37.0%
Total 22,064 | 35.0% ; 35.0%
Nonmet. 2,639 | 24.6% F

2018 | Metro. 17,889 | 36.4% 36.4%
Total 20,529 | 34.3%

Nonmet. 2,410 | 23.5% |

2017 | Metro. 16,641 | 35.7% ¢24M 166M 7 | 35.7%
Total 19,050 | 33.5%

Nonmet. 2,225 | 22.1%

2016 | Metro. 15,423 | 34.1%
Total 17,648 | 31.9%
Nonmet. 2,115 | 21.6%

2015 | Metro. 14,619 | 33.5%
Total 16,733 | 31.3%
Nonmet. 1,966 | 20.5%

2014 | Metro. 13,456 | 31.7%
Total 15,422 | 29.7%
Nonmet. 1,753 | 18.6%

2013 | Metro. 12,339 | 30.0%
Total 14,093 | 27.9%
Nonmet. 1,559 | 17.0%

2012 | Metro. 11,304 | 28.6%
Total 12,863 | 26.4%
Nonmet. 1,394 | 15.6%

2011 | Metro. 10,359 | 27.2%
Total 11,753 | 25.0%
Nonmet. 1,300 | 14.8%

2010 | Metro. 9,744 | 26.3% Oo Total
Total 11,044 | 24.1% oO Metro.
Nonmet. 1,222 | 14.1% O some

2009 | Metro. 9,224 | 25.5% 25.5% 22. ices
Total 10,446 | 23.3% 23.3% - #- Nonmetro.

0% 10% 20% 30% 40%

 

 

 

Source: RUPRI Center for Rural Health Policy Analysis, analysis of Centers for Medicare & Medicaid Services' Medicare Advantage
enrollment data.
Figure 2. Metropolitan and Nonmetropolitan Medicare Advantage Enrollment,
by Plan Type*, March 2009-March 2020

 

 

 

 

 

 

 

 

 

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MN) HMOs Hi Local PPOs Hi Regional PPOs
i PFFS plans Other ff Unattributed

 

 

 

 

 

 

Source: RUPRI Center for Rural Health Policy Analysis, analysis of Centers for Medicare & Medicaid Services' Medicare Advantage
enrollment data.

* 'Other' plans include 1876 Cost, HCPP - 1833 Cost, and National PACE plans. 'Unattributed' refers to beneficiaries that could
not be assigned to a plan type because of CMS reporting restrictions on county/plans with 10 or fewer enrollees.

Table 1a. Overall Medicare Advantage Enrollment by Plan Type*, March
2009-March 2020

 

 

 

 

 

 

 

 

 

 

 

 

 

Total MA % Total Regional
Year Enrollees Enrolled HMO Local PPO PPO PFFS Plan Other Unatt.
2020 | 24,131,468 36.1% 60.3% 32.9% 4.8% 0.3% 1.3% 0.4%
2019 | 22,063,990 35.0% 60.8% 31.1% 5.6% 0.5% 1.4% 0.5%
2018 | 20,528,576 34.3% 61.1% 27.6% 6.4% 0.7% 3.6% 0.5%
2017 | 19,050,353 33.5% 61.8% 25.9% 7.1% 1.0% 3.8% 0.5%
2016 | 17,647,860 31.9% 63.5% 23.5% 7.4% 1.3% 3.8% 0.5%
2015 | 16,733,384 31.3% 62.9% 23.9% 7.4% 1.5% 3.8% 0.6%
2014 | 15,421,808 29.7% 62.3% 23.6% 7.9% 2.0% 3.6% 0.6%
2013 | 14,092,553 27.9% 63.2% 22.1% 7.5% 2.9% 3.6% 0.7%
2012 | 12,863,257 26.4% 62.6% 21.4% 7.2% 3.9% 4.0% 0.9%
2011 | 11,752,518 25.0% 62.8% 17.7% 9.6% 4.9% 4.0% 1.0%
2010 | 11,043,656 24.1% 62.1% 11.2% 7.0% 14.5% 3.9% 1.4%
2009 | 10,445,905 23.3% 61.3% 7.9% 3.6% 22.1% 3.7% 1.3%

 

 

 

 

 

 

 

 

 

 

 

3
Table 1b. Nonmetropolitan Medicare Advantage Enrollment by Plan Type, March
2009-2020

 

 

 

 

 

 

 

 

 

 

 

 

 

Total MA % Total Regional
Year Enrollees Enrolled HMO Local PPO PPO PFFS Plan Other Unatt.
2020 3,271,679 27.5% 35.2% 46.6% 12.1% 1.2% 3.6% 1.3%
2019 2,874,083 25.6% 32.7% 45.2% 14.6% 2.0% 4.1% 1.3%
2018 2,639,354 24.6% 30.4% 40.5% 16.4% 2.9% 8.3% 1.4%
2017 2,409,502 23.5% 29.8% 38.5% 17.7% 3.8% 8.8% 1.5%
2016 2,225,321 22.1% 29.9% 37.3% 17.5% 5.0% 8.6% 1.6%
2015 2,114,836 21.6% 28.5% 38.6% 17.2% 5.6% 8.4% 1.7%
2014 1,966,261 20.5% 27.9% 37.0% 18.5% 6.8% 7.8% 1.9%
2013 1,753,427 18.6% 28.0% 34.1% 17.4% 10.4% 7.8% 2.3%
2012 1,559,261 17.0% 26.8% 31.6% 16.7% 14.1% 7.9% 2.9%
2011 1,393,984 15.6% 26.1% 25.8% 20.0% 17.0% 7.9% 3.2%
2010 1,299,589 14.8% 23.6% 13.1% 14.0% 37.9% 6.8% 4.6%
2009 1,222,259 14.1% 20.9% 6.8% 7.3% 54.5% 5.9% 4.6%

 

 

 

 

 

 

 

 

 

 

 

Table ic. Metropolitan Medicare Advantage Enrollment by Plan Type, March
2009-2020, Metropolitan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total MA % Total Regional
Year Enrollees Enrolled HMO Local PPO PPO PFFS Plan Other Unatt.
2020 20,859,789 38.0% 64.3% 30.7% 3.6% 0.2% 0.9% 0.3%
2019 19,189,907 37.0% 65.0% 29.0% 4.3% 0.3% 1.0% 0.3%
2018 17,889,222 36.4% 65.6% 25.7% 4.9% 0.4% 2.9% 0.4%
2017 16,640,851 35.7% 66.4% 24.1% 5.5% 0.6% 3.1% 0.4%
2016 15,422,539 34.1% 68.3% 21.5% 6.0% 0.8% 3.1% 0.4%
2015 14,618,548 33.5% 67.9% 21.8% 5.9% 0.9% 3.1% 0.4%
2014 13,455,547 31.7% 67.3% 21.7% 6.4% 1.3% 3.0% 0.4%
2013 12,339,126 30.0% 68.3% 20.4% 6.1% 1.8% 3.0% 0.5%
2012 11,303,996 28.6% 67.6% 20.0% 5.9% 2.5% 3.4% 0.6%
2011 10,358,534 27.2% 67.7% 16.6% 8.2% 3.3% 3.5% 0.8%
2010 9,744,067 26.3% 67.2% 10.9% 6.0% 11.4% 3.5% 0.9%
2009 9,223,646 25.5% 66.7% 8.1% 3.2% 17.8% 3.5% 0.8%

 

Source: RUPRI Center for Rural Health Policy Analysis, analysis of Centers for Medicare & Medicaid Services' Medicare
Advantage enrollment data.

* 'Other' plans include 1876 Cost, HCPP - 1833 Cost, and National PACE plans. 'Unattributed' refers to beneficiaries that
could not be assigned to a plan type because of CMS reporting restrictions on county/plans with 10 or fewer enrollees.

Discussion

Overall enrollment in MA plans grew by 9.4 percent from 2019 to 2020, with faster
growth in nonmetropolitan areas (13.8 percent) compared to metropolitan areas (8.7
percent). At first glance, this growth seems counterintuitive to the policy changes made
to the MA program by the 2010 Patient Protection and Affordable Care Act (PPACA). In an
attempt to control rising MA costs, the PPACA introduced a number of modifications to
the program, including changing payment rate calculations and lowering rebate amounts
[2]. Despite these payment cuts, several factors contributed to the continued growth of
the MA program:

e Most MA plans responded to the PPACA payment cuts by containing costs through
revenue-enhancing and cost-saving measures [3].

e The PPACA included a six-year phase-in period for changes to be rolled out, which
may have given MA plans adequate time to adjust to payment reductions [4].

4
e Plans have been eligible for direct bonuses since 2012, which is conditioned on
meeting certain quality ratings [4]. In 2018, the bonus payments were estimated
to exceed $6 billion ($27 per member per month) [5].

e Some plans have consolidated, allowing them to obtain larger quality bonuses [6].

e Over time, MA plans are coding relevant patient diagnoses more completely than
traditional Medicare [7]. This has increased their risk scores and increased risk
adjustment payments to MA plans [3].

Other factors affecting the growth in MA enrollment may include:

e MA plans offer added benefits to beneficiaries that are unavailable in traditional
Medicare plans [8] [9]. MA plans have also kept their premiums low or even zero
[10].

e Higher MA enrollment in certain geographic areas has been found to be associated
with higher numbers of plans with $0 premiums and higher star ratings [2].

e MA plans have a wider array of plan characteristics such as payment options (e.g.
premium levels and out-of-pocket costs) and types of services covered [4] than
traditional Medicare. Further, there is evidence that the quality of MA plans
(including patient satisfaction) "meets and at times exceeds that of traditional
Medicare."[11]. This leads to increased satisfaction, translating into plan
'stickiness' i.e., staying in the same plan year after year [12] [13]. This stickiness
may carry over from the experiences of younger/newer Medicare beneficiaries,
who are more comfortable with managed care plans [4].

As a result of these factors, enrollment in MA plans have more than doubled since 2009,
from 10.4 million to 24.1 million beneficiaries. In 2021, Medicare beneficiaries have
access to an average of 33 MA plans, up from 28 MA plans in 2020 [14]. More than a
quarter of enrollees (27 percent) can choose from plans offered by 10 or more firms.
Overall, in 2021 3,550 MA plans are available nationwide for individual enrollment - a 13
percent increase (402 more plans) from 2020. However, beneficiaries in nonmetropolitan
areas can (on average) choose from about half as many Medicare Advantage plans as
beneficiaries in metropolitan areas (20 plans versus 36 plans, respectively) [15].

Looking ahead, several additional changes to the MA landscape are likely to enhance the
attractiveness of the program to Medicare beneficiaries:

e Beginning in 2020, Medicare Advantage plans have been able to offer
supplemental benefits that are not primarily health related for chronically ill
beneficiaries, known as Special Supplemental Benefits for the Chronically III
(SSBCI) [16].

e CMS announced that the average 2021 premiums for Medicare Advantage plans
are expected to decline 34.2 percent from 2017 [17].

It is unclear whether any of these changes will have a differential impact on MA
enrollment in nonmetropolitan and metropolitan areas. RUPRI will continue to monitor
these policy changes and trends in MA enrollment.
References

[1] CMS, "Monthly MA Enrollment by State/County/Contract," Centers for Medicare and Medicaid Services,
2020. [Online]. Available: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-
Trends-and-Reports/MCRAdvPartDEnrolData/Monthly-MA-Enrollment-by-State-County-Contract.
[Accessed 01 02 2021].

[2] L. Skopec, S. Zuckerman, E. H. Allen and J. Aarons, "Why Did Medicare Advantage Enrollment Grow As
Payment Pressure Increased? Examining the Role of Market and Demographic Changes," Urban Institute,
2019.

[3] S. Guterman, L. Skopec and S. Zuckerman, "Do Medicare Advantage Plans Respond to Payment
Changes? A Look at the Data from 2009 to 2014," The Commonwealth Fund, Washington DC., 2018.

[4] A. D. Sinaiko and R. Zeckhauser, "Medicare Advantage: What Explains Its Robust Health?," The
American Journal of Managed Care, vol. 21, no. 11, 2015.

[5] P. Neuman and G. A. Jacobson, "Medicare Advantage Checkup," New England Journal of Medicine, vol.
379, no. 22, pp. 2163-2172, 2018.

[6] MedPAC, "Report to Congress: Medicare Payment Policy," Medicare Payment Advisory Committee,
Washington, DC, 2018.

[7] R. Kronick, "Projected Coding Intensity In Medicare Advantage Could Increase Medicare Spending By
$200 Billion Over Ten Years," Health Affairs, vol. 36, no. 2, pp. 320-327, 2017.

[8] J. M. Friedman, B. L. Swanson, M. G. Yeh and J. J. Cates, "State of the 2020 Medicare Advantage
industry: As strong as ever," 2020.

[9] J. Semprini, F. Ullrich and K. Mueller, "Availability of Supplemental Benefits in Medicare Advantage,"
February 2021. [Online]. Available:
https: //ruprihealth.org/publications/policybriefs/2021/MA%20plans%20supplemental%20benefits. pdf.

[10] A. D. Sinaiko, C. C. Afendulis and R. G. Frank, "Enrollment in Medicare Advantage Plans in Miami-Dade
County: Evidence of Status Quo Bias?," INQUIRY: The Journal of Health Care Organization, Provision,
and Financing, vol. 50, no. 3, pp. 202-215, 2013.

[11] J. P. Newhouse and T. G. Mcguire, "How Successful Is Medicare Advantage?," The Milbank Quarterly, vol.
92, no. 2, pp. 351-394, 2014.

[12] M. Rivera-Hernandez, K. L. Blackwood, K. A. Moody and A. N. Trivedi, "Plan Switching and Stickiness in
Medicare Advantage: A Qualitative Interview With Medicare Advantage Beneficiaries," Medical Care
Research and Review, 2020.

[13] G. Jacobson, T. Neuman and A. Damico, "Medicare Advantage Plan Switching: Exception or Norm?,"
Kaiser Family Foundation, 2016.

[14] G. Jacobson, M. Freed, A. Damico and T. Neuman, "Medicare Advantage 2020 Spotlight: First Look,"
2019.

[15] J. F. Biniek, M. Freed, A. Damico and T. Neuman, "Medicare Advantage 2021 Spotlight: First Look,"
2020.

[16] K. Coleman, "Implementing Supplemental Benefits for Chronically Ill Enrollees," DEPARTMENT OF
HEALTH & HUMAN SERVICES, [Online]. Available: https://www.hhs.gov/guidance/sites/default/files/hhs-
guidance-documents/Supplemental_Benefits_Chronically_IIIHPMS_042419.pdf. [Accessed 17 01 2021].

[17] CMS, "2021 Medicare Parts A & B Premiums and Deductibles," U.S Centers for Medicare and Medicaid
Services, 2020. [Online]. Available: https://www.cms.gov/newsroom/fact-sheets/2021-medicare-parts-
b-premiums-and-deductibles. [Accessed 27 01 2021].

Suggested Citation
Bin Abdul Baten R, Ullrich F, Mueller K. Medicare Advantage Enrollment Update 2020. RUPRI
Center for Rural Health Policy Analysis, May 2021-6.

6