During the Medicare open enrollment period from October 15 to December 7 each year, beneficiaries can enroll in a plan that provides Part D drug coverage, either a stand-alone prescription drug plan (PDP) as a supplement to traditional Medicare, or a Medicare Advantage prescription drug plan (MA-PD), which provides all Medicare-covered benefits including drugs. Part D plans vary in numerous ways that can have a significant effect on an enrollee’s out-of-pocket spending, including premiums, deductibles, cost sharing, tier placement, the list of covered drugs, and preferred pharmacies.

This issue brief provides an overview of the 2018 Part D PDP landscape, the largest segment of the Part D marketplace, with 20.4 million enrollees in 2017 (excluding enrollees in employer-only PDPs, for whom plan premium and benefits data are unavailable). For detail on the data and methods, see the Methods section.

Key Findings

• For 2018, Medicare beneficiaries will have a choice of 23 Medicare Part D stand-alone PDPs and 17 MA-PD plans in their area, on average.
• The average monthly PDP premium will increase by 9 percent from 2017 t0 2018, to $43.48, weighted by 2017 plan enrollment. This estimate includes premiums for both basic and enhanced PDPs, assumes current PDP enrollees remain in their same plan, and makes no assumptions about plan choices by new enrollees or reassignment of low-income beneficiaries.
• PDP premiums vary widely across plans in 2018. Among the 10 PDPs with the highest enrollment, average premiums will range from $20.21 per month ($243 per year) for Humana Walmart Rx to $83.68 per month ($1,004 per year) for AARP Medicare Rx Preferred (Figure S1).
• Almost all PDPs in 2018 have five cost-sharing tiers, but specific copayments and coinsurance rates vary widely across PDPs. Nearly all PDPs charge coinsurance for higher-cost specialty and non-preferred drugs, which usually results in higher out-of-pocket costs for enrollees than when plans charge copayments.
• Medicare beneficiaries receiving the Low-Income Subsidy (LIS) will have a choice of six premium-free PDPs in 2018, on average. In 2018, 1.4 million low-income beneficiaries who are eligible for premium-free Part D coverage will pay Part D premiums averaging nearly $26 per month, unless they switch or are reassigned by CMS to premium-free plans.

Findings

Part D Plan Availability

In 2018, beneficiaries across the country continue to have a substantial number of Part D plan choices.

• The average beneficiary will have a choice of 23 PDPs in 2018, compared to 22 in 2017 and 56 at the peak in 2007 (Figure 1). In 2018, beneficiaries will also have access to 17 MA-PD plans, on average, up from 16 in 2017.

• The number of PDPs per region in 2018 will range from 19 PDPs in Alaska to 26 PDPs in the Pennsylvania/West Virginia region (Figure 2; Appendix 1, Table A1). The number of PDPs increased by one in every region compared to 2017, except Pennsylvania/West Virginia and North Carolina which have 2 more PDPs in 2018 than in 2017.

• A total of 782 PDPs will be offered nationwide in the 34 PDP regions in 2018, excluding PDPs in the territories. This represents an increase of 36 PDPs, or 5 percent, since 2017, but a reduction of 104 plans, or 12 percent, since 2016 (Figure 3). This total includes two plans that are under sanction and thus not open to new enrollment for 2018. There are no new plan sponsors offering PDPs in 2018, but there are new offerings by existing plan sponsors.

• The number of PDPs in 2018 represents less than half the number offered at the peak level of 1,866 plans in 2007. The reduction in plan availability over time reflects both the cumulative effect of mergers among plan sponsors and the response to CMS policies that encourage plan sponsors to eliminate low-enrollment plans and to drop multiple PDPs that are not meaningfully different from each other.

Premiums

National Premium Trends

The national average monthly PDP premium is expected to increase for the third year in a row—by 9 percent for 2018—based on current enrollment and assuming enrollees do not change plans. Even if a number of beneficiaries switch or are reassigned to lower-premium plans for 2018, the average premium is likely to be higher in 2018 than in 2017, and the three-year increase over the 2015 average premium will mark a significant shift upward.

• The projected average monthly PDP premium for 2018 will be $43.48 (Figure 4). This represents a 9 percent projected increase ($3.58) from the weighted average monthly premium of $39.90 in 2017, and a 68 percent increase from $25.89 in 2006, the first year of the Medicare Part D drug benefit. The 2017 and 2018 estimates are weighted by September 2017 enrollment. The 2018 estimate assumes that beneficiaries remain in their current plan and does not take into account the impact of the Low-Income Subsidy (LIS), which lowers or eliminates premiums for qualifying beneficiaries.

• CMS reported that the average premium for basic Part D coverage offered by PDPs and Medicare Advantage drug plans will be an estimated $33.50 in 2018. The premium reported here differs from the CMS-published premium because our estimate is based on PDPs only and includes PDPs offering both basic and enhanced coverage; enhanced plans typically have higher premiums than basic plans. Our premium estimate does not make any assumptions about plan changes by current PDP enrollees, reassignment of Low-Income Subsidy (LIS) enrollees by CMS, or enrollment decisions by new PDP enrollees.
• In prior years, the average premium calculated after taking into account enrollment decisions made during the open enrollment period has been 4 percent to 6 percent lower than the projection made assuming beneficiaries remain in their current plan. The difference is a result of existing enrollees switching to a lower premium plan, new enrollees choosing low-premium plans, and reassignments of some LIS beneficiaries to lower-premium plans. For example, the weighted average premium in March 2017, after plan elections for 2017 went into effect, was $40.42, which is 4 percent ($1.78) below the projected premium of $42.20 calculated prior to enrollment changes. Applying a similar adjustment to our projected premium for 2018 would produce a lower average premium after open enrollment, but one that would still be higher than in any previous year.

Distribution of PDP Enrollment by Premium Amount

• Among the 12.6 millionPart D PDP enrollees who are responsible for paying the entire premium (which excludes LIS recipients), many enrollees pay premiums that are well above the national average. In 2018, over one-third of PDP enrollees not receiving the LIS (35 percent) are projected to pay monthly premiums of at least $60 if they stay in their current plans (Figure 5). Among them, more than 380,000 (3 percent of non-LIS enrollees) are projected to pay monthly premiums of at least $100.

• The share of non-LIS enrollees who will pay monthly premiums less than $20 if they stay in their current plan is projected to decline substantially between 2017 and 2018—from 20 percent of all non-LIS enrollees in 2017 to 4 percent in 2018—while the share of non-LIS enrollees paying between $20 and $40 per month is expected to increase from 40 percent in 2017 to 49 percent in 2018.

Premium Variation and Changes for PDPs with the Most Enrollees

PDP premiums will continue to vary widely by plan in 2018, as in previous years.

• Among the 10 PDPs with the highest enrollment, average PDP premiums in 2018 will range from a low of $20.21 per month, or $243 annually, for the Humana Walmart Rx PDP to a high of $83.68 per month, or $1,004 annually, for the AARP MedicareRx Preferred PDP (Figure 6).

• There is no national PDP available in all 34 regions for under $20 in 2018, in contrast to previous years, although in 25 of 34 regions, there is at least one PDP with a premium under $20. The EnvisionRxPlus PDP is available in 12 regions for $12.60, while Humana Walmart Rx PDP is available in 2 regions for $18.40 (but $20.40 in 32 regions). Five different sponsors have the lowest premium in at least one region.
• At the high end, 14 PDPs have premiums of at least $125 per month. The highest is $197.10 for Blue Cross MedicareRx Plus PDP in Texas. None of these PDPs, which are mostly offered by sponsors that serve only one region or a few regions, has more than 51,000 enrollees in 2017.

Changes to premiums from 2017 to 2018, averaged across regions and weighted by 2017 enrollment, also vary widely across some of the most popular PDPs, as do the absolute amounts of monthly premiums for 2018  (Table 1).

• Average premiums for 8 of the 10 largest PDPs are projected to increase for 2018, by about $8 per month on average, assuming current enrollees do not switch plans (Figure 7). For 7 of the 8 PDPs, the increase is at least 15 percent—nearly twice as large as the rate of increase in the national average premium. For two of these PDPs (First Health Part D Value Plus and Cigna-HealthSpring Rx Secure) the increase is more than 25 percent. In dollar terms, the weighted average monthly premium is projected to increase by more than $10 for three of the 10 largest PDPs.

• Enrollees in the PDP with the most enrollees in 2017, SilverScript Choice (4.2 million enrollees), will see a 9 percent reduction in their monthly premium for 2018 if they remain in the same plan, from $29.05 to $26.39. The only other PDP among the top 10 that is lowering its monthly premium is Aetna Medicare Rx Saver, with a 5 percent reduction in the monthly premium.
• Enrollees in the second largest PDP, UnitedHealth’s AARP MedicareRx Preferred (2.8 million enrollees), will face a 17 percent increase in the average monthly premium, from $71.66 to $83.68. Of the 10 most popular PDPs, this plan is projected to have the highest monthly premium in 2018, as it did in 2017.

Monthly premiums for the three most popular PDPs available since the start of the Part D program in 2006 have changed in substantially different ways. Whereas one of the oldest PDPs is projected to have a lower premium in 2018 than in 2006, the other two PDPs have raised premiums repeatedly.

• The monthly premium for SilverScript Choice, with the highest number of PDP enrollees overall (4.2 million enrollees in 2017), is 7 percent lower in 2018 ($26.39) than it was in 2006 ($28.32).
• By contrast, the average premium for Humana Enhanced PDP, with 0.9 million enrollees in 2017, is more than five times higher than it was in 2006, having increased from $14.13 to $75.82.
• The average premium for UnitedHealth’s AARP Preferred MedicareRx PDP, the PDP with the second highest number of enrollees in 2017 (2.8 million), has more than tripled since 2006, from $26.32 to $83.68 in 2018.

Premium Variation and Changes by Region

Average PDP monthly premiums, weighted by 2017 enrollment, will vary in 2018 across regions, along with the change in premiums from 2017 to 2018.

• Average PDP premiums will range from $34.61 per month in the Arkansas region (one of only three regions with an average around $35) to $49.34 per month in New Jersey—40 percent higher than in Arkansas (Figure 8; Appendix 1, Table A2). Three other large states (California, Florida, and New York) have projected average premiums around $47, above the national average.

• Projected average premiums are higher in 2018 than in 2017 in every region, but the level of increase varies by region. For example, the average premium in New Jersey is projected to rise by 1 percent and by no more than 6 percent in three other regions. By contrast, average premiums will increase by more than 10 percent in 13 regions, including an increase of 17 percent in both Colorado and New Mexico.

Premium Increases and Decreases for Current Enrollees

Overall, more Part D enrollees are projected to face higher premiums in 2018 if they stay in their current plans, compared to the share of enrollees who were facing projected increases for 2017. And a larger share of current enrollees will see premiums increase than decrease if they remain in their current plan (Figure 9).

• Among the 12.6 millionPart D PDP enrollees who are responsible for paying the entire premium (which excludes LIS recipients), nearly three-fourths (73 percent) are projected to have a higher premium in 2018 if they stay in their current plans, compared to 63 percent who faced higher premiums if they didn’t switch plans for 2017.
• More than one-third of non-LIS enrollees (34 percent, or 4.2 million) are projected to have a premium increase of at least $10 per month if they remain in their current plans. By contrast, 2 percent (about 248,000 non-LIS PDP enrollees) are projected to see their premiums decrease by $10 or more.
• For non-LIS enrollees facing a projected premium increase, the average monthly increase will be $8.50. Those projected to see lower premiums will experience a smaller change—an average reduction of $4.71.

Benefit Design

In 2018, for the third year in a row, all Part D PDPs will offer an alternative benefit design to the defined standard benefit, which has a $405 deductible in 2018 and 25 percent coinsurance for all covered drugs. Some plans modify or eliminate the deductible, and virtually all PDPs will have a benefit design with five tiers for covered generic and brand-name drugs.

Basic versus Enhanced Benefits

Part D plans must offer either the defined standard benefit or an alternative equal in value (“actuarially equivalent”), which is the basic Part D benefit, and can also provide enhanced benefits.

• In 2018, almost half (46 percent) of plans will offer basic Part D benefits (although no plans will offer the defined standard benefit), while 54 percent will offer enhanced benefits (Figure 10). This is similar to the distribution in 2017, but over time, the share of PDPs offering enhanced benefits has increased while the share offering basic benefits has decreased.

• The weighted average premium in 2018 for enhanced benefit PDPs ($60.48) is nearly double the monthly premium for PDPs offering the basic benefit ($31.60), assuming no change in enrollment. The weighted average premium is projected to increase by 2 percent for basic-benefit PDPs, from $31.12 in 2017 to $31.60 in 2018, but by a much larger 15 percent for enhanced-benefit PDPs, from $52.48 to $60.48. In 2017, 41 percent of PDP enrollees were in enhanced-benefit plans.

Deductibles

The standard (maximum) Part D deductible is increasing by a modest $5 in 2018 from $400 to $405, compared to a $40 increase between 2016 and 2017 (from $360 to $400). The increase results from a statutory formula that adjusts the amount each year based on the annual percentage increase in average per capita aggregate expenditures for covered Part D drugs, and prior year revisions. For 2018, the annual percentage increase was 1.22 percent. Other amounts for the standard benefit design parameters are increasing by this percentage as well (Appendix 2).

• Nearly two-thirds of PDPs (63 percent) will charge a deductible in 2018, the same share as in 2017 (Figure 11). More than half of PDPs with a deductible will charge the standard $405 amount (52 percent), a somewhat larger share than in 2017. Another 11 percent of all PDPs charge a partial deductible, an amount below the standard deductible.

• Part D enrollees are projected to be in plans with a deductible of $207 in 2018, on average (Figure 12). This is unchanged from the weighted average deductible in 2017, but the average is up from $107 in 2006—a 93 percent increase, substantially higher than the increase in the average premium.

Tiered Cost Sharing

• As in recent years, all PDPs in 2018 will use tiered cost sharing; all but two PDPs (two local plans offered by the same plan sponsor, with few enrollees) will have five tiers. The typical five-tier design includes tiers for preferred generics, generics, preferred brands, non-preferred drugs (including a mix of brands and generics), and specialty drugs. Five-tier formularies have been the most common type since 2013.
• Overall, PDP cost-sharing amounts in 2018 are relatively similar to 2017 levels. For generic tiers, median copayments across PDPs are $1 for the preferred generic tier and $6 for the generic tier (formerly labeled the non-preferred generic tier in plans with two generic tiers). About 1 in 5 PDPs (19 percent) charge $0 for preferred generics to encourage use of these drugs, whereas a few charge $5 or more. A small number of PDPs charge $0 for both of their generic tiers. Copayments for generics (those not designated as preferred) vary more widely—from $0 to $20.
• Most PDPs charge copayments for preferred brand tiers, but one-fourth of PDPs in 2018 (24 percent) charge coinsurance. For preferred brand tiers, the median copayment in 2018 is $37, varying from $18 to $47; the median coinsurance rate is 20 percent.
• PDPs have increasingly charged coinsurance in place of flat copayments for non-preferred drugs, previously labeled non-preferred brands—often more expensive drugs or those for which plans have not negotiated large rebates from manufacturers. In 2018, virtually all PDPs are using coinsurance for their non-preferred drug tiers. The median coinsurance PDPs charge for non-preferred drugs is 40 percent, but coinsurance rates range from 24 percent to 50 percent.
• Since 2006, nearly all PDPs have charged coinsurance for the specialty tier. In 2018, the threshold for drugs to qualify for placement on a specialty tier is $670 for a one-month supply of the drug, the same as in 2017. For all PDPs, the specialty tier coinsurance ranges from 25 percent to 33 percent (the most allowed by CMS guidelines); most PDPs charge either 25 percent or 33 percent.

Tiered Cost Sharing in PDPs with the Most Enrollees

• Cost sharing for the ten largest PDPs varies across plans (Table 2). Two of the largest PDPs (Humana Preferred and WellCare Classic) have a $0 copayment for preferred generic drugs in 2018. Median copayments for generics range from $1 to $14 among the ten largest PDPs.
• Eight of the 10 largest PDPs charge copayments for preferred brands, varying from $30 (Aetna Medicare Rx Saver) to $47 (First Value Part D Value Plus). Three of the top PDPs reduced their copayments for preferred brands between 2017 and 2018. One of the top PDPs (AARP MedicareRx Saver Plus) increased its preferred brand copayment from $21 to $32.
• Coinsurance for non-preferred drugs varies in 2018 from 35 percent for three of the top PDPs to 50 percent (First Health Part D Value Plus), the maximum allowed by CMS guidance. Two of the top ten PDPs reduced the coinsurance for non-preferred brands (SilverScript Choice and WellCare Classic), but one PDP increased its coinsurance rate from 30 percent to 39 percent (AARP Medicare Rx Saver Plus).
• Five of the top PDPs use 25 percent coinsurance for their specialty tiers, the maximum allowed for plans with a standard deductible. One top PDP charges 26 percent coinsurance for specialty tier drugs, while the remaining four top PDPs charge 33 percent.

Gap Coverage

In 2018, most Part D plans will offer no gap coverage beyond what is required under the basic benefit; because of the Affordable Care Act provision to gradually close the gap by 2020, all enrollees will have substantial coverage in the gap regardless of which plan they are enrolled in. Under the basic benefit, in 2018, manufacturer prices for brand-name drugs purchased in the gap phase of the benefit will be discounted by 50 percent, with plans paying an additional 15 percent of the cost and enrollees responsible for 35 percent. Plans will pay 56 percent of the cost for generic drugs in the gap phase, with enrollees paying 44 percent.

• In 2018, 35 percent of all PDPs will offer some additional gap coverage beyond what the basic benefit covers, an increase from 28 percent in 2017 (Figure 13). UnitedHealth’s AARP MedicareRx Preferred expanded additional gap coverage from two PDP regions in 2017 to all 34 regions in 2018, and Aetna Medicare Rx Select, a new PDP in 2018, will offer additional gap coverage in the 20 regions where this plan is available.

• Plans that offer additional gap coverage charge significantly higher premiums than those that do not. In 2018, the average monthly premium for PDPs with additional gap coverage will be $79.92, versus $30.92 for PDPs with no additional gap coverage beyond what the basic benefit covers. Given the level of gap coverage that all plans are required to provide, the value of the additional gap coverage may not be worth the extra $50, on average, for plans that offer it.

Low-income Subsidy (Benchmark) Plans

In 2018, the total number of premium-free benchmark plans—that is, PDPs available for no monthly premium to Low-Income Subsidy (LIS) enrollees—will be lower than in 2017 and the lowest level since the program started in 2006 (Figure 14; Appendix 1, Table A3).

• In 2018, 216 plans will be premium-free benchmark plans available for enrollment of beneficiaries receiving the LIS. This represents a decrease of 15 PDPs qualifying as benchmark plans (a 6% decrease) from 2017 and the lowest number of benchmark plans available since the start of the Part D program in 2006.
• On average (weighted by enrollment), LIS beneficiaries have 6 benchmark plans available to them for 2018, or about one-fourth the average number of PDP choices available overall. All LIS enrollees can select any plan offered in their area, but if they enroll in a non-benchmark plan, they must pay some portion of their chosen plan’s monthly premium.
• Of the 216 benchmark plans in 2018, 14 plans qualify through the “de minimis” policy—fewer than the 24 de minimis plans in 2017. The de minimis policy makes it easier for plans to qualify by allowing them to waive a premium amount of up to $2 in order to retain their LIS enrollees. Plans qualifying through the de minimis policy are eligible for new enrollees, but will not receive auto-assigned enrollees.
• Among the 2017 benchmark PDPs, two plans (AARP MedicareRx Saver Plus and Cigna-HealthSpring Rx Secure) lost their benchmark status in several regions, accounting for much of the decline in benchmark plan availability between 2017 and 2018. In total, 26 PDPs have lost their benchmark status for 2018, while 11 PDPs will newly qualify as benchmark plans.

Benchmark Plans by Region

• The number of benchmark plans available in 2018 will vary by region, from just two benchmark PDPs in Florida (out of 21 PDPs overall) to 10 benchmark PDPs in the Delaware/Maryland/District of Columbia region (out of 21 PDPs) (Figure 15).

• Benchmark plan availability will be unchanged in 10 of 34 regions between 2017 and 2018. Nineteen regions will experience a decline in of one or two benchmark plans, while five regions will experience an increase in benchmark plan availability of one or two plans.

Benchmark Plans by Sponsor

The number of premium-free plans for LIS enrollees offered by the three largest Part D sponsors (based on total enrollment)—CVS Health/SilverScript, Humana, and UnitedHealth—has fluctuated substantially over the years (Figure 16).

• In 2018, nearly two-thirds of LIS PDP enrollees (64 percent) are projected to be in PDPs operated by these three plan sponsors; including PDPs offered by Aetna brings to share up to 75 percent. All four sponsors offer PDPs that qualify as benchmark plans in at least 29 of the 34 PDP regions in 2018.
• For 2018, six PDP sponsors will offer benchmark plans in at least half of the 34 regions (including PDPs designated as de minimis plans, which will not receive auto-assigned enrollees). No sponsor will offer benchmark plans in all 34 regions in 2018; one sponsor (Aetna) will offer benchmark plans in 33 regions, and one sponsor (CVS Health) will do so in 32 regions.

Impact of Benchmark Plan Changes for Low-Income Subsidy Enrollees

• About 1.4 million LIS beneficiaries—nearly one in five LIS enrollees in PDPs in 2017 (19 percent)—are enrolled in PDPs in 2017 that will not qualify as benchmark plans in 2018 (Figure 17). CMS will reassign those LIS enrollees who were randomly assigned by CMS to their current plan, and several states will help reassign those enrolled in their state pharmacy assistance programs (SPAPs). Many other LIS beneficiaries who are currently not enrolled in plans that will be premium-free in 2018 must switch plans on their own or pay a premium if they remain in their 2017 plan. Those in the latter group will not be automatically reassigned by CMS because in the past they or someone assisting them made a choice to switch plans.

• On average, these 1.4 million LIS beneficiaries face PDP premiums that average $25.56 per month in 2018 ($307 per year) if they do not change plans or are not reassigned by CMS to new plans, compared to an average of $23.85 for LIS enrollees who faced premiums in 2017 if they stayed in their plans. Nearly half (49 percent) are projected to pay premiums of at least $20 per month, and 3 percent will pay at least $60 per month, if they do not switch plans. In 2017, LIS beneficiaries who paid monthly premiums for their coverage paid $26.65 on average.
• Among the LIS beneficiaries who may pay premiums in 2018, 38 percent (544,000) are in benchmark plans in 2017; the remaining 62 percent (903,000) are currently enrolled in non-benchmark plans and thus paid a premium in 2017. No one in the latter situation will be eligible for reassignment by CMS to a premium-free plan, and would need to switch to a premium-free plan on their own to avoid paying premiums. About half (46 percent) of the LIS enrollees who may pay premiums are in enhanced PDPs.
• About three-fourths of the 1.4 million LIS beneficiaries projected to pay premiums are currently enrolled in just five national PDPs: AARP MedicareRx Saver Plus (27 percent), AARP MedicareRx Preferred (23 percent), Humana Preferred (14 percent), First Health Part D Value Plus (7 percent), and Humana Enhanced (7 percent) (Figure 17). For two of these five PDPs, the affected LIS beneficiaries are projected to pay substantial premiums in 2018: $50.73 per month for the AARP MedicareRx Preferred PDP, and $44.89 for Humana Enhanced. Because they are enhanced PDPs, LIS enrollees in these two plans will not be reassigned to a new plan by CMS, so they must select a different plan in order to avoid paying these premiums.

Discussion

This analysis of the Medicare Part D PDP landscape for 2018 shows a modest increase in plan availability for 2018, along with wide variation in premiums across plans. Premium variation for plans similar in design could be due to a number of factors related to differences in plan costs and different market strategies across plan sponsors. For example, plan costs are influenced by the generosity in formulary coverage, tier placement and rebates, deductibles and cost-sharing amounts, use of preferred pharmacy networks, the health risk of enrollees, and geographic area. There is some evidence that some of the most popular PDPs that charge lower premiums have relatively narrow formulary coverage compared to PDPs charging higher premiums. Part D sponsors may also launch new PDPs with premiums well below the average, at least initially, in order to attract new or current enrollees to gain market share.

Part D plans vary in numerous ways that can have a significant effect on an enrollee’s out-of-pocket spending, including premiums, cost-sharing requirements, tier placement, the list of covered drugs, and preferred pharmacies. Although beneficiaries may focus on plan premiums as the primary measure of plan cost, an individual’s costs are also affected by the plan’s deductible, cost-sharing amounts, whether their current drugs are on formulary, and which pharmacy they use. A single drug on or off formulary may have a far larger effect on an enrollee’s total costs than the premiums or other plan design features. Some of these plan features are beyond the scope of this analysis, but they are critical for Medicare beneficiaries to consider when evaluating their Part D plan options.

Beneficiaries have the opportunity to compare Part D plans each year during the open enrollment period, and in 2018 will have nearly two dozen plans from which to choose. The open enrollment period presents both opportunities and challenges for Medicare beneficiaries to compare and choose a plan that best meets their individual needs, though prior research shows a relatively small share do so. Finding ways to get more Part D enrollees engaged in comparing and reviewing plans and making changes that could save them money remains an ongoing challenge for CMS and policymakers. In 2018, some Part D enrollees who retain their current plans may see lower premiums and lower overall costs. But more enrollees will face higher premiums and deductibles if they remain in their current plans, and could also see changes in their plan’s formulary coverage and cost-sharing amounts for their drugs, which could also affect their total out-of-pocket costs. As in prior years, Part D enrollees are likely to benefit from the opportunity to shop during open enrollment.

 

This analysis focuses on the Medicare Part D stand-alone prescription drug plan marketplace in 2018 and trends over time. The analysis includes 20.4 million enrollees in stand-alone PDPs, excluding 4.4 million enrollees in employer-group only PDPs for whom plan premium and benefits data are unavailable.

Data on Part D plan availability, enrollment, and premiums were collected primarily from a set of data files released by the Centers for Medicare & Medicaid Services (CMS) on a regular basis:

• Part D plan landscape files, released each fall prior to the annual enrollment period. These files include basic plan characteristics, such as plan names, premiums, deductibles, gap coverage, and benchmark plan status. For this analysis, we used the 2018 PDP Landscape Source files, v-09-22-17, released on September 29, 2017.
• Part D plan and premium files, released each fall. These files include more detail on plan characteristics, including premiums charged to LIS beneficiaries, the portions of the premiums allocated to the basic and enhanced benefits, and the separate drug premiums for MA-PD plans.
• Part D plan crosswalk files, released each fall. These files identify which plans are matched up when a plan sponsor changes its plan offerings from one year to the next.
• Part D contract/plan/state/county level enrollment files, released on a monthly basis. These files include total enrollment by contract and plan at the state and county level. We use September 2017 enrollment counts for enrollment-weighted analysis in this report for 2017 and projected for 2018. Previous years’ data are based on March enrollment files for each year. Enrollment files suppress totals for plans with 10 or fewer enrollees.
• Part D Low-Income Subsidy enrollment files, released once annually (in March for 2017). These files include total enrollment counts for LIS enrollees. As with the other enrollment files, we exclude plans with small enrollment counts in estimates that are plan-enrollment weighted.
• Medicare plan benefit package files, released each fall. These files supply detailed information on the benefits offered by plans, including cost-sharing amounts for each formulary tier, tier labels, and the different cost-sharing amounts for standard and preferred cost-sharing pharmacies, where applicable.
• Medicare penetration files, released on a monthly basis. These files are used to estimate average counts of plans available per beneficiary.

This analysis adopts different methods with regard to the treatment of certain data elements than previously published analysis of the Part D marketplace conducted by the authors. Our previously published analysis used monthly enrollment files by plan rather than the contract/plan/state/county level enrollment files, and imputed a value of five enrollees for suppressed counts for plans with 10 or fewer enrollees (rather than excluding them, as we do in this analysis); for plan/county data, our prior analysis imputed a value of one beneficiary for all plan/county combinations for suppressed counts of 10 or fewer beneficiaries (rather than excluding them, as we do in this analysis).

Appendix 1: Information about Medicare Part D Stand-alone Prescription Drug Plans (PDPs)

Appendix 2: Medicare Part D Standard Benefit Parameters, 2006-2018

More than 19 million Medicare beneficiaries (33%) are enrolled in Medicare Advantage plans in 2017, which are offered as an alternative to the traditional Medicare program.  This first look at the Medicare Advantage plans available for 2018 analyzes publicly available data to review the Medicare Advantage plans offered during the Medicare Open Enrollment period. It describes the Medicare Advantage plan choices and availability, and how these have changed over time. Findings include:

• Number of Plans. In total, 2,317 Medicare Advantage plans will be available nationwide for individual enrollment in 2018 – the largest number of plans available since 2009. The average Medicare beneficiary will be able to choose among 21 Medicare Advantage plans in 2018, an increase from 19 in 2017.
• Access to Plans. The vast majority (93%) of Medicare beneficiaries will have access to at least one Medicare Advantage HMO, and most (87%) will have access to at least one Medicare Advantage local PPO. In 2018, no Medicare Advantage plans will be available in 149 of the 3,138 counties, similar to the 2017 Medicare Advantage markets; only 1 percent of Medicare beneficiaries live in these counties where no Medicare Advantage plan is offered.
• Variation in Number of Plans. As in past years, the number of Medicare Advantage plans available will vary greatly across counties. In 206 counties, beneficiaries will be able to choose among more than 30 plans for the 2018 plan year, while in 44 counties, only one plan will be available to beneficiaries.
• Number of Firms. The average beneficiary will be able to choose from plans offered by 6 firms. About one in five beneficiaries (22%) nationwide will have a choice of plans offered by three or fewer firms in 2018 while 1 percent of beneficiaries will be able to choose from plans offered by 10 or more firms.  In 441 counties (14% of counties), only one firm will be offering Medicare Advantage plans in 2018; about 3 percent of Medicare beneficiaries live in these counties.
• New Market Entrants and Exits. Seven insurers will be entering the Medicare Advantage market for the first time and five insurers will be exiting the market in 2018.  These entries and exits account for a small number of the total plans in Medicare Advantage market with over 100 insurers offering plans nationwide.

Plan Offerings in 2018

Number of Plans

Total Number of Plans. In total, 2,317 Medicare Advantage plans will be available nationwide for individual enrollment in 2018 – a 14 percent increase (283 more plans) from 2017 and the largest number of plans available since 2009 (Figure 1; Table A1). The increase in plans is predominantly among HMOs and local PPOs, with an additional 179 HMOs and 100 local PPOs.  While the number of HMOs has increased each year since 2011, the size of the increase in 2018 is notable, and more HMOs and local PPOs will be offered in 2018 than any year since 2007.  HMOs continue to account for the majority of plans available, and will account for about two-thirds (68%) of all plans offered in 2018.

Number of Plans Available to Beneficiaries. In 2018, the average Medicare beneficiary will have access to 21 Medicare Advantage plan, the highest number of plans per beneficiary since 2011 (Figure 2).  Among the 21 Medicare Advantage plans available to the average Medicare beneficiary, 18 of the plans will include prescription drug coverage (MA-PDs). Between 2012 and 2017, the average number of plans available to Medicare beneficiaries was relatively stable.  The number of plans available varies widely across the country and, as in past years, beneficiaries have more plans from which to choose in metropolitan than in non-metropolitan areas. On average, beneficiaries in metropolitan areas will be able to choose from nearly twice as many Medicare Advantage plans as beneficiaries in non-metropolitan areas (23 plans versus 12 plans, respectively).

Access to Medicare Advantage Plans

As in recent years, virtually all Medicare beneficiaries (99%) will continue to have access to a Medicare Advantage plan as an alternative to traditional Medicare (Figure 3).  Almost all beneficiaries in metropolitan areas (99%) and the vast majority of beneficiaries in non-metropolitan areas (97%) will continue to have access to at least one Medicare Advantage plan, similar to percentages in 2017.  Consistent with prior years, in non-metropolitan counties relative to metropolitan counties, a smaller share of beneficiaries will have access to HMOs or local PPOs, and a slightly larger share of beneficiaries will have access to private fee-for-service (PFFS) plans and regional PPOs.

Counties with No Medicare Advantage Plans.

In 149 counties, across 15 states, no Medicare Advantage plans will be available in 2018, a modest increase from 147 counties in 14 states in 2017 (Figure 4). These counties tend to be rural, and while they account for 5 percent of all counties, they account for only 1 percent of all Medicare beneficiaries. It is not entirely clear why insurers are not offering Medicare Advantage plans in these counties, but it could be because they have less leverage to negotiate rates with hospitals and other health care providers, smaller margins between the Medicare payment rates (benchmarks) and their operating costs, or other market conditions that make these counties potentially less profitable than others.

Variation in Number of Plans.

On average, 12 Medicare Advantage plans will be available per county in 2018, a slight increase from 11 plans, on average, in 2017, but this varies greatly across the country.  In 15 percent of counties, beneficiaries can choose from more than 20 plans, including 7 percent of counties (206 counties) in which beneficiaries can choose from more than 30 plans in 2018, including Mahoning and Trumbull Counties in Ohio and Lancaster County, PA where more than 45 plans will be available (Figure 5).  In contrast, in 27 percent of counties, beneficiaries can choose from five or fewer Medicare Advantage plans, including 45 counties in which only one plan will be available to beneficiaries; these counties with 1 or no plans account for 4 percent of Medicare beneficiaries.

Number of Firms

The average Medicare beneficiary will be able to choose from plans offered by 6 firms, on average, in 2018, the same as 2017 (Figure 6).  However, about one in six beneficiaries (17%) will be able to choose from plans offered by 10 or more firms, while one in five beneficiaries (21%) will be able to choose from plans offered by three or fewer firms.  The number of firms offering Medicare Advantage plans will be highest in the New York City area (Bronx, Kings, Queens, Nassau, New York, and Richmond Counties), large counties in southern California (Los Angeles, Orange, and Riverside Counties), Miami-Dade and Seminole Counties in Florida, and Butler County, Ohio where 12 or more firms will be offering Medicare Advantage plans. In contrast, in 441 counties, most of which are rural counties with few Medicare beneficiaries, only one firm will offer Medicare Advantage plans in 2018.

New Market Entrants and Exits.

Seven insurers will be entering the Medicare Advantage market for the first time and include start-ups as well as insurers that will only be offering Special Needs Plans. Five insurers will be exiting the market in 2018 – relatively few insurers in a market with over 100 insurers but evidence that not all plans in the Medicare Advantage market are profitable.

KEY FINDINGS:

• The October Kaiser Health Tracking Poll focuses on the Affordable Care Act’s (ACA) marketplaces as the November 1st open enrollment period approaches, amidst a period of uncertainty on the future of the individual market. The majority of the public think it is more important for President Trump and Congress to work on legislation to stabilize the marketplaces rather than continue efforts to repeal and replace the 2010 health care law (66 percent vs. 29 percent). There are distinct differences by party with the majority of Democrats (85 percent) and independents (67 percent) saying legislation to stabilize the marketplaces is more important while about half of Republicans (51 percent) say it is more important for lawmakers to continue efforts to repeal and replace the 2010 health care law.

  Poll: Most want Congress to continue cost-sharing reduction payments as part of bipartisan marketplace deal

• One proposed step Congress could take to stabilize the markets and control costs for people who purchase their plans on their own is to guarantee payments to insurance companies that help cover the cost of deductibles and copayments for lower-income Americans (known commonly as ‘cost-sharing reduction’ (CSR) payments). The Trump Administration has announced they will stop making these payments. While initially the majority of Republicans (55 percent) say these payments should be stopped, when asked whether they support Congress guaranteeing the funds to continue the CSR payments when the proposal is included in a bipartisan compromise that would give states more flexibility in the types of plan sold in their state’s marketplace, a majority of the public (69 percent) – including roughly equal shares of Democrats (69 percent), independents (70 percent), and Republicans (68 percent) – support such a compromise.
• Overall favorability of the ACA increased over the past month with about half (51 percent) of the public holding favorable views of the ACA while 40 percent hold an unfavorable view of the 2010 law. This is five percentage points higher than the share of the public who held favorable attitudes last month (46 percent), and more similar to the share measured in August.

Politics and the ACA Marketplaces

This month’s Kaiser Health Tracking Poll, which was conducted prior to President Trump’s executive order on the Affordable Care Act and the most recent statements from the Trump administration regarding CSR payments, examines the public’s attitudes towards the ACA marketplaces, before the next open enrollment period beginning on November 1^st.

The majority of the public think it is more important for President Trump and Congress to work on legislation to stabilize the marketplaces in order to minimize premiums increases and encourage more insurers to participate in the marketplaces than continue efforts to repeal and replace the 2010 health care law (66 percent vs. 29 percent). There are distinct differences by party with the majority of Democrats (85 percent) and independents (67 percent) saying legislation to stabilize the marketplaces is more important while about half of Republicans (51 percent) say it is more important for lawmakers to continue efforts to repeal and replace the 2010 health care law.

Attitudes Towards Current Proposals to Stabilize the ACA

One proposed step Congress could take to stabilize the markets and control costs for people who purchase their plans on their own is to guarantee payments to insurance companies that help cover the cost of deductibles and copayments for lower-income Americans (known commonly as ‘cost-sharing reduction’ (CSR) payments). The Trump Administration has announced they will stop making these payments, which has led to insurance companies saying they may raise premiums or stop participating in the marketplaces.

When asked what Congress should do, a majority of the public (60 percent) support Congress guaranteeing the funds to continue these payments to help stabilize the insurance market, while one-third think these payments amount to a bailout of insurance companies and should be stopped. While the majority of Democrats (82 percent) and independents (62 percent) say Congress should guarantee the CSR payments, slightly more than half of Republicans (55 percent) say the payments should be stopped.

Most Americans Support Bipartisan Compromise on CSR Payments and State Flexibility

As part of the debate surrounding CSR payments and the future of the ACA marketplaces, Senators Lamar Alexander (R) and Patty Murray (D) have been working on a bipartisan effort aimed at stabilizing, rather than replacing, the ACA. When asked whether they support Congress guaranteeing the funds to continue the CSR payments when the proposal is included in a bipartisan compromise that would give states more flexibility in the types of plan sold in their state’s marketplace, a majority of the public (69 percent) – including roughly equal shares of Democrats (69 percent), independents (70 percent), and Republicans (68 percent) – say they support such a compromise.

Most Are Not Confident President Trump and Congress Will Be Able to Work Together

Despite support for a bipartisan approach to health care, public confidence that President Trump and Congress will be able to work together to make improvements to the ACA marketplaces remains low, with seven in ten Americans saying they are either “not too confident” (27 percent) or “not at all confident” (43 percent), compared to three in ten saying they are “very confident” (8 percent) or “somewhat confident” (22 percent) that they will be able to work together. Half of Republicans (55 percent) are confident that President Trump and Congress will be able to work together while most Democrats and independents are not confident (85 percent and 71 percent, respectively).

President Trump and the Future of the ACA

On October 12^th, President Trump announced a new executive order aimed at making changes to the ACA. Seven in ten Americans (71 percent) think President Trump and his administration should do what they can to make the current health care law work while one in five (21 percent) say they should do what they can to make the law fail so they can replace it later. The vast majority of Democrats (93 percent) say the Trump administration should do what they can to make the law work, as do about three-fourths (74 percent) of independents. Republicans are more divided in their opinions of what the Trump administration should do next. About half of Republicans (48 percent) say President Trump and his administration should do what they can to make the law work while 43 percent of Republicans say the administration should do what they can to make the law fail.

Public Opinion on Trump Administration’s Actions on ACA Marketplaces

In the past few months, President Trump’s administration has made a number of changes related to the ACA and the marketplaces. In general, about twice as many say the actions taken by President Trump and his administration are generally “hurting” (40 percent) the way the ACA marketplaces are working as say the actions are “helping” (19 percent). One-third (34 percent) say their actions are not having much impact on the way the marketplaces are working.

This month’s survey also asked the public whether they approve or disapprove of some of the specific actions the Trump administration has taken with regard to ACA marketplaces. Half of the public approve of the Trump administration decreasing federal spending on advertisements encouraging people to sign up for health insurance and suggesting the federal government may stop enforcing the individual requirement to have health insurance or else pay a fine. On the other hand, six in ten (61 percent) disapprove of the Trump administration decreasing federal funding to organizations that help people enroll in health insurance and half disapprove of limiting federal involvement in community events held by states to encourage enrollment.

Not surprisingly, approval of the actions taken by President Trump’s administration are largely driven by party identification with the majority of Republicans expressing approval for each of the four actions while few Democrats approve of any of the actions. A majority of independents (64 percent) disapprove of decreasing federal funding to the organizations that help people enroll in health insurance through the marketplaces but across the other issues, independents are largely divided.

Half of the Public Holds Favorable Views of the ACA But Also Half Want Debate Over the Law to Continue

Amidst all of this, this month’s tracking poll finds about half (51 percent) of the public expresses a favorable view of the ACA while 40 percent express an unfavorable view of the 2010 law. This is five percentage points higher than the share of the public who held favorable attitudes last month (46 percent) and more similar to August, when more expressed a favorable opinion than an unfavorable one (52 percent vs. 39 percent).

This month’s survey also finds half of the public (54 percent), overall, and across parties – Republicans (52 percent), independents (56 percent), and Democrats (55 percent) – saying it is important for the country to continue the debate over the health care law. Smaller shares – about four in ten – say that they are tired of the debate and think the country should focus more on other issues.

This Kaiser Health Tracking Poll was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted October 5^th-10^th 2017, among a nationally representative random digit dial telephone sample of 1,215 adults ages 18 and older, living in the United States, including Alaska and Hawaii (note: persons without a telephone could not be included in the random selection process). Computer-assisted telephone interviews conducted by landline (429) and cell phone (786, including 502 who had no landline telephone) were carried out in English and Spanish by SSRS of Media, PA. Both the random digit dial landline and cell phone samples were provided by Marketing Systems Group (MSG). For the landline sample, respondents were selected by asking for the youngest adult male or female currently at home based on a random rotation. If no one of that gender was available, interviewers asked to speak with the youngest adult of the opposite gender. For the cell phone sample, interviews were conducted with the adult who answered the phone. KFF paid for all costs associated with the survey.

The combined landline and cell phone sample was weighted to balance the sample demographics to match estimates for the national population using data from the Census Bureau’s 2015 American Community Survey (ACS) on sex, age, education, race, Hispanic origin, and region along with data from the 2010 Census on population density. The sample was also weighted to match current patterns of telephone use using data from the July-December 2016 National Health Interview Survey. The weight takes into account the fact that respondents with both a landline and cell phone have a higher probability of selection in the combined sample and also adjusts for the household size for the landline sample. All statistical tests of significance account for the effect of weighting.

The margin of sampling error including the design effect for the full sample is plus or minus 3 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll. Kaiser Family Foundation public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

 

On September 20^th, Hurricane Maria made landfall in Puerto Rico as a category 4 hurricane causing significant damage to much of the island’s basic infrastructure and severely limiting access to electricity, water, and basic necessities. To better understand the public’s awareness of the damage to Puerto Rico and their assessment of the federal government’s response, the Kaiser Family Foundation polled the public on these issues and found a large majority are aware of the severity of the hurricane’s impact on

Poll finds more Americans blame federal government than Puerto Rico for problems restoring electricity, food, etc.

Puerto Rico and most (62 percent) say the people there are not yet getting the help they need. In terms of the federal government’s response, about half feel the federal government is not doing enough to restore electricity and access to food and water (52 percent) and that the response has been too slow (52 percent). The largest share place the blame for problems restoring basic services on a slow response by the federal government (44 percent), followed by 32 percent who place blame on disorganization at the local level and 10 percent who blame lack of coverage by the news media. Given that Hurricane Maria was the third hurricane to hit U.S. ground in one month, the survey also assessed the public’s views of how the response to Maria in Puerto Rico compared to the government’s response to earlier hurricanes and found that 44 percent of the public feel that President Trump and his administration have done less to respond to the damage in Puerto Rico than they did to respond to hurricane damage in parts of Florida and Texas. And, nearly half (46 percent) say that the federal government’s response would be moving faster if Puerto Rico had been a wealthier place with fewer Hispanic people, while a similar share (44 percent) say ethnicity and poverty have not affected the recovery effort. Views of the response vary significantly across Democrats, Republicans and independents.

Knowledge and Awareness of Hurricane Maria’s Impact on Puerto Rico

Large majorities of the public, including Democrats, independents and Republicans, say they have heard ‘a lot’ about the damage Hurricane Maria caused the U.S. Territory of Puerto Rico (73 percent) and say they know the damage to the island was ‘very’ severe (88 percent). The poll was conducted just after President Trump visited Puerto Rico on October 3.

Since the hurricane, there has been some discussion of whether the U.S. public is aware that Puerto Rico is part of the United States. The public largely knows that most residents of Puerto Rico are U.S. citizens (76 percent), including at least seven in ten across parties. This is higher than a recent online poll conducted immediately after the hurricane, which found just over half of the public was aware that people born in Puerto Rico are U.S. citizens.¹  This difference may be due, at least in part, to the differences in question wording, poll methodology, and/or timing of the poll.

Most of the public (62 percent) says that most people in Puerto Rico affected by Hurricane Maria are not yet getting the help they need, while about a third say they are (32 percent). However, views vary by party with majorities of Democrats (80 percent) and independents (61 percent) saying people are not yet getting the help they need, compared to 56 percent of Republicans who feel they are getting the help they need.

The Public’s Views of the Federal Government’s Response to Damage in Puerto Rico after Hurricane Maria

In the wake of the hurricane and the devastation it caused, some have questioned whether the federal government is doing enough to respond. About half (52 percent) of the public says the federal government is not doing enough to restore electricity and access to food and water in Puerto Rico, while four in ten say the federal government is doing enough. This varies greatly by party. Three-quarters of Democrats (74 percent) say the federal government is not doing enough while the same share of Republicans feel it is (74 percent). A majority of independents say the government is not doing enough (54 percent), compared to 38 percent who say it is. People who feel that most people in Puerto Rico are getting the help they need are much more likely to say that the federal government is doing enough (78 percent), whereas those who feel like most Puerto Ricans are not yet getting what they need are most likely to say the federal government is not doing enough (75 percent).

The speed at which the federal government is responding has also been a concern for some, and half of the public (52 percent) feel the federal government’s response to Hurricane Maria in Puerto Rico has been too slow, while 41 percent say it has been about right, and just 3 percent say it has been too fast. Again, responses vary by party with Republicans most likely to say the speed of the government’s response has been about right (75 percent) whereas Democrats, and to a lesser extent independents, say it’s been too slow (72 percent and 55 percent, respectively). In addition, most who say they have heard ‘a lot’ about the damage Puerto Rico say the federal government’s response has been too slow (56 percent), compared to 40 percent of those who say they haven’t heard as much about it.

When asked to select who they blame most for the problems restoring basic services in Puerto Rico after Hurricane Maria, more than four in ten (44 percent) say it’s the slow response by the federal government, a third (32 percent) say it’s disorganization in the local Puerto Rican government, and 10 percent say it’s the lack of attention from the news media. Democrats are more likely to say the blame falls to the federal government (64 percent) while the same share of Republicans (64 percent) say disorganization in the local Puerto Rican government is most to blame.

More than four in ten (44 percent) of the public feels that President Trump and his administration have done less to respond to the damage in Puerto Rico than they did to respond to hurricanes that damaged parts of Florida and Texas. An additional 36 percent say President Trump and his administration’s response has been about the same as in Texas and Florida and 16 percent say they have done more to respond in Puerto Rico. Here too attitudes vary by party with most Democrats feeling the response in Puerto Rico has been less than in Florida and Texas (67 percent) and most Republicans feeling it’s been about the same (65 percent).

Some have suggested the fact that Puerto Rico has a largely Hispanic population and a high poverty rate has influenced the federal government’s response. The public is divided on whether ethnicity and poverty have played a role: 46 percent say that the federal government’s response would be moving faster if Puerto Rico had been a wealthier place with fewer Hispanic people and a similar share (44 percent) say ethnicity and poverty have not affected the recovery effort. Most Democrats say ethnicity and poverty have affected the recovery effort (69 percent), while Republicans say it haven’t (80 percent) and independents are divided (48 percent say it has and 44 percent say it hasn’t).

To better understand the public’s awareness of the damage to Puerto Rico after Hurricane Maria and their assessment of the federal government’s response, the Kaiser Family Foundation fielded several questions on the SSRS Omnibus Survey. These questions were designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The SSRS Omnibus survey was conducted October 4-8, 2017, among a nationally representative random digit dial telephone sample of 1,008 adults ages 18 and older, living in the United States, including Alaska and Hawaii (note: persons without a telephone could not be included in the random selection process). Computer-assisted telephone interviews conducted by landline (306) and cell phone (702, including 520 who had no landline telephone) were carried out in English and Spanish by SSRS of Media, PA. Both the random digit dial landline and cell phone samples were provided by Marketing Systems Group (MSG). For the landline sample, respondents were selected by asking for the youngest adult male or female currently at home based on a random rotation. If no one of that gender was available, interviewers asked to speak with the youngest adult of the opposite gender. For the cell phone sample, interviews were conducted with the adult who answered the phone. KFF paid for all costs associated with fielding the questions about Puerto Rico on the SSRS Omnibus Survey.

Different research clients purchase space on the omnibus survey and therefore this topline does not include additional questions that preceded or followed the questions shown here. The survey included four questions about the U.S. economy at the top of the questionnaire, and then questions about the following topics were asked on a random rotation along with the Puerto Rico questions: LGBTQ rights (3 questions), Household products (17 questions), financial security (7 questions), current events (not including hurricanes or Puerto Rico, 9 questions), and Halloween (4 questions).

The combined landline and cell phone sample was weighted to balance the sample demographics to match estimates for the national population using data from the Census Bureau’s 2017 March supplement of the Current Population Survey (CPS) on sex, age, education, race, Hispanic origin, nativity (for Hispanics only), marital status, and region along with data from the 2010 Census on population density. The sample was also weighted to match current patterns of telephone use using data from the July-December 2016 National Health Interview Survey. The weight takes into account the fact that respondents with both a landline and cell phone have a higher probability of selection in the combined sample and also adjusts for the household size for the landline sample. All statistical tests of significance account for the effect of weighting.

The margin of sampling error including the design effect for the full sample is plus or minus 4 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll. Kaiser Family Foundation public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

 

1. New York Times, Nearly Half of Americans Don’t Know Puerto Ricans Are Fellow Citizens, Kyle Dropp and Brendan Nyhan, September 26, 2017, https://www.nytimes.com/2017/09/26/upshot/nearly-half-of-americans-dont-know-people-in-puerto-ricoans-are-fellow-citizens.html?_r=0 ↩︎

The Affordable Care Act (ACA) created Navigator programs to provide outreach, education, and enrollment assistance to consumers eligible for coverage through the Marketplaces and through Medicaid and requires that they be funded by the marketplaces.  For the past two years, the Centers for Medicare and Medicaid Services (CMS) has funded Navigator programs in the 34 states that use the federal marketplace through a multi-year agreement that was expected to continue for the current budget year.  In August, CMS officials announced significant reductions to Navigator funding for the 2018 budget year.  These funding reductions coming so close to the start of the 2018 open enrollment period will affect the help many Navigators can provide to consumers seeking to enroll in coverage.

This data note analyzes funding changes and discusses the implications for Navigators and consumers.  It presents results of a Kaiser Family Foundation online survey of federal marketplace (FFM) Navigator programs conducted from September 22, 2017 – October 4, 2017 about 2017 funding awards (for the 2018 open enrollment period), the relationship between funding amounts and program performance, and the likely impact of funding changes on programs and the consumers they serve. It also includes insights from a roundtable meeting of more than 40 Navigators co-hosted by the Robert Wood Johnson Foundation and Kaiser Family Foundation held on September 15, 2017, as well as analysis of administrative data.

Background

In 2015, CMS signed three-year agreements with Navigator organizations to provide consumer assistance to residents of federal marketplace states.  The multi-year agreements promoted continuity and experience among Navigator professionals.  Multi-year agreement also spared CMS and Navigators the time and expense involved in reissuing grants during critical weeks leading up to open enrollment.  Under the agreements, Navigator programs in the FFM states are required to set goals and report performance data throughout the year relating to specific duties and activities.

Funding amounts under the multi-year agreements have been determined annually — $60 million for the first budget year (which runs September through August), and $63 million for the second budget year.  CMS notified continuing programs of the grant amount available to them for the coming year in late spring; programs then submitted work plans, budgets, and performance goals based on that amount.  Once CMS approved these plans, final awards were made in late August.

In May 2017, continuing Navigator programs were notified of available third-year funding amounts, which totaled $60 million, with grants for most programs similar to the year-two funding amount. In June, programs submitted their work plans and budgets corresponding to these amounts. The Navigator programs expected final Notice of Awards (NOA) by September 1, 2017.

On August 31, one day prior to the end of the second budget period of the grants, CMS announced it would reduce Navigator funding by more than 40%. CMS issued a bulletin stating that funding for the third year would be based on program performance on its enrollment goals for the second budget period.  On September 13, 2017, two weeks into the third budget year of the grant, FFM Navigator programs received preliminary NOAs for third-year funding, which totaled $36.8 million, or 58% of the year-two awards. (See Appendix A for funding awards by program.)

2017 Navigator Funding Reductions

CMS notified Navigator program of their preliminary 2017 grant awards on September 13, 2017.  The full list of preliminary awards was obtained and released by a third party (see Appendix A). This section summarizes funding changes based on information from that list.

Funding changes at the state level for 2017 were uneven across states.  Three FFM states (Delaware, Kansas, and West Virginia) received no net reduction in year-three Navigator funding.  Among the other 31 FFM states, the funding reductions ranged from 10% in North Carolina to 80% or more in Indiana, Nebraska, and Louisiana (Table 1).

When the multi-year agreement was established, federal funding was allocated across FFM states based on the state’s share of the number of uninsured people, with a minimum amount ($600,000) reserved for each of the smallest states.  This allocation formula no longer seems to apply.  For example, total funding for Navigators in Indiana ($290,000) was less than that for Navigators in Alaska ($447,000) despite the fact that there are four times as many uninsured residents in Indiana compared to Alaska (422,000 vs 95,600 in 2016).  Similarly, funding for Navigators in Ohio was less than that for Navigators in Oklahoma ($568,000 vs $798,000) though there are more uninsured residents in Ohio (631,000 vs 409,000).¹ 

Overall, the funding reductions varied widely across individual Navigator programs. The vast majority (82%) of Navigator programs experienced reductions, while 18% of programs saw their funding stay the same or increase compared to funding levels in 2016. Forty-nine percent of programs had their funding reduced by more than half and more than one-quarter experienced funding reductions of over 75% (Figure 1).

Navigator Program Funding versus Performance

This section summarizes findings from the KFF Survey of FFM Navigators about 2017 funding changes and program performance on certain metrics during the second year of the multi-year agreement.  All Navigator programs were contacted, and 51% participated in the survey.

Navigators say the basis for 2017 funding decisions has not been clear.  Nearly half (49%) of respondents said that the rationale for the funding notice they received on September 13 was not provided at all, and another 40% said it was unclear (Figure 2).

The August 31 CMS bulletin indicated that funding for the Navigators would be based on performance against year-two “enrollment goals.” According to the bulletin, “a grantee that achieved 100 percent of its enrollment goal for plan year 2017 will receive the same level of funding as last year, while a grantee that enrolled only 70 percent of its enrollment goal would receive 70 percent of its previous year funding level, a reduction of 30 percent. The new funding formula will ensure accountability within the Navigator program.”

It is not clear what metric CMS used to determine funding levels since Navigators have been required to track a number of activities relative to goals, all of which could result in or contribute to enrollment in health coverage.  These include:

• Number of consumers assisted with qualified health plan (QHP) selection/enrollment (including reenrollment);
• Number of one-on-one interactions with consumers, including both general and specific inquiries; and
• Number of consumers assisted with applying for Medicaid/CHIP, including referral of consumers in non-expansion states to the state Medicaid office;
• Number of consumers reached through outreach and public education activities.² 

Navigator-assisted qualified health plan selection Metric

The number of consumers assisted with QHP selections is the most direct measure of marketplace enrollment tracked by Navigators, although as discussed below, it does not capture all marketplace enrollments that involved Navigator assistance.

There are two measures of Navigator-assisted QHP selections, one self-reported by the programs and one based on data collected by healthcare.gov – the Multidimensional Information and Data Analytics System, or MIDAS data.  The healthcare.gov online application includes a field where Navigator staff can enter their identification number for each consumer whom they assist. Navigators report that program staff have not been trained on this data entry and did not consistently enter it. Several weeks after the start of the fourth open enrollment period, some Navigator programs said they were encouraged by their CMS project officers to improve consistency of staff identification numbers on applications.  Some say they subsequently received reports from CMS staff during the project year comparing MIDAS and self-reported data on QHP selections that did not match – in some cases by a factor of two – and programs did not know why.  Other programs said they did not receive reports from CMS on their MIDAS data.  Navigators expressed concern about the accuracy of data counting QHP selections, especially if this will become the basis for future funding decisions.

The survey asked Navigators to provide both their goal and self-reported performance data for Navigator-assisted QHP selections as reported to CMS for the second budget period. Navigator performance relative to the goal was compared to the change in funding from 2016 to 2017.  Among programs that provided the performance data, findings include:

For 22.5% of programs, 2017 funding matches performance on the self-reported QHP selection metric (Figure 3).  Included in this group were:

• 15.0% of programs that exceeded or met at least 95% of the goal and whose 2017 funds were not reduced; and
• 7.5% of programs that did not meet the goal and had funding reduced by the same or similar percentage (+/- 5%).

For 77.5% of programs, 2017 funding does not reflect performance on the QHP selection metric.  Included in this group were:

• 22.5% of programs that exceeded or met at least 95% of the goal and whose 2017 funds were reduced;
• 27.5% of programs that did not meet the goal and had funding reduced by a greater percentage; and
• 27.5% of programs that did not meet the goal and had funding changed by a smaller percentage.

The QHP selection metric tends to undercount enrollment that is connected to assistance provided by Navigators. Through the survey and at the roundtable, Navigators expressed concern that the QHP selection measure does not reflect the number of consumers whom they help and who ultimately enroll in marketplace health plans.  This metric, as defined by CMS, counts only those consumers who select a plan in the Navigator’s presence, a fraction of the total number of individuals who enroll in coverage and who were helped by Navigators.  For example, if a Navigator helped a consumer complete her application and reviewed plan choices, but the consumer went home to consider her options and made a final selection that evening, that visit could not be reported as a Navigator-assisted plan selection.³  According to the Kaiser Family Foundation 2016 Survey of Health Insurance Marketplace Assister Programs and Brokers, 18% of assister programs reported that nearly all consumers they helped who were determined eligible to enroll in a QHP made their plan selection during the initial visit. Thirty-five percent said they knew the final plan selection of all or nearly all such consumers whom they helped.

Other Navigator Performance Metrics

Funding changes for 2017 also do not appear to align with performance on other metrics.  Navigators reported goals and performance data on other key metrics that relate to enrollment (Figure 4). Most programs met or exceeded these goals, so these metrics do not appear to be related to the funding reductions.  Among programs that answered these questions, Eight in ten programs (83%) met their goals for one-on-one consumers interactions, 71% met their goals for helping consumers enroll in Medicaid or CHIP, and three quarters met their outreach and education event goal.

One-on-one assistance: The most comprehensive measurement required by CMS is the number of consumers provided one-on-one assistance.  A one-on-one encounter can involve helping a consumer with any step along the process that ends with enrollment:  educating consumers about the availability of plans and assistance, completing a marketplace application for financial assistance, appealing a marketplace decision, reviewing and understanding plan options, or selecting a QHP.  Navigators also provide one-on-one assistance to consumers after they enroll so that they can remain covered.  Such help includes answering tax reconciliation questions, resolving premium payment disputes, and referring consumers for help with denied claims.  Once they have resolved the problem they came in with, many consumers leave and complete the enrollment process on their own.  The one-on-one assistance metric would also count consumers who are helped but who do not enroll in coverage.  On average, the number one-on-one encounters Navigators reported was 15 times higher than the number of QHP selections.

Medicaid/CHIP enrollment assistance or referrals: The ACA requires a “no wrong door” application process through which consumers can apply through the marketplace, using a single streamlined application, for either private health insurance subsidies or Medicaid/CHIP.  Navigators are required to help all consumers with the application.  Navigators from Medicaid expansion states noted that most consumers who sought help were ultimately determined Medicaid eligible.  At the roundtable, some commented that, when the August 31 bulletin was released, they assumed CMS would base funding on enrollment under both types of coverage.

Outreach and public education: Four years after implementation, the public’s understanding of ACA benefits and requirements remains limited.  For example, many consumers continue to be unaware that signups for private non-group health insurance, generally, must take place during open enrollment.⁴   Turnover in marketplace plans is high, as most participants need non-group coverage only while they are between jobs or other types of coverage.  Navigators report that consumers are less likely to seek, or be receptive to, information about the marketplace until they actually need it.

Impact of Navigator Funding Reductions

This section summarizes findings from the KFF Navigator survey as well as insights from the Navigator Roundtable meeting on program changes that may result from the funding reductions.

Most Navigator programs say they will continue to operate in 2018 despite the funding reductions. However, three programs said they will terminate work for year-three.  These include two programs – one statewide and one nearly statewide⁵  – that had been the only Navigator service providers for consumers in most areas of their respective states.  Their decision to withdraw was based on the level and timing of funding reductions.  The September 13 NOA directed that no more than 10% of the grantee’s award could be spent by programs pending CMS review and approval of the final budget and work plan.  Because the preliminary award was announced two weeks into the plan year with final awards scheduled to be made as late as October 28, grantees were faced with maintaining staff payroll and other expenses for as long as two months without assurances they would be reimbursed. The terminating programs, both operated by nonprofits, determined this was not feasible.

Most programs report they will likely reduce their geographic service area and limit help to rural residents. Among programs whose funding was reduced, 45% of statewide programs and two-thirds of regional programs said it is somewhat or very likely they will have to limit the territory their program will serve in year three. Programs emphasized their inability to afford the same level of travel expenses and/or the cost of satellite offices that they had previously incurred in order to offer in-person help to consumers living farther away.  Consumers living in rural communities may be the most affected.  Most (55%) statewide Navigator programs and 72% of regional programs expect to limit services to rural residents this year (Figure 5).

Nearly all programs (89%) expect to lay off staff as a result of funding reductions (Figure 6).  Some programs expect to cut Navigator staff by 75% or more.  The KFF 2016 Assister Survey found that continuity among staff has been high to date.  One advantage of the multi-year agreement was to allow staff experience to grow over time.  To fill in the gaps left by staff lay-offs, some programs plan to rely more heavily on less experienced volunteers.

Most Navigator programs expect to reduce services in other ways, as well.  Nearly all programs (81%) say they will likely reduce outreach and public education activities as a result of budget reductions.  In addition, 89% of programs say they will likely reduce spending on marketing and advertising. Nearly six in ten programs (57%) said they will likely reduce the number of months in which they offer Navigator assistance.  Some programs expect to close following open enrollment, others will cut back to a skeletal staff.  As a result, consumers who need assistance at tax time, or help with special enrollments or post-enrollment problems during the year, may have difficulty finding it.

Over four in ten programs say it is likely they will curtail help to consumers related to Medicaid.  At the roundtable, some discussed a strategy of pre-screening consumers during open enrollment to identify those likely eligible for Medicaid/CHIP.  These consumers might be asked to come back at a later date, if they do not have an immediate medical or coverage need, because Medicaid and CHIP enrollment is year round.  Other expressed concern that, if CMS bases future funding on QHP plan selections, Navigators in Medicaid expansion states could be disadvantaged.

In addition, 57% of programs say they will likely limit time staff can devote to helping consumers with complex cases.  These cases include consumers experiencing identity proofing problems (for example, faced by young adults who have not previously filed income tax returns or established credit ratings).⁶   They also include consumers with income data-matching problems (for example, self-employed individuals who have difficulty estimating income for the coming year).  People who cannot resolve identity or other data verification problems within 90 days risk losing their marketplace coverage or subsidies.

Another 54% of programs say they will likely limit the number of limited English proficiency (LEP) consumers they can serve.  Programs often pay a premium for bi-lingual staff, an expense they may no longer be able to afford with reduced funding.

Consumers who need these kinds of assistance may have difficulty finding it elsewhere.  Many consumers seek help from other types of marketplace assister programs.  Federally qualified health centers (FQHCs) also receive funding from the federal government to provide in-person enrollment assistance, although the authorization for most federal funding expired September 30 and has yet to be extended.  In addition, Certified Application Counselor (CAC) programs provide in-person help in the marketplace, though are not paid by the marketplace.  The KFF 2016 Assister Survey found that all three types of programs play an important role in helping consumers.  They also tend to differ from Navigator programs in some key respects.  In particular, Navigator programs typically undergo a higher level of training; they are more likely to operate statewide, sponsor outreach and enrollment events, handle complex cases, and provide help throughout the year.

The KFF 2016 Assister Survey also found that agents and brokers are less likely than marketplace assister programs to serve consumers who need translation services, help with complex cases, and help with Medicaid applications. Brokers and agents are also less likely to help uninsured consumers, immigrants, and consumers who lack internet at home.

Discussion

The Administration’s decision to reduce funding for Navigator programs comes at a challenging time for consumers who rely on coverage through the marketplaces. High-profile insurer exits from the marketplaces, rising premiums, and uncertainty over the federal commitment to funding the cost sharing subsidies are likely sowing confusion among consumers about whether coverage and financial assistance remain available. This confusion, coupled with a shortened open enrollment period, increases demand for the consumer education and in-person enrollment assistance Navigators provide. At a time when more help may be needed, the funding reductions are likely to reduce the level of in-person help available to consumers during this fall’s open enrollment and throughout the 2018 coverage year.

Navigator programs generally report that they do not understand the basis for the funding decisions, and our survey results suggest that there is not a clear link between funding and performance of programs relative to goals on the measures they are required to track and self-report. This ambiguity makes it difficult for programs to plan for the future.

Both the magnitude of the reductions and the timing has caused disruption to Navigator program planning and operations.  Programs plan to adopt various strategies in response to the reductions, including reducing their geographic service area and cutting services, such as outreach and assisting with complex cases. Three programs report they will terminate operations, leaving consumers in their states with very limited access to in-person help. While consumers may be able to turn to other assister programs or brokers, less in-person assistance will be available in some areas, especially for people with complex situations or who live in remote or rural communities.

 

Appendix A

Appendix B

1. See Kaiser Family Foundation State Health Facts, for data on uninsured by state, 2013-2016.  Available at modern.kff.org/other/state-indicator/nonelderly-0-64/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D ↩︎
2. Cooperate Agreement to Support Navigators in Federally-facilitated and State Partnership marketplaces, 2016 Non-Competing Continuation Application, April 14, 2016 ↩︎
3. Navigator Cooperative Agreement, HIOS Reporting Guidance, 2016-2017 Budget Period, October 13, 2016 ↩︎
4. See for example, Kaiser Family Foundation Tracking Poll, January 2016, which found 85% of uninsured could correctly identify the deadline to enroll in coverage through the marketplace.  Available at https://modern.kff.org/health-costs/poll-finding/kaiser-health-tracking-poll-january-2016/ ↩︎
5. For this report, we counted as “nearly statewide” Navigator programs that serve 80% or more of counties in their state. ↩︎
6. Terri Shaw and Shelby Gonzales, Remote Identity Proofing: Impacts on Access to Health Insurance, January 2016, available at https://www.cbpp.org/research/remote-identity-proofing-impacts-on-access-to-health-insurance ↩︎

One of the biggest trade-offs between Medicare Advantage and traditional Medicare is that Medicare Advantage plans have a more limited network of doctors and other providers. The size and breadth of provider networks can be an important factor for beneficiaries when choosing between traditional Medicare and Medicare Advantage, and among Medicare Advantage plans. As of 2017, 19 million of the 58 million people on Medicare (33%) are enrolled in a Medicare Advantage plan, yet little is known about their provider networks.

19 million people on Medicare are in a #MedicareAdvantage plan, yet little is known about their provider networks.

This report is the first known study to examine the size and composition of Medicare Advantage plans’ physician networks. This analysis draws upon data from 391 plans, offered by 55 insurers in 20 counties, and accounted for 14% of all Medicare Advantage enrollees nationwide in 2015. Key findings include:

• More than three in ten (35%) Medicare Advantage enrollees were in narrow-network plans while about two in ten (22%) were in broad-network plans. To some degree, the relative narrowness of plan networks masks the total number of physicians that enrollees could access, particularly in larger counties.
• Medicare Advantage networks included less than half (46%) of all physicians in a county, on average.
• Network size varied greatly among Medicare Advantage plans offered in a given county. For example, while enrollees in Erie County, NY had access to 60% of physicians in their county, on average, 16% of the plans in Erie had less than 10% of the physicians in the county while 36% of the plans had more than 80% of the physicians in the county.
• Access to psychiatrists was typically more restricted than for any other specialty. Medicare Advantage plans had 23% of the psychiatrists in a county, on average; 36% of plans included less than 10% of psychiatrists in their county. Some plans provided relatively little choice for other specialties as well; 20% of plans included less than 5 cardiothoracic surgeons, 18% of plans included less than 5 neurosurgeons, 16% of plans included less than 5 plastic surgeons, and 16% of plans included less than 5 radiation oncologists.
• Broad-network plans tended to have higher average premiums than narrow-network plans, and this was true for both HMOs ($54 versus $4 per month) and PPOs ($100 versus $28 per month).

Insurers may create narrow networks for a variety of reasons, such as to have greater control over the costs and quality of care provided to enrollees in the plan. The size and composition of Medicare Advantage provider networks is likely to be particularly important to enrollees when they have an unforeseen medical event or serious illness. However, accessing the information may not be easy for users, and comparing networks could be especially challenging. Beneficiaries could unwittingly face significant costs if they accidentally go out-of-network. Differences across plans, including provider networks, pose challenges for Medicare beneficiaries in choosing among plans and in seeking care, and raise questions for policymakers about the potential for wide variations in the healthcare experience of Medicare Advantage enrollees across the country.

Introduction

For people on Medicare, one of the biggest trade-offs between Medicare Advantage and traditional Medicare is that Medicare Advantage plans have a more limited network of doctors and other providers. Medicare Advantage plans restrict the doctors, hospitals, and other providers from whom their enrollees can receive care, while traditional Medicare allows people to see any provider that accepts Medicare (overwhelming majority of providers). Seniors value having the ability to choose their own doctors as well as keep their existing doctors, and say that the doctors in the network are an important factor in their plan selections.¹ 

Although Medicare Advantage enrollment is rising rapidly, with one in three beneficiaries now in a Medicare Advantage plan, relatively little is known about Medicare Advantage plans’ provider networks.²  The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage plans to include a specified number of physicians for each of the 26 specialties, along with hospitals, and other providers within a particular driving time and distance of enrollees;³  however, little information is available about the extent to which plans go beyond these basic requirements. A prior analysis showed that Medicare Advantage hospital networks vary greatly in size and composition.⁴  The size and composition of a plan’s physician network can have important implications for Medicare Advantage enrollees, including whether or not they can see a given physician (for HMO enrollees) or how much more they would need to pay for out-of-network care (for PPO enrollees).

When forming their networks, insurers may choose to contract with some but not all physicians for a variety of reasons. For example, the insurer may want to have greater control over the cost or quality of care provided by a physician or they may prefer to limit the number of physicians included in their network for other reasons. Curating and restricting their provider networks may also allow insurers to improve the coordination and efficiency of care for their enrollees.

At the same time, physicians may or may not want to be a part of a Medicare Advantage network. They may not want the extra paperwork and time that may come with accepting another insurer, may not want additional patients, or may have concerns with a plan’s payment rates or other terms of a given plan’s contract.

This report is the first known study to examine the size and composition of Medicare Advantage plans’ networks, focusing on physicians. This analysis draws upon data from 391 plans, offered by 55 insurers, in 20 counties, accounting for 14 percent of all Medicare Advantage enrollees nationwide in 2015. The report analyzes the size of provider networks across and within the 20 counties, overall and by specialty, and looks at the relationship between network size and other plan features, including plan types, premiums, star ratings, and insurers. We defined Medicare Advantage networks as broad if they included 70 percent or more of the physicians in a county, medium if they included between 30 and 69 percent of the physicians in a county, and narrow if they included less than 30 percent of the physicians in a county.

Growing evidence indicates that many plans do not maintain accurate directories.⁵  For example, in an investigation, CMS found that the directories had many errors and 45 percent of the doctors listed had incorrect information in plans’ directories.⁶  Unlike CMS, we do not assess the accuracy of the directories, nor do we assess whether the physicians in the directories actually accept the insurance.

Methods

For this analysis, we examined physician networks of Medicare Advantage Health Maintenance Organizations (HMOs) and local Preferred Provider Organizations (PPOs) offered in 20 counties in 2015 (Figure 1). We selected a geographically diverse set of counties that encompass a sizeable share of the total Medicare Advantage population. These counties range in size, per capita Medicare spending, the number of plans offered to Medicare beneficiaries, and Medicare Advantage penetration rates in 2015 (Table A1).

We downloaded from each insurer’s website the provider directories for each Medicare Advantage plan offered in the 20 counties during the 2015 open enrollment period; provider directories could only be accessed directly from the insurers because the directories are not posted on the Medicare Plan Finder, the website developed by CMS to support Medicare Advantage plan comparisons. We converted the directories for each plan to a machine-readable format. We then matched the text in the directories against a national census of physicians maintained by SK&A using a text-matching method that searched the directories for the names of every doctor practicing in each county (see Appendix for details).

We categorized networks into one of three sizes based on the share of physicians in the county that were included in the directory: broad (70% or more of the physicians), medium (30-69% of the physicians), and narrow (less than 30% of the physicians). These categories are the same as those used in a prior analysis of Medicare Advantage hospital networks, and are the same cut-offs that were used in a McKinsey & Company report examining ACA Marketplace networks.⁷  The analysis included the 26 physician specialties that Medicare Advantage plans were required to include in their networks, and excluded all other specialties. For a more detailed description of the study methods, see the Appendix.

Results

Size of Plans’ Networks

By Plan

Medicare Advantage plan networks included less than half (46%) of all physicians in a county, on average, in 2015 (Figure 2). In comparison, other studies have found that about 30 percent of all physicians in a rating area were included in ACA Marketplace plans in 2014.⁸  About one in four (27%) plans had narrow networks (with less than 30% of physicians in the county), about half (52%) of all plans had medium-sized networks (with 30 to 69% of physicians in the county), and about one in five (21%) plans had broad networks (with 70% or more of the physicians in the county).

By Enrollment

While about one in four (27%) Medicare Advantage plans had narrow networks, these plans included about one in three (35%) Medicare Advantage enrollees in the 20 counties in 2015, indicating that enrollees were somewhat disproportionately enrolled in plans with narrow networks (Figure 3). Four in ten (43%) enrollees were in plans with medium networks of physicians and about two in ten (22%) enrollees were in plans with broad networks of physicians. Some Medicare Advantage enrollees may be in plans with relatively narrow networks because they are comfortable with the way in which the plan delivers care, or they selected the plan based on other factors, such as low premiums.

Closed-panel HMOs (also known as staff model HMOs) generally have narrow networks because the plans’ parent insurers directly employ the majority of physicians in insurer’s provider networks. This study includes some closed-panel HMOs, such as Kaiser Permanente, but the majority of enrollees in narrow-network plans in the study were not in closed-panel HMOs; the largest closed-panel HMO in the study was Kaiser Permanente, which included 26 percent of all enrollment in narrow-network plans and 10% of total enrollment in the study.

By County

Network size varied widely across counties in 2015 (Figure 4; Table A2). In three large counties (Clark, Harris, and Los Angeles), most Medicare Advantage enrollees were in plans with narrow physician networks. In contrast, in seven counties (New Haven, Salt Lake, Douglas, Milwaukee, Erie, Allegheny, and Mecklenburg), more than half of all Medicare Advantage enrollees were in plans with broad networks, including four counties in which nearly all Medicare Advantage enrollees were in plans with broad networks (Allegheny, Erie, Mecklenburg, and Milwaukee).

Similarly, the average size of Medicare Advantage plans’ physician networks varied greatly across the 20 counties. In Allegheny County, for example, Medicare Advantage plans included in their provider networks 77 percent of all physicians practicing in the county, on average; in contrast, the Medicare Advantage plans in Miami-Dade County included just 25 percent of all physicians in the county, on average (Figure 5). In four counties (Allegheny, Mecklenburg, Milwaukee, and Salt Lake), Medicare Advantage enrollees had access to at least two-thirds of all practicing physicians in the county, on average; however, in three counties (Cook, Los Angeles, and Miami-Dade), enrollees had access to less than one-third of the physicians in the county, on average.

The percent of physicians included in a Medicare Advantage plan network may mask the large number of physicians that an enrollee can access, particularly for plans in large counties. For example, while the average plan in Los Angeles County included only 28 percent of the physicians in the county, there were over 13,000 physicians in Los Angeles County and the average plan in Los Angeles County included 3,758 physicians – more physicians than the average plan in any of the other counties in this study. In effect, even though Medicare Advantage plans in Los Angeles had some of the narrowest physician networks, enrollees in plans in Los Angeles often had access to more physicians than enrollees in broader plans in other counties. Nevertheless, even in large counties, Medicare Advantage enrollees in narrow-network plans have access to fewer physicians than enrollees in medium or broad-network plans or beneficiaries in traditional Medicare.

The size of Medicare Advantage provider networks also varied across plans within counties – an important consideration for beneficiaries choosing between plans (Figure 6; Table A3). For example, in Queens County, the size of plan networks ranged from 71 percent of the physicians in the county to as few as 6 percent of physicians in the county, with the average plan including 40 percent of physicians in the county. Similarly, while Medicare Advantage enrollees in Erie County had access to 60 percent of the physicians in the county, 16 percent of the plans in Erie had less than 10 percent of the physicians in the county while 36 percent of the plans had more than 80 percent of the physicians in the county.

By Specialty

Medicare Advantage plans included about four in ten (42%) primary care physicians in a county, on average, ranging from 20 percent in Miami-Dade to 77 percent in Allegheny (Table A4). However, the average share of physicians included in Medicare Advantage networks also ranged across specialties (Figure 7). For 12 of the 26 required specialties, Medicare Advantage plan networks included the majority of the physicians in their county, on average. The plan networks also included nearly half (43%) of geriatricians (not a required specialty) in a county, on average, ranging from 18 percent in Miami-Dade County to 88 percent in Allegheny County.

Access to psychiatrists was more restricted than for any other specialty, on average.⁹  On average, plans included less than one-quarter (23%) of the psychiatrists in a county, ranging from 7 percent in Los Angeles and Pima to 45 percent in Allegheny. More than one-third (36%) of the 391 Medicare Advantage plans included less than 10 percent of the psychiatrists in their county. The small share of psychiatrists in Medicare Advantage plan networks, particularly in some counties such as Los Angeles, raises the likelihood that beneficiaries in traditional Medicare receiving care for serious mental health issues would likely need to switch psychiatrists to remain in their plan’s network if they were to enroll in a Medicare Advantage plan.

Some plans included relatively small numbers of some specialties, indicating that enrollees would have relatively little choice in physicians (Figure 8). For example, 20% of plans included less than 5 cardiothoracic surgeons, 18% of plans included less than 5 neurosurgeons, 16% of plans included less than 5 plastic surgeons, and 16% of plans included less than 5 radiation oncologists. We examined whether these plans with limited access for some specialties were concentrated in counties with predominantly narrow networks, but found that they were generally spread across many counties, including counties with broader networks.

Ratio of Enrollees to Network Physicians

To examine an additional indicator of network size, we calculated the ratio of Medicare Advantage enrollees for each network physician across the 20 counties, and found considerable variation both by county and by specialty. In Mecklenburg County, for example, enrollees were in plans that had 69 enrollees for each medical/surgical oncologist in network, on average. This ratio contrasts significantly from Clark County, which had an average of 2,486 Medicare Advantage enrollees for each medical/surgical oncologist (Figure 9). For psychiatrists, the range was even greater across counties—from an average of 43 enrollees per in-network psychiatrist in Douglas County to over 5,000 in Clark and Pima Counties (not shown).¹⁰  In general, plans had lower ratios for primary care physicians, with about half the counties averaging fewer than 30 Medicare Advantage enrollees for each in-network primary care physician (not shown).

These ratios supplement our overall analysis of network size in Medicare Advantage, but they do not, on their own, provide specific information about network adequacy for patient access to care. Without information on physicians’ actual caseloads (including Medicare Advantage, commercial insurance, Medicaid, and traditional Medicare patients), it is not possible to assess if counties with high enrollee-to-physician ratios indicate access issues. Nonetheless, Medicare beneficiaries in plans with higher ratios have fewer physicians per enrollee listed in their plans’ provider directories. Additionally, counties with higher shares of narrow-network plans tended to have higher ratios of enrollees to network physicians, which suggests a relationship between narrow networks and high enrollee-to-physician ratios.

Relationship Between Size of Plans’ Networks and Other Plan Features

HMOs versus PPOs

Medicare Advantage PPOs tended to have broader physician networks than Medicare Advantage HMOs (Figure 10). PPOs included 57 percent of physicians in their county, on average, compared to HMOs, which included 42 percent of physicians in their county, on average. The smaller size of the HMO networks compared to the PPO networks is important because most Medicare Advantage enrollees are in HMOs, which will not cover the cost of non-emergency care received from physicians outside the provider network. In contrast, PPOs will partly cover the cost of out-of-network care with beneficiaries paying a higher amount if they see an out-of-network provider.¹¹ 

These results held across most counties, with the HMOs in most of the counties having narrower networks than PPOs, on average (Table A5). The differences between HMO and PPO networks are diluted by the fact that a number of insurers use the same network for their Medicare Advantage HMO and PPOs in a given county. Among PPOs offered by insurers that also offered an HMO in the county, 44 percent had the same provider network as the insurer’s HMO.¹² 

Network Size by Plan Premiums

Broad-network plans tended to have higher average premiums than narrow-network plans, and this was true for both HMOs ($54 versus $4 per month) and PPOs ($100 versus $28 per month; Figure 11).

While PPOs tend to have both higher premiums and broader networks than HMOs, the correlation between network size and premiums is independent of the correlation between network size and plan type.

In most but not all counties, broad-network plans typically had higher premiums than narrow-network plans. In 8 of the 11 of the counties that had a broad-network plan as well as medium and/or narrow-network plans (Allegheny, Davidson, Jefferson, King, Milwaukee, New Haven, Queens, and Salt Lake), the average premium was higher for broad-network plans than narrow and/or medium-network plans (Figure 12). In one county, Mecklenburg, only broad-network plans were offered. This finding is similar to findings from ACA Marketplace studies, and suggests that, in some counties, enrollees could use premiums as a rough proxy for network size.¹³ 

However, in 5 of the 12 counties with narrow-network plans (Cuyahoga, Erie, Fulton, Miami-Dade, and Multnomah), average premiums were higher for narrow-network plans than for medium and/or broad-network plans. 

Network Size By Star Rating

Medicare Advantage plans’ quality star ratings do not appear to be related to the size of plans’ networks: the average star ratings for narrow-network plans were similar to those for broad-network plans in 2015 (3.9 stars versus 4.0 stars, respectively; Figure 13). Similarly, examining the relationship within plan types, star ratings did not differ significantly for narrow and broad network PPOs (4.0 stars and 3.9 stars, respectively) and narrow and broad network HMOs (3.9 stars and 4.0 stars, respectively). For consumers, this finding suggests that star ratings are not a good proxy for network size.

Variations in Networks By Insurer

Among the insurers offering plans in multiple counties, none consistently had broad or narrow networks. For example, while UnitedHealthcare had broad networks in Douglas, Mecklenburg, Milwaukee, Queens, and Salt Lake Counties, it had narrow networks in Clark, Harris, and Miami-Dade Counties. Likewise, Blue Cross Blue Shield (BCBS) affiliated plans had broad networks in seven counties (Allegheny, Davidson, Erie, Jefferson, King, Mecklenburg, and Salt Lake), but narrow physician networks in three counties (Harris, King, and Los Angeles). This finding suggests that local market characteristics typically are a stronger influence on network design than the philosophy or general practices of particular insurers. For consumers, this finding suggests caution against assuming a given insurer’s brand is a reliable proxy for network size.

Average County Network Size By Other County Characteristics

The average size of plans’ physician networks in a given county was not correlated with the Medicare Advantage penetration rate in the county, the Medicare spending quartile in the county, the extent to which enrollment in the county was concentrated in one plan, or enrollment. In other words, large plans with many enrollees did not have significantly broader networks than plans with fewer enrollees.

It is possible that specific local market characteristics that we could not measure, such as provider consolidation or the dominance of certain insurers in an area, are related to the size of networks. For example, in Clark County, most (55% in 2015) enrollees are in plans operated by UnitedHealthcare, which has relatively narrow networks in the county because it owns (through its Optum subsidiary) a large medical group that comprises most of its network.¹⁴ 

Access To Provider Directories

The CMS Medicare Plan Finder, designed by CMS to help Medicare beneficiaries and others choose among competing plans, currently includes a link to each Medicare Advantage plan’s website, where beneficiaries can find a downloadable provider directory and/or a searchable database. Motivated consumers could check the directory or database to see if their doctors are included in the plan’s network. However, accessing the information may not be easy for users, and comparing networks could be especially challenging. Additionally, as was found in the prior analysis of Medicare Advantage hospital networks, as well as other studies, the information in the directories is often inaccurate.¹⁵ 

The Medicare Plan Finder also posts an estimate of the total number of providers in the network, but the total includes physicians as well as other providers, such as hospitals, nurses, skilled nursing facilities, and laboratory testing sites. This estimate would not be helpful for Medicare beneficiaries who are looking to see if the plans available to them have a narrow or broad physician network. Further, the estimated number of providers displayed on the CMS website for each plan does not necessarily cover the same geographic area because some plans cover much broader areas than others. For example, the estimate for one plan may include the number of in-network providers in a county while the estimate for another plan may include the number of in-network providers in a state, the latter of which may or may not be useful for beneficiaries who may need to travel a great distance to see some of the in-network providers. As a consequence, the number of providers posted on the Medicare Plan Finder may not be particularly useful for people who are trying to compare plans to figure out how many physicians (or other providers) are available in-network in the area where they live.

Discussion

The results of this analysis, the first known study of Medicare Advantage physician networks, has important implications for the 19 million Medicare beneficiaries now enrolled in Medicare Advantage plans, and for the millions of Boomers who are becoming eligible for Medicare and choosing between traditional Medicare and Medicare Advantage plans.¹⁶  A prior analysis showed that Medicare Advantage hospital networks vary greatly in size and composition.¹⁷  The breadth and scope of provider networks has the potential to affect out-of-pocket costs and quality of care for Medicare enrollees. Medicare Advantage enrollees incur higher costs if they go out-of-network without prior approval in Medicare PPOs, and pay the full cost for out-of-network care in Medicare HMOs. With half of all Medicare beneficiaries living on an income of about $26,000 or less per person in 2016,¹⁸  the cost of out-of-network care could be prohibitively expensive. Provider networks can also be an important consideration for beneficiaries who value the ability to maintain care arrangements with specific physicians, or have access to certain specialists if they develop a serious medical condition. Many seniors as well as younger people find it difficult to navigate complex networks and incur “surprise” medical bills because they unintentionally went out of their plan’s network.¹⁹ 

Seniors say they value having the ability to choose their own medical providers, and that provider networks are a key factor in choosing a health plan.²⁰  Yet, seniors would be hard-pressed to compare the Medicare Advantage plan provider networks in their area to learn which have broad or narrow physician networks. The Medicare Plan Finder includes an estimate of the number of physicians and other providers in a plan’s network, but these estimates are not a reliable proxy for the relative size of a plan’s physician network.

Given the strong need for accurate, up-to-date provider directories to inform beneficiaries as they choose plans, CMS could consider a range of strategies to improve the quality of information available to current and prospective Medicare Advantage enrollees, in addition to its proposal to review all Medicare Advantage networks at least every three years.²¹  CMS could post provider directories for each Medicare Advantage plan, along with other information provided on the Medicare Plan Finder website. CMS could also require plans to produce provider directories in an easily comparable, uniform format to make it easier for consumers to compare the physician networks of Medicare Advantage plans in their area, as is required by plans participating in the ACA Marketplaces. Also, CMS could give insurers a stronger incentive to maintain current and accurate directories by incorporating a measure of these attributes in their star rating system.

This report documents that Medicare Advantage plans’ networks vary across the country and within counties – to a degree and in a manner that has not been previously recognized. The extent of this variation raises important questions about the experiences of current and future enrollees who unwittingly end up in narrow-network plans, as a result of their inability to evaluate plans’ provider networks. These wide variations in provider networks are also important for policymakers because they raise questions about the minimum standards for physician access and the lack of tools and resources to allow Medicare beneficiaries to compare the scope and composition of Medicare Advantage plans’ provider networks.

Geographic Focus

This study examined Medicare Advantage plans available in 2015 in 20 counties: Allegheny County, PA; Clark County, NV; Cook County, IL; Cuyahoga County, OH; Davidson County, TN; Douglas County, NE; Erie County, NY; Fulton County, GA; Harris County, TX; Jefferson County, AL; King County, WA; Los Angeles County, CA; Mecklenburg County, NC; Miami-Dade County, FL; Milwaukee County, WI; Multnomah County, OR; New Haven County, CT; Pima County, AZ; Queens County, NY; and Salt Lake County, UT. The county is the smallest area, in general, that a Medicare Advantage plan must cover. Counties vary greatly in size and may not be the best metric to assess the health care market of particular locales, but an analysis at the county level provided the most complete set of data available for this type of analysis, as well as a reasonable snapshot of the health care market accessible to beneficiaries in that region.

Sources and Analysis of Data

We categorized networks into one of three sizes based on the share of physicians in the county that were included in the directory: broad (70% or more of the physicians), medium (30-69% of the physicians), and narrow (less than 30% of the physicians). The analysis included the 26 specialties that Medicare Advantage plans are required to include in their networks in 2015, and excluded all other specialties. For example, the analysis does not include pediatricians, diagnostic radiologists, anesthesiologists, or emergency medicine specialists.

The provider directories were collected from the websites of the insurers offering the plans during the Medicare Open Enrollment Period in order to best mimic what Medicare beneficiaries would access when selecting a plan. We focus our analysis on HMOs and local PPOs because the other types of Medicare Advantage plans either do not have networks (e.g., some private fee-for-service plans), have networks that are structured to cover areas larger than a county (e.g., regional PPOs), are paid in unique ways that influence the selection of providers available to beneficiaries (e.g., cost plans), or are not available for general enrollment (Special Needs Plans and employer group waiver plans). In 19 of 20 counties, both HMOs and local PPOs were available in 2015, with the exception of Los Angeles County, which only had Medicare Advantage HMOs. Of the 422 plans eligible to be included the analysis in the 20 counties, we were able to download the provider directories for 391 plans, including 292 HMOs and 99 local PPOs. These 391 plans accounted for 94 percent of the Medicare Advantage enrollment in the 20 counties. The provider directories missing from the analysis (31 out of 422 plans) either could not be downloaded and saved in a readable format, or were not available on the insurer’s website or directly from the insurer.

The directories were converted to machine-readable format and the text in the directories were matched against a national census of physicians maintained by SK&A using a text-matching method.²²  The text-matching program searched the directories for the names of every doctor practicing in each county.

We converted the directories for each plan to a machine-readable format to conduct this analysis. Many PDF were saved as PDFs without text, requiring the files to be recreated in order to be read. Once converted to a machine-readable format, we matched the text in the directories against a national census of physicians maintained by SK&A using a text-matching method. SK&A Information Services Inc., maintains a national database of physicians, which they continuously update through a telephone verification process, and this analysis used an SK&A database prepared on January 4, 2016. The text-matching program searched the directories for the names of every doctor practicing in each county.

Using the R statistical software program, we used a publicly available PDF text converter to load each directory as a text file (.txt).²³  The analysis excluded the following doctors:

• Doctors who work exclusively for the Veterans Administrations (about a percent of all physicians).
• Doctors whose listed specialty in SK&A was not a required category for Medicare Advantage plan networks.

SK&A assigns physicians up to two specialties. If a doctor’s primary classification was pediatrics or a select number of other specialties, they were excluded. The largest specialties not included in the analysis are pediatricians, diagnostic radiologists, anesthesiologists, emergency medicine specialists and optometrists. For the remaining doctors, we used the primary classification to categorize them into one of the 26 classifications established by CMS. For the remaining providers who were neither excluded nor classified, we turned to the secondary specialty and either grouped them with the 26 categories or dropped them. Nationally the largest specialty was primary care (32%) followed by gynecology OB/GYN (7%), cardiology (6%) and orthopedic surgery (6%). Geriatricians were defined separately; any doctor included in the analysis was grouped into a specialty as well as a geriatrician. Therefore, a geriatrician could be listed as both a primary care specialist, as well as a geriatrician. About one percent of physicians are geriatricians. In sum, more than 25% of doctors were excluded from the analysis.

The boundaries of counties do not always align with the zip codes available in the SK&A data. To be conservative, we included doctors who have at least one practice location in a zip code, which is at least partially included in one of the 20 counties. Our text-matching method searched for a string match of all the doctors in a given county. For each doctor’s name within the county, we flagged every occurrence where the last name was within three words of the first name. This method would identify both “Johnathan Hancock” and “Hancock, Johnathan” as well as cases in which the directory included a middle name or title such as “Johnathan Adam Hancock”, “Hancock IV, Johnathan Adam” or “Hancock, (Surgeon), Johnathan Adam”.

In addition, we searched last names and up to nine nicknames for every doctors in the county. For example, we would successfully identify “Johnathan Hancock” as either “John Hancock” or “Johnny Hancock”. We selected 435 formal names, which often have nicknames; for example Matt as a nickname for Matthew or Bill, Billy, Will, Willie, Willy as nicknames for William. Thirty-eight percent of physicians in the 20 counties had at least one nickname – about 0.64 percent had six or more nicknames (Elizabeth, Katherine, Margaret).

To reduce match errors with hyphenated last names – we eliminated punctuation – so regardless of whether a directory listed Kareem Abdul-Jabbar as “Kareem Abdul-Jabbar”, “Kareem Abdul Jabbar”, or “Kareem AbdulJabbar” we would successfully identify the doctor as practicing.

To test the validity of the text-matching program, 20 names were drawn at random from each of the 20 counties (400 names in total) using the SK&A dataset, and then a person searched for those names in the directories by hand, in the same fashion that an enrollee would look for their doctor. For 377 out of 400 names (94%), the person and the text-matching program agreed. Of the names that did not match, 3% were false-negatives (text-matching program did not count the physician in the directory when it should have done so) and 3% were false-positives, indicating that the totals were 99.8% accurate. The most important form of error may be the accuracy of the provider directory – our text analysis only identifies whether a provider is listed in the directory, not whether that provider is taking new patient or even still practicing in the service area. The error in our text analysis method may work to both overestimate and underestimate the percentage of doctors.

Some examples of potential false-positives – or cases in which out method would over estimate the number of doctors may include:

• Cases in which the directory contains the name of someone who is not an eligible physician and there is an eligible physician by the same name practicing in the county but is not included in the network. For example, a plan does not include a primary care doctor named “Marie Curie” but does include an optometrist by the same name “Marie Curie”.
• While most directories are structured as list of physicians followed by contact information it is possible that there are at least some occurrences of false-positives through the proximity of names. For example if a directory included the sentence, “Thomas Jefferson and John Adam were fierce political rivals” and there happened to be a physicians in the county named “John Jefferson” we would incorrectly identify him as a physician in the plan.
• If a county included multiple doctors with the same name, and a plan only included one of these doctors in its network – we would incorrectly identify them all as participating. Only 502 instances occurred where there were duplicate names (out of 66,679 physicians).

Alternatively, there are cases in which our text analysis may undercount the percentage of doctors participating in the network. Some examples of true-negatives may include cases in which a directory lists a physician under a different name than the one listed in the SK&A directory. This may include cases in which the physician’s name is spelled differently in the directory and the SK&A database or the doctor uses only one of their two hyphenated last names.

Some of this study’s findings were aggregated by county and across counties by weighting each plan’s results by its enrollment using the Centers for Medicare and Medicaid Services Medicare Advantage Enrollment files for March 2015. Data on plan enrollment was made available by CMS for March 2015 (”State/County/Contract/Plan (CPSC) Enrollment Data”). No enrollment data is available for plans with fewer than 10 enrollees (7% of the plans in our sample).²⁴  Categorization of the plans as Preferred Provider Organizations (PPO) and Health Maintenance Organization (HMO) was made by CMS.²⁵ 

Tables

1. Jacobson G, Swoope C, Perry M, and Slosar M. “How are Seniors Choosing and Changing Health Insurance Plans?,” Kaiser Family Foundation, May 2014. Available at: http://modern.kff.org/medicare/report/how-are-seniors-choosing-and-changing-health-insurance-plans/. ↩︎
2. Jacobson G, Damico A, Neuman T, and Gold M. “Medicare Advantage 2017 Spotlight: Enrollment Market Update,” Kaiser Family Foundation, June 2017. Available at: http://modern.kff.org/medicare/issue-brief/medicare-advantage-2017-spotlight-enrollment-market-update/. ↩︎
3. See Centers for Medicare and Medicaid Services, CY2016 MA HSD Provider and Facility Specialties and Network Adequacy Criteria Guidance. Available at: https://www.cms.gov/Medicare/Medicare-Advantage/MedicareAdvantageApps/Downloads/CY2016_MA_HSD_Network_Criteria_Guidance.pdf. ↩︎
4. A prior analysis found that 16 percent of Medicare Advantage plans had narrow hospital networks, defined as including less than 30 percent of the hospitals in a county. See Jacobson G, Trilling A, Neuman T, Damico A, and Gold M. “Medicare Advantage Hospital Networks: How Much Do They Vary?,” Kaiser Family Foundation, June 2016. Available at: http://modern.kff.org/report-section/medicare-advantage-hospital-networks-how-much-do-they-vary-results/. ↩︎
5. US Government Accountability Office, “Medicare Advantage: Actions Needed to Enhance CMS Oversight of Provider Network Adequacy,” August 2015. Available at: http://www.gao.gov/assets/680/672236.pdf. Resneck JS, Quiggle A, Liu M, and Brewster DW. “The Accuracy of Dermatology Network Physician Directories Posted by Medicare Advantage Health Plans in an Era of Narrow Networks,” JAMA Dermatol., October 2014; 150(12):1290-1297. Available at: http://jamanetwork.com/journals/jamadermatology/fullarticle/1919439. ↩︎
6. Centers for Medicare and Medicaid Services, “Online Provider Directory Review Report,” January 13, 2017. Available at: https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/Downloads/Provider_Directory_Review_Industry_Report_Final_01-13-17.pdf. ↩︎
7. For a description of the network categories relative to McKinsey & Company’s categories, see the Methods section of Jacobson G, Trilling A, Neuman T, Damico A, and Gold M. “Medicare Advantage Hospital Networks: How Much Do They Vary?,” Kaiser Family Foundation, June 2016. Available at: http://modern.kff.org/report-section/medicare-advantage-hospital-networks-how-much-do-they-vary-results/. ↩︎
8. Polsky D, Cidav Z, and Swanson A. “Marketplace Plans with Narrow Physician Networks Feature Lower Monthly Premiums Than Plans with Larger Networks,” Health Affairs, October 2016. Available at: http://content.healthaffairs.org/content/35/10/1842.abstract. ↩︎
9. This finding is similar to those in another report discussing physician networks for mental health care in the ACA marketplaces; see Zhu J, Zhang Y, and Polsky D. “Networks In ACA Marketplaces Are Narrower For Mental Health Care Than For Primary Care,” Health Affairs, September 2017. Available at: http://content.healthaffairs.org/content/36/9/1624.abstract. ↩︎
10. Note that 9 plans in our analysis had no psychiatrists in the directories, and are not included in the ratio analysis. We consider this to be a conservative method in estimating the enrollee burden; if these plans were included, the ratios of enrollees to psychiatrists would be larger. ↩︎
11. Jacobson G, Damico A, Neuman T, and Gold M. “Medicare Advantage 2017 Spotlight: Enrollment Market Update,” Kaiser Family Foundation, June 2017. Available at: http://modern.kff.org/medicare/issue-brief/medicare-advantage-2017-spotlight-enrollment-market-update/. ↩︎
12. Among plans offered in the same county by the same insurer, but without a common provider network, HMOs included 48 percent of all physicians in their county, on average, while PPOs included 58 percent of physicians in their county, on average. ↩︎
13. Dafny L, Hendel I, Marone V, and Ody C. “Narrow Networks On The Health Insurance Marketplaces: Prevalence, Pricing, And The Cost Of Network Breadth,” Health Affairs, September 2017. Available at: http://content.healthaffairs.org/content/36/9/1606.abstract?sid=230cbad6-de5b-4c55-b4aa-26b01641a875. ↩︎
14. Business Wire, “UnitedHealth Group Signs Definitive Agreement to Acquire Sierra Health Services, Inc.” March 12, 2007. Available at: http://www.businesswire.com/news/home/20070312005513/en/UnitedHealth-Group-Signs-Definitive-Agreement-Acquire-Sierra. ↩︎
15. A prior analysis of Medicare Advantage hospital networks found that 11 out of 231 plans included hospitals that had been torn down or closed. See Jacobson G, Trilling A, Neuman T, Damico A, and Gold M. “Medicare Advantage Hospital Networks: How Much Do They Vary?,” Kaiser Family Foundation, June 2016. Available at: http://modern.kff.org/report-section/medicare-advantage-hospital-networks-how-much-do-they-vary-results/. See also Centers for Medicare and Medicaid Services, “Online Provider Directory Review Report,” January 13, 2017. Available at: https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/Downloads/Provider_Directory_Review_Industry_Report_Final_01-13-17.pdf. See also US Government Accountability Office, “Medicare Advantage: Actions Needed to Enhance CMS Oversight of Provider Network Adequacy,” August 2015. Available at: http://www.gao.gov/assets/680/672236.pdf. ↩︎
16. Jacobson G, Damico A, Neuman T, and Gold M. “Medicare Advantage 2017 Spotlight: Enrollment Market Update,” Kaiser Family Foundation, June 2017. Available at: http://modern.kff.org/medicare/issue-brief/medicare-advantage-2017-spotlight-enrollment-market-update/. ↩︎
17. A prior analysis found that 16 percent of Medicare Advantage plans had narrow hospital networks, defined as including less than 30 percent of the hospitals in a county. See Jacobson G, Trilling A, Neuman T, Damico A, and Gold M. “Medicare Advantage Hospital Networks: How Much Do They Vary?,” Kaiser Family Foundation, June 2016. Available at: http://modern.kff.org/report-section/medicare-advantage-hospital-networks-how-much-do-they-vary-results/. ↩︎
18. Jacobson G, Griffin S, Neuman T, and Smith K. “Income and Assets of Medicare Beneficiaries, 2016-2035,” Kaiser Family Foundation, April 2017. Available at: http://modern.kff.org/medicare/issue-brief/income-and-assets-of-medicare-beneficiaries-2016-2035/. ↩︎
19. For more information, see Pollitz, K. “Surprise Medical Bills,” Kaiser Family Foundation, March 2016. Available at: http://modern.kff.org/private-insurance/issue-brief/surprise-medical-bills/. ↩︎
20. Jacobson G, Swoope C, Perry M, and Slosar M. “How are Seniors Choosing and Changing Health Insurance Plans?,” Kaiser Family Foundation, May 2014. Available at: http://modern.kff.org/medicare/report/how-are-seniors-choosing-and-changing-health-insurance-plans/. ↩︎
21. Federal Register, Volume 82, No. 137, July 19, 2017. Available at: https://www.gpo.gov/fdsys/pkg/FR-2017-07-19/pdf/2017-15071.pdf. ↩︎
22. See SK&A, Physician Data. Available at: http://www.skainfo.com/databases/physician-data. ↩︎
23. Cichini, K. “Reading and Text Mining a PDF-File in R,” September 2012. Available at: http://thebiobucket.blogspot.com/2012/09/reading-and-text-mining-pdf-file-in-r.html. ↩︎
24. See Centers for Medicare and Medicaid Services, Monthly Enrollment by Contract/Plan/State/County. Available at: https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/mcradvpartdenroldata/monthly-enrollment-by-contract-plan-state-county.html. ↩︎
25. See Centers for Medicare and Medicaid Services, Plan Crosswalks. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MCRAdvPartDEnrolData/Plan-Crosswalks.html. ↩︎