Most of the 65 million beneficiaries who receive health insurance coverage through the federal Medicare program are enrolled in some form of private plan. In 2023, 31 million Medicare beneficiaries are enrolled in Medicare Advantage (Medicare Part C) plans administered by private health insurers. The other 34 million beneficiaries are in traditional Medicare, including 22 million beneficiaries who are enrolled in a Medicare Part D prescription drug plan offered by private sponsors, and more than 14 million who have Medicare supplemental insurance (Medigap) offered by private insurers (traditional Medicare beneficiaries may be enrolled in a Part D plan, a Medigap plan, or both).

Private plan offerings have grown in recent years, most notably in the Medicare Advantage market. More Medicare Advantage plans are available in 2023 than in any prior year. Medicare Advantage enrollment has doubled since 2010, due in part to extensive marketing efforts and the draw of extra benefits and attractive cost features. Each year, beginning on October 1^st, insurers, as well as brokers and other third-party entities, are permitted to begin marketing Medicare Advantage for the annual open enrollment period for coverage in the following year. The open enrollment period for Medicare Advantage and Medicare Part D plans runs from October 15^th through December 7^th. Television ads are one of many marketing activities used by insurers, brokers and other third-party entities to boost enrollment.

Recently, the Centers for Medicare and Medicaid (CMS) has reported a steep rise in beneficiary complaints related to the marketing of Medicare Advantage and Part D plans. Many of these complaints have centered on the activities of brokers and other third-party entities, referencing misleading claims and aggressive sales tactics. Concerns raised by the National Association of Insurance Commissioners and in a report released by the majority staff of the U.S. Senate Committee on Finance have also called attention to this issue. In response, CMS published updated regulations, effective June 2022, mandating stricter oversight of these third parties by the insurers they represent. Additional CMS requirements intended to curtail misleading marketing activities came into effect in June 2023, and will apply to the open enrollment period for 2024 coverage and beyond.

To capture the state of television marketing activities and consider the implications for people with Medicare, KFF analyzed ad data compiled by the Wesleyan Media Project, that were obtained from Vivvix (formerly Kantar) CMAG, a data analytics and consulting firm, and were coded by the Wesleyan Media Project in collaboration with KFF. The data set included all English-language TV ads that aired across national and local markets on broadcast television or national cable, from October 1^st, 2022, through December 7^th, 2022, the period that includes the Medicare open enrollment period for coverage in 2023. (see Methods).

Key Takeaways:

• TV airways were flooded with ads for Medicare plans. Nearly 650,000 airings of Medicare ads appeared during the nine weeks of advertising, more than 9,500 airings per day. Most of these ads were aired in local media markets. While most TV ads were sponsored by health insurers, about one in every five TV ads were sponsored by brokers and other third-party entities, such as marketing firms.
• TV ads for Medicare Advantage comprised more than 85% of all airings for the open enrollment period for 2023. The remaining ads focused on other types of plans, such as Medigap and stand-alone Part D prescription drug plans, or promoted the open enrollment period more generally. Medicare Advantage ads were disproportionately sponsored by health insurers who offer plans that comprise a relatively small share of Medicare Advantage enrollees.
• TV ads for Medicare Advantage often showed images of a government-issued Medicare card or urged viewers to call a “Medicare” hotline other than the official 1-800-Medicare hotline. More than a quarter of all airings (27%) included a government-issued Medicare card or image that resembled it, including 28% of insurer-sponsored airings and 21% of airings sponsored by brokers and other third-party entities, a trend that CMS has flagged as potentially misleading to beneficiaries. Roughly 16% of airings featured a privately-run phone line described as a “Medicare” hotline, most of which were sponsored by brokers and other third-party entities.
• Some ads suggested that people with Medicare miss out on benefits to which they are entitled if they are not enrolled in a Medicare Advantage plan. These TV ads were more common among ads sponsored by brokers and other third-party entities than those sponsored by health insurers, and used language that implied viewers were “missing out” on benefits they were “entitled to,” or receiving incomplete coverage under Medicare Parts A and B if they were not enrolled in a Medicare Advantage (Part C) plan
• The vast majority of Medicare Advantage ad airings touted low costs and extra benefits, while few mentioned quality ratings. Nearly all Medicare Advantage ad airings emphasized extra benefits, such as dental, vision, and hearing (92%) or the potential for lower out-of-pocket spending (85%). Airings sponsored by brokers and other third-party entities often (67%) promoted the potential for enrollees to get money back in their Social Security check (or lower their Medicare Part B premium). Few airings (4%) mentioned quality star ratings.
• Medicare Advantage ad airings often featured active seniors engaged in physical activities, but rarely showed people who appeared to have a serious health problem or visible disability. One in four Medicare Advantage ad airings (26%) showed seniors taking part in activities such as hiking or yoga, but few included people with visible disabilities (4%) or the appearance of serious illness (1%) for whom health insurance coverage and choice of providers may be a high priority.
• TV ads sponsored by brokers and other third-party entities used celebrity endorsements more often than health insurers to promote Medicare Advantage. Celebrities, such as actors, athletes, and politicians, appeared in more than half of Medicare Advantage ad airings sponsored by brokers and other third parties (55%), but rarely appeared in airings sponsored by insurers (3%). Familiar figures included Joe Namath, Lionel Richie, William Shatner, and JJ Walker. Joe Namath was featured more than any other celebrity, appearing in nearly 56,000 airings.

Medicare beneficiaries have a wealth of choices for their health insurance coverage. While beneficiaries may appreciate the ability to select from multiple options, the variable costs, benefits, provider networks, and other characteristics of Medicare Advantage plans make the decision complex, especially in light of the barrage of advertising. Additionally, information about coverage under traditional Medicare is rarely included in television ads, leaving beneficiaries with an incomplete view of their coverage options and the tradeoffs among them. While CMS has issued new rules to address concerns about aggressive and misleading marketing tactics, ongoing monitoring and resources independent of commercial interests could help to improve beneficiary decision-making.

Introduction

During the annual Medicare open enrollment period that runs from October 15^th through December 7^th, Medicare beneficiaries can review the coverage options available in their area and make changes for the upcoming year. Drawn by the prospect of strong financial performance, buoyed by generous payments from the federal government, many insurers have expanded their Medicare Advantage offerings in recent years. In 2023, Medicare beneficiaries can choose from an average of 43 Medicare Advantage plans, offered by 9 different insurers, the highest number ever available. Traditional Medicare beneficiaries selecting prescription drug coverage can choose from an average of 24 stand-alone Part D plans.

Plans rely on TV advertising, among other marketing activities, to attract and retain enrollees during the open enrollment period. Recent years have seen an increase in print and television ads from third-party marketing organizations, such as agents and brokers, lead generation businesses, and media firms. At the same time, the Centers for Medicare and Medicaid Services (CMS) has reported a steep rise in beneficiary complaints related to the marketing of private Medicare plans, from less than 16,000 in 2020 to nearly 40,000 in the first eleven months of 2021, many of them centered on the marketing activities of these third-party entities.

In May 2022, the National Association of Insurance Commissioners (NAIC) sent a letter to Congress urging action on this issue, citing concerns about misleading claims and aggressive sales tactics. The following November, the majority staff of the Senate Finance Committee released a report detailing complaints and associated marketing materials from key stakeholders across 14 states. In response, CMS released new regulations, effective June 2022 and June 2023, tightening restrictions on health insurers and third parties who market Medicare Advantage and Part D plans.

This report describes the content and characteristics of all English-language TV ads focused on Medicare that aired on broadcast television or national cable between October 1, 2022 and December 7, 2022. Ads were obtained by the Wesleyan Media Project from Vivvix (formerly Kantar) CMAG, a data analytics and consulting firm, and coded by trained undergraduate student coders using an instrument developed jointly by the Wesleyan Media Project and KFF. The KFF analysis includes 1,267 unique ads that aired 643,852 times during the advertising period and focuses mainly on Medicare Advantage ads, the dominant Medicare plan type advertised during the period (see Methods).

Background

Trends in Medicare Coverage

More than 65 million people receive health insurance coverage through the federal Medicare program. Increasingly, this coverage is provided by private companies who contract with the federal government to offer Medicare Part A and Part B covered services (Medicare Advantage or MA), Part D prescription drug plan coverage (PDP), or both (MA-PD). Medicare Advantage enrollment has doubled since 2010, covering over half (31 million people) of eligible Medicare beneficiaries in 2023. Among traditional Medicare beneficiaries, 22 million are enrolled in a stand-alone PDP and most have some form of private supplemental coverage, including more than 14 million who purchase a private Medigap supplement policy.

The growth in Medicare Advantage enrollment is due, in part, to the extra benefits and attractive cost features offered by most Medicare Advantage plans. Virtually all Medicare Advantage plans offer some benefits not included in traditional Medicare, such as coverage of dental, vision, or hearing services. Additionally, unlike traditional Medicare, which places no cap on out-of-pocket spending for hospital or physician services, Medicare Advantage plans are required to set out-of-pocket limits for services covered by Parts A and B. At the same time, Medicare Advantage plans often have restrictions, such as prior authorization and referral requirements, rarely used in traditional Medicare, and most include networks that set limits on which providers enrollees may see. Close to 60% of Medicare Advantage beneficiaries are enrolled in HMO plans that typically do not cover out-of-network services.

Marketing Complaints and Regulatory Response

The report from the majority staff of the Senate Finance Committee documents numerous examples of beneficiary complaints about marketing practices used by Medicare Advantage insurers, as well as brokers and other third-party entities, including false or misleading information about plan costs and available benefits, concerns which have been raised by the National Association of Insurance Commissioners as well. For example, advertisements promising lower Part B premiums or higher Social Security checks were a common source of complaints. States frequently reported incidents in which agents or brokers used this claim to attract potential enrollees, even when advertising in service areas where no such plans were available, or when enrolling beneficiaries in a plan that offered this benefit would be an otherwise poor fit for their needs. In 2023, just 17% of Medicare Advantage plans offer a rebate toward the Part B premium.

Likewise, CMS has raised concerns that the prominent use of the word “Medicare” in company names or headers and images of the Medicare card or logo in print and TV ads creates confusion for beneficiaries and may lead them to believe that these organizations are speaking on behalf of the Medicare program. Focus groups conducted by KFF in the fall of 2022, suggest that beneficiaries find these ads to be misleading, often reporting uncertainty about who had sponsored the ads they saw on TV and whether they were endorsed by the Medicare program or the federal government.

CMS has moved to address these issues in several ways. Regulations that went into effect in June 2022, and apply to all Medicare Advantage and Part D ads discussed in this analysis, broaden the definition of third-party marketing organizations, mandate greater oversight by health insurers of the third parties who represent them, and require third parties to include a standard disclaimer in all communications and marketing materials informing beneficiaries that they do not represent every plan available in their area and advising them to contact official CMS resources for a complete list of their options (though CMS does not specify whether or not this disclaimer may be featured in fine print). In April 2023, CMS finalized additional requirements to address misleading marketing practices that will apply to the upcoming Medicare open enrollment period that begins in October 2023, for coverage in 2024. (See Appendix for details.)

TV Ads For the 2023 Medicare Open Enrollment Period

Key Takeaways:

• TV airways were flooded with ads for Medicare plans.
• TV ads for Medicare Advantage comprised more than 85% of all airings for the open enrollment period for 2023. 
• TV ads for Medicare Advantage often showed images of a government-issued Medicare card or urged viewers to call a “Medicare” hotline other than the official 1-800-Medicare hotline.
• Some ads suggested that people with Medicare miss out on benefits to which they are entitled if they are not enrolled in a Medicare Advantage plan. 
• The vast majority of Medicare Advantage ad airings touted low costs and extra benefits, while few mentioned quality ratings. 
• Medicare Advantage ad airings often featured active seniors engaged in physical activities, but rarely showed people who appeared to have a serious health problem or visible disability. 
• TV ads sponsored by brokers and other third-party entities used celebrity endorsements more often than health insurers to promote Medicare Advantage. 

TV airways were flooded with ads for Medicare plans.

There were 643,852 airings of English-language Medicare ads run on broadcast television and national cable between October 1, 2022, and December 7, 2022, an average of more than 9,500 airings per day, more than were seen for any individual Healthcare.gov open enrollment period between 2013 and 2018. Just over 40,000 Spanish-language airings (not included in our analysis) bring the total number of Medicare-related airings close to 690,000.

Medicare ads were most common during the weekday afternoons. Across the top 20 markets, viewers of programs aired on Fox affiliates saw an average of at least 6 ads per day, viewers of programs aired on ABC and NBC affiliates saw an average of at least 5 ads per day and viewers of programs aired on CBS saw an average of at least 4 ads per day each weekday afternoon between October 1, 2022 and December 7, 2022 (data not shown).

The most common television programs during which Medicare ads were aired included talk shows, reality court shows and game shows. For example, across the top 20 markets, regular viewers of Dr. Phil saw an average of 404 Medicare ads, or 8 ads per day that were directed at the open enrollment period. Regular viewers of Hot Bench saw 336 ads on average, or 7 ads per day, and regular viewers of Family Feud saw 281 ads on average, or 6 ads per day (Appendix Table 1).

Local news broadcasts also often included commercials for Medicare plans. On December 1^st, the day with the highest number of airings, a person watching News 5 at 5pm on ABC in Cleveland would have seen nine Medicare ads during the one-hour broadcast. Likewise, a person watching WCCO Mid-Morning on CBS in Minneapolis would have seen seven ads during the hour, and a person watching Eyewitness News 4 at Midday on NBC in Albuquerque would have seen six in the hour (data not shown).

Most Medicare ads aired in local media markets rather than nationally. Of the 643,852 Medicare ad airings analyzed, the vast majority (86%) aired locally, while 14% aired nationally. The targeting of TV ads to local media markets likely reflects a strategy to compete and grow enrollment in specific regions and service areas. (See Appendix for details.)

While health insurers sponsored the majority of Medicare TV ad airings, brokers and other third-party entities had a significant presence, especially with ads that aired nationally. Roughly 73% of all Medicare ad airings (468,808) were sponsored by health insurers, while more than one in five (21%, 135,699) were sponsored by brokers and other third-party entities. Just 3% (18,321) were sponsored by the Department of Health and Human Services or other government agency (Figure 1). Brokers and other third parties relied more on national airings than local markets, accounting for 50% of national airings but just 16% of all local airings.

Roughly 3% (21,024) of all Medicare ad airings did not identify the organization who sponsored the ad. Among national airings, nearly one in ten did not include this information, a pattern that may reflect the larger share of national ads sponsored by brokers and other third parties, who may have less to gain from brand recognition.

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TV ads for Medicare Advantage comprised more than 85% of all airings for the open enrollment period for 2023.

Of the 643,852 airings of Medicare ads that ran during the nine-week advertising period for open enrollment for coverage in 2023, 556,068 (86%) promoted Medicare Advantage. Many of these airings also mentioned Part D benefits, but a review of the top 150 most-frequently aired ads (representing more than 80% of all Medicare ad airings) showed that nearly all of these were marketing Medicare Advantage plans that included Part D coverage, rather than offering stand-alone Part D plans as a separate product. Of the remaining 87,784 airings, 7,790 (1%) promoted Medigap plans and 465 (less than 1%) promoted stand-alone Part D plans with no mention of Medicare Advantage. Another 32,692 airings (5%) promoted multiple types of plans, while 46,837 (7%) did not mention any type of plan, instead offering general information on the open enrollment period or counseling on Medicare plan choice (Figure 2).

The emphasis on Medicare Advantage matches trends in Medicare enrollment. As of 2023, just over half of all eligible Medicare beneficiaries receive their Medicare Part A and Part B benefits through a Medicare Advantage plan, a twofold increase in the past decade that has outpaced the more modest growth seen in Medigap enrollment. Likewise, enrollment in stand-alone Part D plans has declined as a growing share of beneficiaries enroll in Medicare Advantage plans that include prescription drug coverage. At the same time, a KFF analysis of private Medicare advertising for the 2008 open enrollment period demonstrated that insurers have devoted the largest share of their advertising resources to Medicare Advantage plans for some time.

The remaining discussion is focused on Medicare Advantage, as these ads made up the vast majority of Medicare ad airings for the open enrollment period.

Four of every five Medicare Advantage ad airings were sponsored by health insurers, with the remaining sponsored by brokers and other third-party entities, such as marketing companies. Among the 556,068 ads promoting Medicare Advantage, health insurers sponsored a majority (79%) of ad airings while brokers and other third-party entities sponsored 19%. The remaining 2% of sponsors were not readily identifiable. Ads sponsored by brokers and other third parties rarely listed the specific Medicare Advantage organizations they represented or the plans they offered, though many advertised specific benefits and plan features that might be available. Brokers may contract with multiple insurers, and offer plans with varying benefits and costs, across many service areas, which may lead to confusion if beneficiaries are unaware which of the plan features advertised are available where they live. Further, brokers have a financial incentive to steer people towards Medicare Advantage plans over other coverage options. In the 2023 plan year, brokers receive $601 per new enrollee in most Medicare Advantage plans, substantially higher than for new enrollees in most Part D plans ($92). Though comparable data do not exist for Medigap plans, brokers report substantially lower commissions for Medigap enrollment.

Though not applicable to these ads, new regulations from CMS came into effect in June 2023 which prohibit brokers and other third parties from advertising specific plans or plan features without clearly identifying the insurers that offer them. Further, all groups are prohibited from marketing benefits in service areas where those benefits are not available (see Appendix for details).

UnitedHealthcare and Humana comprise nearly half of Medicare Advantage enrollment but sponsored just 20% of insurer-sponsored ad airings. Many TV ad airings promoting Medicare Advantage were sponsored by health insurers that enroll a relatively small share of Medicare Advantage enrollees. While UnitedHealthcare and Humana together comprise nearly 50% of Medicare Advantage enrollment in recent years, these two insurers sponsored less than 20% of airings for Medicare Advantage plans. In contrast, three insurers accounted for a larger share of airings than enrollment: Blue Cross Blue Shield affiliates (26% of airings vs. 14% of enrollment), Centene (12% vs. 4%), and Cigna (9% vs. 2%). Roughly one in five airings (24%) came from insurers that account for less than 2% of Medicare Advantage enrollment each, and 16% as a group (Figure 3). Despite rapid growth, Medicare Advantage enrollment remains concentrated among a small group of firms, and insurers with a smaller footprint in the Medicare Advantage market may rely more heavily on TV advertising to promote their plans and expand market share.

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TV ads for Medicare Advantage often showed images of a government-issued Medicare card or advertised a “Medicare” hotline other than 1-800-Medicare.

Over one in four ad airings (27%) promoting Medicare Advantage showed a government-sponsored Medicare card or an image that resembled it, and 16% included a phone number other than 1-800-Medicare that was described as a “Medicare” hotline. Both CMS and the Senate Finance Committee have expressed concern that the use of the Medicare name, logo, or card in private marketing materials could confuse beneficiaries and lead them to believe they are contacting an official government resource. New regulations from CMS aim to address this issue by prohibiting the use of the Medicare card, except for educational purposes (see Appendix for details).

The Medicare card or a similar image appears on screen in more than one-quarter of ad airings for Medicare Advantage. Images of the Medicare card, or something that closely resembles it, appeared in more than one-quarter (27%) of all ad airings for Medicare Advantage, including 28% of insurer-sponsored airings and 21% of airings sponsored by brokers and other third-party entities. Some of these framed the screen with a red, white, and blue border that resembles the Medicare card design, in some instances, for the duration of the airing.

Though not applicable to these ads, new regulations, which will apply to the upcoming open enrollment period in October 2023, prohibit misleading use of the Medicare name, logo, or card in private marketing and communication materials, or any use without prior approval from CMS. CMS has stated that it will approve use for educational purposes only, such as a graphic showing beneficiaries how to tell the difference between their federally-issued Medicare card and their insurer-issued Medicare Advantage plan card. However, it is unclear whether images that are similar, but not identical, to a Medicare card will still be permitted in marketing materials, such as the use of a Medicare card design to frame the screen.

Most Medicare Advantage ad airings sponsored by brokers and other third parties featured a “Medicare” hotline that is not the official government-sponsored 1-800-Medicare hotline. A large majority of Medicare Advantage airings sponsored by brokers and other third-party entities (83%) featured a “Medicare” hotline other than the 1-800-Medicare line run by the federal government (Figure 4). These were often described using general names such as a “Medicare Helpline,” “Medicare Benefits Support Line,” or “Medicare Benefits & Questions Line,” with no reference to a specific company name. In contrast, airings sponsored by health insurers rarely included this type of “Medicare” hotline, instead directing viewers to call their own agents (data not shown). Virtually no ad airings promoting Medicare Advantage mentioned 1-800-Medicare, the official Medicare phone number, outside of fine print.

Among airings sponsored by brokers and other third parties, 19% included both an image of the Medicare card and mention of a privately-run “Medicare” hotline, increasing the possibility that beneficiaries will believe that the ad and its contents were sponsored by an official government agency.

VIDEO: Medicare Advantage ads often showed images of a government issued Medicare card or urged viewers to call a “Medicare” hotline other than 1-800-Medicare.

Focus groups conducted by KFF in the fall of 2022 suggest that beneficiaries are often overwhelmed by the volume and complexity of choices available to them, yet few make use of official Medicare resources such as 1-800-Medicare. Airings sponsored by brokers and other third parties often referenced this volume of choices, encouraging beneficiaries who felt “overwhelmed” or “confused” by their coverage options to call their privately-operated “Medicare” hotline for advice.

Under current rules that became effective in June 2022, and are applicable to the period examined, ads sponsored by brokers and other third-party entities are required to include a disclaimer explaining that they do not represent every plan available in a service area and advising beneficiaries to call 1-800-Medicare for a complete list of their coverage options. While this disclaimer was included in the subset of third-party airings we reviewed, it was often shown for just a few seconds or written in small font, potentially making it difficult for viewers to read.

In some cases, ads advised callers against giving their personal information to national hotlines or “1-800 numbers,” suggesting that local experts were more trustworthy. While these messages may be aimed at other broker-sponsored hotlines that operate at the national level, they may also discourage viewers from calling 1-800-Medicare for additional information.

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Some ads suggest that people with Medicare miss out on benefits to which they are entitled if they are not enrolled in a Medicare Advantage plan.

More than 50,000 Medicare Advantage ad airings used language that suggested people with Medicare are “missing out” on important benefits if they are not enrolled in a Medicare Advantage plan. Additionally, some ads tell viewers that they are “entitled” to receive supplemental benefits or cost savings offered by some Medicare Advantage plans. Language such as “missing” or “entitled” may give some viewers the impression that they have incomplete coverage or have overlooked a necessary enrollment step if they receive their Medicare coverage from traditional Medicare.

Medicare Advantage plans often include low or $0 supplemental premiums and extra benefits not included in traditional Medicare, such as coverage of dental, vision, and hearing services. The language used in the TV ads refers to these benefits by emphasizing that they are not covered by Medicare Parts A and B, and beneficiaries “do not get these benefits automatically” without enrolling in Medicare Advantage (also referred to as Medicare Part C). For example, some common phrases included:

This messaging may be especially confusing when paired with references to the Medicare name, logo, or card. Ads with this messaging were more commonly sponsored by brokers and other third-party entities. These third-party sponsored ads also included a privately-run “Medicare” hotline in four out of every five airings, often alongside images of (and references to) the Medicare card. While these references may be intended to alert Medicare beneficiaries that these ads are directed at them, they may lead some viewers to believe the ads were produced by a government source, creating the impression that the government is endorsing the message that Medicare Advantage is “missing” from traditional Medicare coverage.

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The vast majority of Medicare Advantage ad airings touted low costs and extra benefits, while few mentioned quality ratings.

More than 90% of airings for Medicare Advantage promoted extra benefits, such as dental, vision, and hearing, and 85% promoted cost features, such as $0 co-pays, no additional premiums, or reductions to the standard Part B premium (Figure 5). A KFF analysis of private Medicare advertising in 2008 also found extra benefits to be the most common message appearing in TV, print, and radio ads for Medicare Advantage.

By contrast, only one in five airings (22%) mentioned plan features that promote flexible access to providers and services, such as nationwide networks and out-of-network coverage, and fewer than 4% made any reference to a plan’s quality star rating.

Ads promoting Medicare Advantage touted a range of supplemental benefits. Mentions of dental, vision, hearing, and prescription drug benefits each appeared in more than 50% of all airings promoting Medicare Advantage. Dental coverage was included in 84% of airings, more often than any other type of supplemental benefit or any cost-related message (Figure 6).

Benefits that may appeal to people in poorer health were marketed substantially less often, including allowances for food or grocery spending (20%), transportation services (20%), and meals (10%), though these were somewhat more common in insurer-sponsored airings than broker or other third-party airings (Appendix Table 2). Other benefits that are valuable to people with serious illnesses or mobility impairments were uncommon regardless of sponsor. Caregiver support, such as respite care or custodial care, was included in just 2% of airings, and bathroom safety devices such as bathtub rails and grab bars were included in less than 1%.

Supplemental benefits are a common feature of Medicare Advantage plans. In 2023, virtually all Medicare Advantage plans offer some supplemental benefits, most often dental, vision, hearing, gym memberships or other fitness benefits, and telehealth services, all of which were offered in at least 97% of available plans. Just 43% of plans included coverage for transportation services, and fewer than 15% included coverage for in-home support services, caregiver support, or bathroom safety devices, consistent with the smaller share of airings that mentioned these benefits.

More than two-thirds of airings sponsored by brokers and other third parties mentioned money back in your Social Security check. Two in three (67%) Medicare Advantage airings sponsored by brokers and other third-party entities included messaging about Part B premium rebates, compared to just 7% of insurer-sponsored airings and 19% overall (Figure 7; Appendix Table 2). While all Medicare Advantage enrollees must continue to pay the Part B premium (or in the case of dual-eligible individuals, have it paid on their behalf), Medicare Advantage plans can offer a rebate against the Part B premium as a supplemental benefit. This is sometimes referred to as the “give back” benefit and results in beneficiaries receiving higher Social Security payments each month.

Airings that included this message often featured endorsements from national celebrities. Joe Namath was featured more than any other celebrity (appearing in nearly 56,000 airings) and mentioned Part B premium rebates in 100% of his appearances.

Few airings, regardless of sponsor, stated that Medicare Advantage enrollees were required to pay the standard Part B premium, which may lead to confusion when plans are advertised as having “no premium.” Frequency of this message could not be measured precisely, due to the very small number of airings in which it appeared (see Methods for details).

Part B premium rebates are less common than many other supplemental benefits, offered by just 17% of plans available in 2023, with an even smaller share of enrollees (10%) opting for plans with this benefit. Though not applicable to these ads, new CMS rules, effective June 2023, prohibit marketing of benefits that are not available in the service area where the ad is aired, which may lead to fewer mentions of this benefit during the upcoming open enrollment period.

Low or $0 supplemental premiums were frequently mentioned among airings sponsored by Medicare Advantage insurers. Roughly two-thirds (66%) of airings promoting Medicare Advantage mentioned low or $0 supplemental premiums. Two-thirds of Medicare Advantage plans available in 2023 do not have a premium (other than the Part B premium) and among all plans the average premium is $15 per month. Mentions of low or $0 premiums were more common in airings sponsored by health insurers (79%) than those sponsored by brokers and other third-party entities (13%) (Appendix Table 2).

By contrast, airings promoting low out-of-pocket spending, including low or $0 co-pays, low cost-sharing, and low deductibles, were common among insurers and third-party sponsors, appearing in half (50%) of all Medicare Advantage airings (Figure 7; Appendix Table 2).

Messages about low premiums were often presented in contrast to the cost of supplemental plans such as Medigap. Traditional Medicare places no cap on out-of-pocket spending for hospital or physician services, and supplement plans can help to insulate beneficiaries from financial risk, but Medigap plans can be costly, with premiums ranging from less than $100 to more than $300 per month. Traditional Medicare beneficiaries may choose to purchase a Medicare supplement to assist with cost-sharing for services covered under Medicare Parts A and B.

VIDEO: Nearly all Medicare Advantage ads touted low costs and extra benefits.

Messages about low out-of-pocket spending sometimes featured estimates of savings that beneficiaries could expect to retain by enrolling in a Medicare Advantage plan. While not applicable to these ads, new regulations from CMS include a prohibition against advertising unrealized “savings” that are calculated relative to the expenses borne by uninsured individuals, the unpaid costs of beneficiaries dually eligible for Medicare and Medicaid, or other unrealized costs of a Medicare beneficiary. According to CMS, these savings estimates can be misleading, as they do not reflect the out-of-pocket costs paid by most Medicare beneficiaries and may give an unrealistic impression of the cost difference between plans.

About one in five Medicare Advantage TV airings emphasized access to doctors. Roughly one in five (22%) Medicare Advantage airings mentioned plan features that reflect flexible access to providers and services, such as promises to “keep your doctor” (14%), nationwide networks (6%), no referrals or pre-approvals for covered services (3%), or coverage for out-of-network providers (1%) (Figure 8). These messages were less common among TV ad airings sponsored by health insurers (13%) than brokers and other third-party entities (59%) (Appendix Table 2).

Health insurers may not choose to advertise access to providers as often as supplemental benefits because most plans employ networks, which place restrictions on which providers enrollees may see or offer more limited coverage for out-of-network services. Further, virtually all Medicare Advantage enrollees are in a plan that requires prior authorization for at least some services.

In contrast, 59% of Medicare Advantage airings sponsored by brokers and other third-party entities include the promise to “keep your doctor” (Appendix Table 2). Many brokers offer a range of plans with different networks, and may feel confident that they can offer a plan that includes a beneficiary’s current doctor, but it is unlikely that most beneficiaries would be able to keep their doctor regardless of the plan they choose. In 2023, 58% of Medicare Advantage plans are HMOs, which typically do not cover out-of-network services

Less than 4% of Medicare Advantage ad airings reference quality star ratings. CMS regularly publishes quality ratings of Medicare Advantage plans to assist beneficiaries in comparing the options available in their area. Plans are rated on a 5-star scale, with 1 star indicating poor performance, 3 stars indicating average performance, and 5 stars indicating excellent performance. While these ratings are intended, in part, to help consumers select a plan, they are very rarely used in TV advertising. Fewer than 4% of Medicare Advantage airings made any reference to a plan’s star rating (Figure 5).

An exception was Kaiser Permanente, which promoted the quality star rating of their plans in 86% of airings, while no other single insurer mentioned star ratings in more than 5% (Appendix Table 3). This may be due to the high ratings received by most Kaiser Permanente plans. Virtually all Medicare Advantage beneficiaries enrolled in Kaiser Permanente were in a plan with a quality rating of at least four stars in 2022, the highest share of any major insurer.

Focus groups conducted by KFF in the fall of 2022 suggest that beneficiaries do not generally take star quality ratings into account when choosing a plan. In 2023, 7 in 10 (71%) Medicare Advantage beneficiaries were enrolled in plans with a rating of 4 or more stars, which may make the rating system less meaningful to beneficiaries looking to distinguish between plans with similar scores. MedPAC has raised concerns about the star rating system in recent years, noting, among other things, that star ratings are reported at the contract rather than the plan level, which may make them less useful to beneficiaries interested in the quality of a specific plan.

Medicare Advantage insurers varied in whether they promoted particular supplemental benefits, the potential for savings, access to providers, or quality most often. Medicare Advantage insurers differed in the plan features they chose to emphasize (Appendix Table 3). UnitedHealthcare, Blue Cross Blue Shield affiliates, and CVS all touted dental coverage more often than any other supplemental benefit, consistent with the overall trend. In contrast, Humana mentioned dental coverage in just 44% of airings, but included mentions of cost features such as low or $0 premiums and low or $0 co-pays in more than 80% of airings. Centene mentioned less common offerings more often than other insururers, including benefits such as meals, transportation, and vouchers for food and groceries or over-the-counter items in more than 50% of airings.

UnitedHealthcare mentioned plan features related to access to providers more often than other insurers, promoting a nationwide network in 27% of airings and lack of referrals or prior authorization requirements in 28% (compared to just 8% and 4% of insurer-sponsored Medicare Advantage airings overall).

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Medicare Advantage ad airings often featured active seniors engaged in physical activities, but rarely showed people who appeared to have a serious health problem or visible disability.

Most Medicare Advantage airings (78%) featured people in some capacity. While ads were diverse in terms of the race, ethnicity, gender, and age of people shown (data not shown), people were generally shown to be in good health and free from serious illness. A prior KFF analysis of private Medicare advertising found a similar pattern among print, radio, and TV ads for Medicare Advantage plans in 2008, with one in ten showing seniors engaging in physical sports, just 3% showing people under 65 with a visible disability, and none showing people with visible signs of illness or frailty (such as a walker or a cane).

About one-quarter (26%) of Medicare Advantage airings show seniors participating in physical activity. One in four Medicare Advantage airings (26%) (Figure 9), including 32% of those sponsored by health insurers, showed seniors engaging in some form of physical activity. While some ads featured wellness activities, such as yoga or stretching, others showed seniors engaging in activities that demand much greater health and fitness, such as mountain biking, ziplining, trampoline jumping, and other forms of vigorous exercise. These ads may be targeting healthier seniors who might find these activities appealing or aspirational, and may promote the message that these plans ensure a certain standard of health, but they may also signal to those in poorer health that the plans promoted in these ads are not designed to meet more serious health needs.

VIDEO: Medicare Advantage ads often featured active seniors engaged in physical activity.

Fewer than 5% of airings include a person with a physical disability or someone receiving treatment for a serious illness. People with physical disabilities were shown in less than 4% of airings promoting Medicare Advantage, while just 1% showed a person receiving treatment for serious illness (Figure 9). Nearly all of these airings were sponsored by health insurers, as virtually no airings sponsored by brokers or other third-party entities featured people in either demographic. While this may represent an effort by insurers to associate their plans with good health, this pattern does not represent the demographics of Medicare beneficiaries as a whole. One-fifth (22%) of Medicare beneficiaries are in fair or poor self-reported health, and more than one-quarter (28%) have at least one functional impairment. Among beneficiaries under 65 and living with a permanent disability, these shares are much higher, 57% and 52% respectively.

Just over one-fifth (22%) of Medicare Advantage airings show a senior using technology. One in five Medicare Advantage airings (22%) (Figure 9), including 25% of those sponsored by health insurers, showed seniors using technology such as laptops, smartphones, or tablets. As with ads that show physical activity or exercise, this may be an attempt to appeal to a younger, more engaged group of beneficiaries, rather than those who struggle with serious health issues such as cognitive impairment.

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TV ads sponsored by brokers and other third-party entities used celebrity endorsements more often than health insurers to promote Medicare Advantage.

More than half (55%) of all Medicare Advantage airings sponsored by brokers and other third-party entities featured endorsements from celebrities such as actors, athletes, and politicians. Most featured celebrities who were seniors themselves, and virtually all national celebrities featured in these ads were men. In contrast, just 3% of insurer-sponsored ads featured celebrities. Brokers and other third parties may feel more of a need to give viewers a familiar name to catch their attention, while insurers may have more of an interest in establishing their own brand.

Focus groups conducted by KFF in the fall of 2022 suggest that beneficiaries are not swayed by celebrity endorsements and frequently disregard them. Nonetheless, many reported encountering these ads, suggesting that they are memorable, and that celebrities may help draw attention and promote a brand, even if beneficiaries do not regard them as credible.

Joe Namath was featured more often than any other celebrity, appearing in nearly 10% of all Medicare Advantage airings (55,839). One ad in which he appeared aired more often than any other single Medicare ad during the advertising period, and a second was in the top ten, with 41,252 airings and 14,421 airings respectively. No other celebrity appeared in more than 1% of Medicare Advantage airings. Other familiar figures included former sports stars such as David Ortiz, Magic Johnson, and Joe Montana, musicians such as Lionel Richie, politicians such as Mike Huckabee, and popular actors such as William Shatner, J.J. Walker, and William Devane.

VIDEO: Ads sponsored by brokers and other third parties often used celebrity endorsements to promote Medicare Advantage.

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Discussion

Every fall, Medicare beneficiaries are flooded with TV ads during the nine-week marketing period for open enrollment, most of which promote Medicare Advantage plans. The open enrollment period for 2023 coverage saw an average of more than 9,500 Medicare ad airings each day, nearly all of them from health insurers and third-party entities, such as brokers. This volume of advertising has been accompanied by a rise in beneficiary complaints related to aggressive and misleading marketing tactics, leading to heightened attention from CMS, the NAIC, and other policymakers.

New rules from CMS, effective June 2022 and June 2023, aim to address these issues by strengthening oversight of third-party marketing organizations, requiring greater transparency pertaining to the availability of advertised benefits and plan features, and prohibiting the use of certain language and images, such as the Medicare name, logo, or card, in ways that may be misleading to beneficiaries. While not all of these regulations applied to the ads discussed in this analysis, all will be in effect for the open enrollment period that begins in October 2023. Some of the observations described in this report, such as the use of a government-issued Medicare card, which may lead viewers to think the ads are sponsored by the government rather than a private company, may occur less frequently, if at all, in the future. While the new rules may address some concerns about aggressive and misleading marketing tactics, ongoing monitoring and resources independent of commercial interests could help to improve beneficiary decision-making.

Few if any ads mentioned the traditional Medicare program, the alternative to private Medicare Advantage plans, except in the context of the small number of ads promoting supplemental coverage, such as Medigap and stand-alone Part D plans. This is not surprising, since TV ads are sponsored by health insurers and brokers selling private plans, although it may leave beneficiaries without a clear understanding of their coverage options, and the tradeoffs that arise from one choice over another. Many beneficiaries may find it helpful to have support when making decisions about their Medicare coverage, including from financially disinterested sources such as State Health Insurance Assistance Programs, Social Security Administration district offices, and 1-800-Medicare. A recent survey found that many people age 65 and older would like to know more about the out-of-pocket costs and benefits of their Medicare coverage options and felt that they would benefit from one-on-one help. Adequate resources to meet the demands for assistance – beyond brokers, who have a financial interest in steering people to certain options — may help ensure Medicare beneficiaries are choosing the coverage option that best meets their needs.

Additional Data and Figures

Time Slots, Concurrent TV Programs, and Broadcast Networks of Medicare Ad Airings: Medicare advertisements appeared at all times of day, and throughout the week, but airings were most frequent on weekday afternoons (24%), weekday mornings (19%), and in the hours leading up to prime time (16%). Airings were most often shown during local news broadcasts (data not shown), while court shows, game shows, and talk shows were among the top single programs during which Medicare ads were aired (Appendix Table 1). The largest number of airings appeared on the four major broadcast networks: the Fox Broadcasting Company (16%), the American Broadcasting Company (ABC) (16%), Columbia Broadcasting System (CBS) (15%), and the National Broadcasting Company (NBC) (14%). Local advertising was more concentrated in some areas than others, with the top 20 local media markets comprising 27% of all local airings (Appendix Figure 1).

Common Messages Featured in Medicare Ad Airings by Sponsor Type and Insurance Firm:

CMS Regulations

Rules Effective June 2022: Current rules from CMS, which came into effect in June 2022 and applied to all Medicare Advantage and Part D ads discussed in this analysis, include several changes aimed at tightening oversight of third-party marketing activities. The rules introduce a broad definition of third-party marketing organizations, encompassing all organizations and individuals paid to perform lead generation, marketing, sales, or enrollment functions on behalf of a private Medicare plan, either directly or indirectly through another third party.

Health insurance companies that offer Medicare plans are now responsible for ensuring that third-party marketing organizations adhere to any CMS requirements that apply to plans themselves (previously only required for direct contractors). In the context of TV advertising, some examples include existing rules that forbid ads from using the term “free” to describe a $0 premium, implying that a plan is recommended or endorsed by CMS or another government office, or implying that a plan is only available to seniors rather than all eligible Medicare beneficiaries. Health insurers are also required to add certain monitoring and oversight provisions to any direct contract with a third-party marketing organization, and keep track of any downstream relationships that organization is using to represent their plans.

Finally, third-party marketing organizations are now required to include a standardized disclaimer in all communications and marketing materials informing beneficiaries that they do not represent every plan available in their service area and encouraging them to contact Medicare.gov or 1-800-MEDICARE for a complete list of their options.

Rules Effective June 2023: Additional rules from CMS, which came into effect in June 2023 and will apply to the upcoming open enrollment period that begins in October, introduce several more provisions aimed at curtailing misleading marketing practices. While some of these provisions go beyond the scope of TV advertising, several will have a direct impact on TV ads in the fall and in future periods.

Ads are now prohibited from mentioning any benefits or plan features that are not available in the service area where the ad appears. Ads that air in media markets that cross multiple service areas are required to list which benefits apply to each service area (Medicare Advantage and Part D service areas are defined at the county level). The Washington, DC market, for example, includes not only DC itself but also surrounding counties in Maryland and Virginia, representing several distinct service areas for which an insurer may offer plans with different premiums, cost-sharing, and benefits.

Ads are also prohibited from using the Medicare name, logo, or card in ways that could be misleading to beneficiaries. Any use requires prior approval from CMS, and CMS has stated that it will only grant this approval in cases where it is serving an educational (as opposed to marketing) purpose. CMS defines marketing as any material or activity that meets certain standards for both intent (to influence enrollment decisions or draw attention to plans) and content (any mention of specific plan features such as benefits, costs, or quality rankings), standards which would likely apply to any ad targeting open enrollment.

Third-party marketing organizations, such as agents and brokers, are prohibited from advertising specific plans or plan features without identifying the Medicare Advantage organizations or Part D sponsors that offer them. CMS requires these names to be displayed in the same font size, or read at the same pace, as any benefits included in the ad. Third parties are prohibited from airing ads without the plan sponsors promoted in the ads agreeing to their content, and sponsors may be subject to penalties for endorsing ads that do not comply with CMS regulations.

Additional regulations include prohibiting the mention of unrealized “savings” calculated relative to the expenses borne by uninsured individuals, the unpaid costs of beneficiaries dually eligible for Medicare and Medicaid, or other unrealized costs of a Medicare beneficiary; prohibiting the use of superlatives such as “best” and “most” in marketing materials, taglines, or logos; and revising the disclaimer required for all third-party ads (described in the section above) to include State Health Insurance Assistance Programs (SHIPs) alongside Medicare.gov and 1-800-MEDICARE as a resource that beneficiaries can turn to for more information about their coverage options.

File & Use: Health insurers and third parties must submit all marketing materials to CMS for review before they can be aired, or in the case of some third parties, have them submitted by the insurer they represent. Until recently, CMS permitted TV ads to be submitted through its File & Use framework. Materials designated as File & Use may be aired five days after submission to CMS, though CMS reserves the right to review these materials for compliance both during and after this five-day window. Marketing materials that do not qualify for File & Use must be submitted forty-five days before they are aired, prospectively approved or disapproved during this timeframe, or “deemed approved” if no decision is reached within forty-five days. Beginning January 1^st, 2023, in light of ongoing concerns, CMS no longer allows TV ads to be submitted as File & Use. Ads slated to air on October 1^st, 2023 must be submitted to CMS by mid-August, allowing a longer window for prospective review.

Our data consist of 1,267 unique ads and 643,852 total airings, representing all English-language TV ads focused on Medicare that aired on broadcast television or national cable between October 1^st, 2022 and December 7^th, 2022. While the open enrollment period does not begin until October 15^th each year, sponsors are permitted to advertise beginning October 1^st. Ads were supplied to the Wesleyan Media Project by Vivvix (formerly Kantar) CMAG along with additional information on the timing of the airing, the media market, TV station, and broadcast network where it was aired, and the TV programming shown on the same station during that time slot. The Wesleyan Media Project compiled and processed all data flagged by Vivvix CMAG as relevant to our study, including ads classified as “Medical & Dental Insurance” or “Insurance Agencies & Brokers,” ads sponsored by the Department of Health and Human Services or AARP, and any ad with Medicare in the title.

In the first phase of processing, the Wesleyan Media Project used optical character recognition (OCR) to extract the textual information on screen and automatic speech recognition (ASR) to extract the audio into text for each video. Ads that did not contain the word Medicare in either OCR or ASR were removed from the set. The Wesleyan Media Project then assessed the degree of text similarity from the ASR data to identify advertising that was greater than 90% matching in audio content. Ads with 90% or higher similarity were grouped and only one ad per group was flagged for human coding (described below), along with any ads that did not match with others. Finally, the Wesleyan Media Project identified and removed Spanish-language advertising that ran on Spanish-language networks Telemundo, Unimas, and Univision. A secondary step to filter out Spanish-language advertising was conducted in the human coding stage. This left us with a final analytical set of 1,267 unique ads.

KFF and the Wesleyan Media Project then developed a coding instrument to analyze ad content. Key variables included in the instrument were those relevant to the evolving policy context surrounding Medicare marketing, such as the sponsor, Medicare products, and plans represented in each ad, as well as messaging on plan features, slogans or repeated phrases, activities and characteristics of people shown in the ad, websites and contact information, and use of the Medicare name, logo, or card.

Ten undergraduate student coders received training and completed four sets of practice ads prior to beginning live coding. A random sample of ads (20%) were double coded to assess intercoder reliability, and all Krippendorff’s alpha statistics were calculated for each variable. All results described in this report all met the 0.7 threshold for acceptable levels of reliability, with some exceptions noted below. For ads that included fine print, coders were asked to indicate whether they could read the fine print without pausing. While coder impressions are noted where relevant, this variable is not scientific, as monitor sizes vary, which affects readability. Coders were also asked to flag any ads that stood out to them as surprising, misleading, or notable in some other way and offer their qualitative impressions.

KFF analyzed the frequency of ad characteristics in the data as a whole, as well as by sponsor type, advertised product, and media market. Insurer sponsored ads were also analyzed by firm. KFF further reviewed a sample of ads in their entirety, including ads for which coders had given qualitative comments, to identify relevant examples of common messages, elements, and themes. Messages related to in-home support services, caregiver support, and bathroom safety devices were categorized as “other supplemental benefits” by our coding instrument. These were identified by coders in a free text field and reviewed by KFF as described, but were not formally assessed for intercoder reliability. Likewise, some characteristics, such as the message that beneficiaries were required to pay the standard Part B premium, appeared too rarely to meet the 0.7 threshold for acceptable intercoder reliability. In these cases, we noted that the characteristic was rare, but were not able to report its frequency with precision.

We focused much of our analysis on the substantial majority of ads promoting Medicare Advantage, the most common product advertised during the period.

Medicare is the federal health insurance program that covers over 65 million adults 65 and older and younger adults with long-term disabilities. Medicare is a very popular program, with 81% of the public holding favorable views of the program, and is viewed positively by large majorities of Democrats, Republicans, and Independents.

Over the past 15 years, the role of private plans in Medicare has increased dramatically. Today, more than half of all Medicare beneficiaries are enrolled in a Medicare Advantage plan, with an average of 43 plans to choose from in addition to traditional Medicare. Beneficiaries in traditional Medicare can choose among 24 stand-alone Part D plans, on average, and may choose supplemental coverage, such as Medigap, if they don’t have supplemental coverage under Medicaid or an employer or union-sponsored retiree health plan. This increasingly crowded marketplace has been accompanied by extensive marketing and advertising as well as agents and brokers competing to attract enrollees.

To capture Medicare beneficiaries’ views and experiences in choosing between traditional Medicare and private plans, and among private plans, and the factors that influence these decisions, KFF worked with PerryUndem to conduct focus groups with Medicare beneficiaries in the Fall of 2022, during the annual Medicare open enrollment period. This report summarizes first-hand accounts of participants’ reactions to phone calls, TV advertisements and other marketing activities they encounter during the open enrollment period, what influences their decision-making, including the role of licensed agents (also known as brokers), how much Medicare beneficiaries understand about their Medicare choices, what they think of the Medicare marketplace, and how well their Medicare coverage is working for them.

The focus group participants included Medicare beneficiaries ages 65 and older and younger adults with disabilities who make health coverage decisions for themselves and/or their spouse or family member. Some focus groups also consisted of people with both Medicare and Medicaid (also referred to as dual-eligible individuals or dual eligibles) as well as adults 64 years old who were approaching Medicare enrollment. Because the study focused on decisions pertaining to Medicare coverage, including Medicare Advantage and traditional Medicare supplemented by Medigap, we excluded people on Medicare with retiree coverage from a former employer or union.

Key Takeaways

• Many participants reported experiencing aggressive marketing tactics pushing Medicare plans, including unsolicited phone calls. Many participants reported getting frequent phone calls from brokers or plan representatives advertising Medicare plans, though it was not always clear to participants who was calling.
• Nearly all participants have seen TV advertisements that are marketing Medicare, most frequently Medicare Advantage plans. Participants reported they were often confused about who was sponsoring the ads. Some participants emphasized that who was sponsoring the ads was often unclear, noting many of the ads had the appearance of being sponsored by the government though they believed the ads were in fact sponsored by private companies.
• Participants did not trust the content of the ads, particularly the ones that marketed a slew of “free” benefits. In general, many thought TV advertisements were misleading. Celebrities are often spokespeople for these advertisements, though participants did not seem to be swayed by them. Overall, participants said that Medicare private plan marketing and advertising did not play a role in their plan choices.
• Most participants found the process of selecting their coverage to be confusing, difficult and overwhelming. As a result, many participants relied on a broker to assist them when choosing their coverage and valued their expertise. Participants who use brokers to help select and enroll in a Medicare plan say brokers are a trusted resource. Most of the participants who used brokers did not seem bothered by potential financial incentives to enroll them in a certain plan.
• Few participants used government resources when making coverage decisions, such as the Medicare Handbook or 1-800 Medicare, but those participants who did use these government resources generally found them helpful. Most participants had not heard of or used State Health Insurance Assistance Programs (SHIPs), which provide local and objective insurance counseling to people on Medicare.
• Focus group participants highlighted a number of factors that were important in choosing their coverage when they first enrolled in Medicare, including premiums and out-of-pocket costs, access to specific doctors, availability of extra benefits, and coverage of prescription drugs. Some participants who are enrolled in Medicare Advantage plans also said they enrolled in a particular plan because its name was familiar or because the company had a good reputation. Participants generally did not take into account Medicare’s star quality ratings of plans to inform their plan choices, though some did their own research on a plan’s quality using non-government resources.
• Most focus group participants – whether in traditional Medicare or Medicare Advantage – said they were relieved to get on Medicare and are satisfied with their coverage. However, some participants cited specific issues with their coverage that varied based on their source of Medicare coverage.
• Participants with traditional Medicare and a supplemental Medigap policy are generally pleased with their coverage, including low or no cost-sharing for Medicare services, protection against catastrophic expenses, broad access to providers since virtually all physicians take Medicare and Medigap, and feeling that have control over their health care, but some expressed concern about the cost of Medigap premiums.
• Participants in Medicare Advantage are also generally satisfied with their coverage because of the zero or low premiums, and extra benefits offered by their plan, such as dental, vision, and hearing services, but some encountered high medical bills when using certain services, faced delays in care, such as having to wait weeks to see specific physicians due to prior authorization and referrals, and had issues in accessing preferred doctors due to network restrictions.
• Dual-eligible participants – whether they had Medicare coverage through traditional Medicare or a Medicare Advantage plan – also reported being generally satisfied with their coverage, particularly due to the low out-of-pocket costs for their health care, such as no copays for doctor’s visits. However, some-dual eligible participants with Medicare Advantage had issues finding providers, such as primary care doctors, who would take both their Medicare and Medicaid coverage.
• Participants enrolled in Medicare Advantage, including some dual-eligible individuals, also noted difficulty using some of their supplemental benefits, particularly dental benefits, due to network restrictions and certain providers not taking their coverage.
• Participants in Medicare Advantage and Medicare Part D stand-alone drug plans reported being frustrated at the high out-of-pocket costs of some of their prescriptions.
• The majority of participants do not review their coverage options every year, and even fewer switched plans because they felt they would not be better off with a different option. Participants generally feel they made the right choice – whether in traditional Medicare or Medicare Advantage – when selecting their coverage and feel it is working well enough for them. Therefore, participants do not see the need to look again at their coverage options; however, many wish they had had more information before enrolling.
• Some participants with both Medicare and Medicaid were concerned about losing their Medicaid coverage, and were anxious about losing Medicaid during the redetermination process as states resume disenrollments after a three year pause during the pandemic.

Introduction

The Medicare plan landscape has transformed markedly in recent years, with more than half of all Medicare beneficiaries enrolled in Medicare Advantage plans. When Medicare beneficiaries first enroll in Medicare and during the annual open enrollment period, they can choose traditional Medicare or enroll in a Medicare Advantage plan. If Medicare beneficiaries select traditional Medicare, they may also need to purchase a stand-alone Part D prescription drug plan (PDP), and potentially a supplemental Medigap plan, which fully or partially covers Part A and Part B cost-sharing requirements. In lieu of traditional Medicare, beneficiaries can get coverage through private Medicare Advantage plans, which are mainly HMOs and PPOs, that provide all Medicare Part A and B benefits, often for no additional premium for plans open for general enrollment (other than the Part B premium), typically include Part D drug coverage, and may cover other benefits such as dental, vision, and hearing. Some people with Medicare may otherwise receive supplemental coverage through an employer retiree health plan or Medicaid, which may supplement either traditional Medicare or a Medicare Advantage plan.

Dozens of private Medicare Advantage and Part D drug plans are available to people on Medicare. With a large number of plans and coverage options to review, beneficiaries have a myriad of choices to make when they enroll in the Medicare program, particularly as there may be tradeoffs for each of these decisions. For example, Medicare Advantage plans typically have lower premiums compared to traditional Medicare plus a Medigap policy and have extra benefits that traditional Medicare does not cover, such as dental, vision, and hearing. However, Medicare Advantage plans have limited provider networks and apply cost management tools such as prior authorization, which traditional Medicare does not.

Both people in Medicare Advantage and traditional Medicare also make choices about their prescription drug coverage, which can vary across numerous domains, including premiums, cost sharing, formularies, and pharmacy networks, among others.

Further, each year, plans may change their premiums, benefits, and other features, and beneficiaries have the opportunity to assess these changes and switch plans during the annual open enrollment period. At the same time, people with Medicare are often inundated with marketing and advertisements for private Medicare plans – typically Medicare Advantage plans – which can add to the complexity of decision-making around Medicare choices.

KFF research has shown, however, that few beneficiaries revisit their coverage decisions each year to determine which option is best for them based on their individual needs and the specific features of the plans available to them, and few change their coverage at all: during the open enrollment period for 2020, 10% of Medicare beneficiaries with Medicare Advantage switched plans. This could be because beneficiaries are satisfied with their current coverage selection, but also may also speak to the challenges of understanding and comparing the multitude of plan options.

To better understand Medicare beneficiaries’ experience with the Medicare program, how they make their Medicare coverage choices, the factors that influence these decisions, including the role of marketing and brokers, and whether they reconsider their plan choices, KFF worked with PerryUndem to conduct a series of focus groups to provide insight on these issues (see Appendix for more details on focus groups).

Perspectives from Beneficiary Focus Groups on Medicare Coverage, Marketing, and Plan Choice

• Focus group participants said they were inundated by Medicare marketing, including unsolicited phone calls and TV ads, and believed the ads were often misleading and deceptive
• Participants found selecting Medicare coverage overwhelming and relied on brokers to assist them with their choices while few used official Medicare resources
• Participants said they considered many factors when selecting Medicare coverage, including premiums, access to doctors, extra benefits, and coverage of prescriptions
• Participants reported high satisfaction with Medicare coverage but cited specific issues that varied depending on their source of Medicare coverage
• Despite high satisfaction, participants cited specific Issues that varied depending on their source of Medicare coverage
• Participants generally feel they made the right choice when selecting a plan, and most participants have not revisited their plan choices

Experiences Unique to Dual-Eligible Participants

• Dual-eligible participants had varying experiences signing up for Medicaid coverage with some participants choosing coverage and others being assigned their coverage
• Some dual-eligible participants were concerned about the possibility of losing medicaid coverage due to the annual redetermination process

Focus Group Participants Said They Were Inundated by Medicare Marketing, Including Unsolicited Phone Calls and TV Ads, And Believed the Ads were Often Misleading and Deceptive

Private Medicare plans are allowed to engage in a variety of Medicare marketing and communication activities, including over the phone, on television, and in-person, as long as they adhere to the Centers for Medicare & Medicaid Services (CMS) rules and regulations. However, there has been concern over misleading and deceptive marketing tactics by private Medicare plans as well as third-party marketing organizations who work for these plans. For example, CMS has seen a substantial increase in beneficiary complaints in recent years – they received more than twice as many beneficiary complaints related to marketing in 2021 (~40,000) compared to 2020 (~16,000). In response to these and other concerns, CMS finalized new marketing regulations in May 2022 and in April 2023 to help protect Medicare beneficiaries who are looking for Medicare coverage.

Focus group participants were asked to provide their reactions to Medicare marketing and advertising, including over the phone and on television, whether they could tell who was sponsoring these calls or ads, what they thought about the messaging, how they felt about celebrity spokespeople in many of the ads, and if any of these communications played a role in their Medicare choices. Dual-eligible participants had similar reactions to those enrolled only in Medicare.

Unsolicited phone calls

Many participants reported getting frequent unsolicited phone calls advertising Medicare plans. Participants said marketers promoting these plans used deceitful tactics, and participants usually ignored these calls.

For marketing solicitations over the phone, private Medicare plans are subject to a number of requirements and are not permitted to use telephone solicitation (that is, cold calling), as well as robocalls, text messages, or voicemail messages if unsolicited. However, a recent report from the majority staff of the Senate Finance Committee documented robocalls, telemarketing, and frequent phone calls as a common source of complaints among Medicare beneficiaries. Most focus group participants mentioned receiving unsolicited phone calls from marketers, some of whom were calling from insurance plans or were brokers or agents representing these plans, but many participants said it was not always clear who was calling.

Confusion about TV ad sponsors

Nearly all participants have seen TV advertisements that are marketing Medicare, most frequently Medicare Advantage plans. However, many participants emphasized they were often confused who was sponsoring the ads and that many ads had the appearance of being sponsored by the government though they believed the ads were in fact sponsored by private companies.

One area of particular concern to CMS has been the use of the Medicare name and logo to give the appearance that advertisements or communications are being sponsored or endorsed by the Medicare program or the federal government, when they are actually sponsored by private Medicare plans or by representatives acting on behalf of these plans. The recent Senate Finance Committee majority staff report has also documented similar beneficiary complaints that highlight confusion over what is truly official correspondence and advertisements from the government. Likewise, a KFF analysis of Medicare TV advertising found that more than one in four ads aimed at the most recent open enrollment period, in the fall of 2022, included a government-issued Medicare card or an image that closely resembled it.

In order to address this issue, CMS has finalized changes to this type of marketing, which would prohibit the use of the Medicare name, CMS logo, or official products, including the Medicare card, in a misleading manner. Similar to these complaints, focus group participants also expressed confusion over who was sponsoring some of the ads. Many participants noted that the ads were clearly designed to give the impression they were coming from the government when they believe these ads were fact sponsored by private companies.

“Free” is not always free

One of the most common complaints among participants about TV marketing is that they often advertise that services and benefits are “free”, though this is not always true.

In many of the focus groups, participants mentioned their Medicare Advantage plans come with zero premiums and copays and access to many extra benefits, some of which give them additional money to spend, such as money for over-the-counter items. A KFF analysis of Medicare TV advertising aimed at the most recent open enrollment period, in the fall of 2022, confirmed that messaging about extra benefits was included in more than 90% of ads, while messaging about the potential for lower out-of-pocket costs was present in 85% of Medicare ads. Despite the fact that some beneficiaries report receiving these types of benefits at no cost, nearly all participants, regardless of the Medicare coverage they have, do not trust the content of these type of ads and are inclined to ignore it.

Participants feel inundated by TV ads

In general, participants feel inundated by TV ads. Most find them off-putting, misleading, and unhelpful, and say the ads did not influence their Medicare plan selections.

Celebrity spokespeople

While celebrities are often spokespeople for Medicare Advantage plans, participants did not seem swayed by them and frequently disregarded them.

KFF analysis has found that celebrity endorsements are commonly featured in TV ads for Medicare Advantage, appearing most often in ads sponsored by brokers and other third-party organizations, such as marketing firms, who may contract with insurers to promote plans and boost enrollment. Participants reported encountering these ads but most did not find the endorsements helpful or persuasive.

Participants Found Selecting Medicare Coverage Overwhelming and Relied on Brokers to Assist Them with Their Choices While Few Used Official Medicare Resources

The average Medicare beneficiary has an average of 43 Medicare Advantage plans to choose from and 24-stand-alone prescription drug plans to choose from. Most participants said they were surprised to hear that was the average number of coverage options available and were overwhelmed at the idea of having to sort through so many plan options.

Many find the process overwhelming

Most participants said the process for selecting a plan was overwhelming and confusing to navigate. Some did try to sort through plan options themselves, but emphasized the process was challenging.

Use of Medicare insurance brokers

For this reason, many participants have used a broker at some stage to assist them when choosing their plan, and many found them helpful in sorting through the enrollment process. Many brokers were recommended by a friend or family members. For people who use brokers, they are seen as a trusted resource.

Many participants, including some dual-eligible individuals, relied on brokers to help narrow down their plan options. Medicare insurers contract with brokers to solicit and enroll beneficiaries in their plans, and in return, the brokers receive a commission from the insurer. Research has shown that people who received help making decisions about their Medicare coverage most commonly turned to brokers to help them compare and narrow down their Medicare plan options, and the focus group participants generally confirmed this trend.

Participants who used brokers said they liked that brokers simplify shopping, can ensure they choose a plan with their preferred providers, and can help navigate whether a plan covers their prescriptions. When dual-eligible participants used brokers, it was generally to help them choose a Medicare Advantage plan. In many cases, brokers were recommended to them by family and friends, who reported being happy with their plans, so participants see brokers as a trusted resource.

Beneficiaries not bothered by commissions that brokers received 

Most of the participants who used brokers did not seem bothered by potential biases or financial incentives to enroll them in a Medicare Advantage plan and relied on their advice.

Medicare brokers receive a commission for enrolling beneficiaries in plans, whether they are for Medicare Advantage, stand-alone Part D plans or supplemental Medigap plans. Yet, research has shown that brokers tend to be paid more for enrolling beneficiaries in Medicare Advantage plans rather than Medigap plans, which could create conflicts for brokers who may have an incentive to recommend one type of plan over another based on their potential compensation rather than the needs of the beneficiary. In general, beneficiaries did not seem to be aware how brokers were paid – that they might be paid by a specific insurer or receive different fees for separate products. For example, in 2020, Medicare Advantage commissions were $510 nationally, while commissions were $322 for a Medigap supplement and $78 for a Part D plan, a total commission of $400 for Medigap plus a Part D plan. However, when asked if they had concerns about any potential biases or conflicts of interest, beneficiaries did not seem bothered by the commissions that brokers received as long as they felt they were getting good recommendations on their plan options.

Few have used official Medicare information resources

Few participants have used Medicare’s official information resources such as the 1-800 Medicare toll free number, the Medicare.gov website, and the Medicare & You Handbook that is provided each year to all Medicare beneficiaries, though for the few who did, some found these resources helpful.

Medicare has official information resources beneficiaries can turn to help with their coverage decisions, including the 1-800 Medicare toll free number, the Medicare.gov website, including the Medicare Plan Finder, and the Medicare & You Handbook. KFF research has shown that these resources are not widely used, and focus group participants generally confirmed this. Participants who used these resources, however, said the resources were mostly helpful and felt they could get answers to important questions, although some participants thought the toll-free phone number, in particular, was too slow. Further, most focus group participants had not heard of or used State Health Insurance Assistance Programs (SHIPs), which provide local, in-depth, and objective insurance counseling to people on Medicare.

Participants Said They Considered Many Factors When Selecting Medicare Coverage, Including Premiums, Access to Doctors, Extra Benefits, and Coverage of Prescriptions

When Medicare beneficiaries first enroll in Medicare and select their coverage, they are encouraged to weigh a variety of factors, including premium costs, cost sharing for services, access to specific doctors, availability of extra benefits, coverage of prescription drugs, and quality ratings of plans, among others. Beneficiaries may revisit their choice of plan each year during the annual open enrollment period.

Focus group participants were asked what factors entered into their decision making when choosing a plan, how they viewed the process of selecting a plan, and why they ultimately chose Medicare Advantage or traditional Medicare.

Many confused by coverage options and how Medicare program works

Despite looking forward to going on Medicare, many said they were confused, stressed and overwhelmed by the various coverage options and how the Medicare program works.

Many participants lacked awareness or a good understanding about the different Medicare options available to them. They mentioned confusion with the different parts of Medicare – Parts A, B, C, D – and were unclear what makes them different from each other and which parts are mandatory or optional. They often did not know which parts of Medicare were included as part of a Medicare Advantage plan and if that was the same or different as a Medicare “supplement.”

Zero or low premiums often cited as top reason for selecting a Medicare Advantage plan

For those who chose or were considering Medicare Advantage for their coverage, zero or low premiums was often cited as the top reason for selecting a Medicare Advantage plan, followed closely by low cost-sharing requirements for services.

People on Medicare are often concerned about the cost of health care because most live on fixed incomes with limited savings. When thinking about health care costs, the first thing that often comes to mind is a plan’s monthly premium, because it is monthly expense they will incur regardless of their health needs, and it is relatively easy to compare across plans. Many of the focus groups participants noted that they lived on tight budgets and could not afford to pay for coverage that required higher premiums, which may have led them to believe that Medicare Advantage seemed like a more affordable option than traditional Medicare plus a Medigap supplemental policy with an additional premium. Due to their budgets, they also looked closely at copay amounts, particularly for services that they thought they might use with some frequency.

In-network doctors are top priority

Another factor that weighs heavily in their decision-making when selecting Medicare Advantage is whether their doctors are in the plan’s network.

For people considering Medicare Advantage plans, a top priority is whether their doctors are part of the plan’s network. In many cases, people are concerned about maintaining access to their primary care physician, but depending on their health needs, some are more concerned about having access to particular specialists.

Availability of extra benefits in Medicare Advantage

An additional factor that influenced participants’ decision-making is the availability of extra benefits in Medicare Advantage such as dental and vision.

Medicare Advantage plans are able to offer extra benefits not available not offered by traditional Medicare, such as dental, vision, and hearing, as well as some that provide money to enrollees, such as over-the-counter benefits, and for this reason, many participants were attracted to Medicare Advantage plans.

Reasons for choosing traditional Medicare

Those who ultimately chose or were considering traditional Medicare (and often a Medigap supplement) liked the relatively low cost-sharing requirements, comprehensiveness of their coverage, control over their health care, and ability to see any provider they wanted.

Medigap policies, sold by private insurance companies, are supplements to traditional Medicare and fully or partially cover Part A and Part B cost-sharing requirements, including deductibles, copayments, and coinsurance. Medicare beneficiaries with traditional Medicare, including those with a Medigap policy, can see any provider who accepts Medicare. Medigap insurance provided supplemental coverage to 36% of people in traditional Medicare (roughly 11.5 million beneficiaries) in 2020.

Relationships with insurance providers

Some participants had relationships with insurance providers that they felt comfortable with or liked the reputation of the company.

Medicare star quality ratings

Participants did not generally use Medicare’s star quality ratings when making coverage decisions, though some participants used other non-government sources to get information about plan quality.

On the Medicare plan finder, each Medicare Advantage plan has a star rating to provide beneficiaries with additional information about the quality of plans offered in their area. All plans are rated on a 1 to 5-star scale, with 1 star representing poor performance, 3 stars representing average performance, and 5 stars representing excellent performance. When asked whether these star ratings influenced their decision-making when choosing a plan, the majority of participants said no.

For the few participants who did look at ratings, they reported turning to other non-government sources for reviews on a plan’s quality.

Prescription drug coverage important factor in decision-making

Regardless of whether they selected or were going to select traditional Medicare with a stand-alone Part D plan or a Medicare Advantage plan with drug coverage, ensuring that their prescription drugs were covered was also an important factor in participants’ decision-making.

People with Medicare can get prescription drug coverage by enrolling in a stand-alone plan that provides Part D prescription drug coverage for people with traditional Medicare or by enrolling in a Medicare Advantage plan. Coverage of prescription drugs is based on each plan’s formulary, and depending on a plan’s formulary, beneficiaries can also be subject to prior authorization, step therapy, and quantity limits. Medicare beneficiaries with Part D coverage also face cost-sharing amounts for covered drugs and may pay an annual deductible ($505 in 2023) and depending on the plan, a monthly premium.

Participants Overall Reported High Satisfaction with Their Medicare Coverage

Most participants satisfied with Medicare coverage

Most participants – whether in traditional Medicare or Medicare Advantage – were relieved to be on Medicare and reported being satisfied with their Medicare coverage.

Medicare continues to be a very popular program, with 81% of the public holding very or somewhat favorable views of the program. Most participants mentioned being excited or relieved to go on Medicare, often because of the lower costs compared to their previous insurance coverage or because of the security of having Medicare coverage. When asked on a scale of 1-10 how they would rate their Medicare coverage, with 10 being very satisfied, most participants gave their coverage an 8, 9 or 10, saying it is working well for them.

Varied reasons for satisfaction depending on source of coverage

Participants cited a variety of reasons for their satisfaction, including costs, access to providers, and supplemental benefits, depending on their source of Medicare coverage.

Participants with traditional Medicare and a Medigap policy are generally happy with their coverage because they like the relatively low cost-sharing requirements, not having to deal with bills, protection against catastrophic expenses, ability to see any provider they want, and having control over their health care.

Medicare Advantage plan participants pleased with their coverage

Participants in Medicare Advantage plans are pleased with their coverage and noted that this was due to having zero or low premiums, and coverage of extra benefits, such as dental, vision, hearing, services and over-the-counter debit cards.

Dual-eligible participants also generally satisfied with coverage

Dual-eligible participants – whether they had Medicare coverage through traditional Medicare or a Medicare Advantage plan – are also generally satisfied with their coverage, particularly due to the low cost of their health care.

Dual-eligible individuals feel their health care coverage is affordable and covers most services they need. Most referenced the low out-of-pocket costs for their health care, such as no copays for doctor’s visits and prescriptions, as the primary reasons they were satisfied with their coverage. Some who had their Medicare coverage through a Medicare Advantage plan also were pleased at having coverage of some extra benefits, such as an over-the-counter allowance or money to buy food and produce.

Despite High Satisfaction, Participants Cited Specific Issues that Varied Depending on their Source of Medicare Coverage

Concerns about premiums

While participants with traditional Medicare and a Medigap policy are generally pleased with their coverage and access to physicians, they had concerns about the premium.

While Medigap limits the financial exposure of Medicare beneficiaries for services covered under Parts A and B, Medigap premiums can be costly and can rise with age, depending on the state in which they are regulated. Estimated average monthly premiums for Medigap policies can range from less than $100 per month to over $300 per month depending on the plan.

High medical bills for some participants in Medicare Advantage

While many participants with Medicare Advantage are satisfied with their coverage, some with serious medical conditions encountered high medical bills when using certain services.

Delay in care experienced by some participants in Medicare Advantage

Some participants with Medicare Advantage, including some dual-eligible individuals, experienced delays receiving care due to utilization management tools, such as prior authorization and/or referral requirements.

Medicare Advantage plans can require enrollees to get approval from the plan prior to receiving a service, and if approval is not granted, then the plan generally does not cover the cost of the service. Similarly, Medicare Advantage can impose referral requirements, in which a primary doctor must provide a written letter in order for a patient to see a specialist for services, and if not provided, then the plan generally does not cover the cost. In 2023, virtually all Medicare Advantage enrollees (more than 99%) are in plans that require prior authorization for some services. Health insurers use these utilization management tools to both contain spending and prevent enrollees from receiving unnecessary or low-value services, though there are some concerns these requirements may create barriers and delays to receiving necessary care. Some Medicare Advantage participants experienced delays receiving care, but nearly all ultimately got approval for their prior authorization and/or referral requests.

Issues with provider networks 

While Medicare Advantage enrollees were generally aware of the importance of having their doctors in-network, many participants encountered situations when the doctor they wanted to see for a particular service was not in-network. Issues with provider networks was also a particular challenge for dual-eligible participants with a Medicare Advantage plan who sometimes could not find a provider who accepted both their Medicare and Medicaid coverage.

Unlike traditional Medicare, where Medicare beneficiaries can see any provider who accepts Medicare, beneficiaries enrolled in Medicare Advantage have a network of physicians and hospitals for their care. If providers are not in-network, Medicare Advantage enrollees typically must pay more to see out-of-network providers, or they may be responsible for the entire cost of seeing that provider. When beneficiaries select their Medicare Advantage plan, they are encouraged to check whether their preferred providers are in-network as provider networks vary across plans. However, evidence indicates provider directories might not always be accurate, and it may be difficult for beneficiaries to compare networks and providers across plans as they may be in different formats across insurers. Focus group participants noted situations when they could not see their preferred doctor because they were not in their plan network and were frustrated with having to see a different provider.

In addition, some dual-eligible participants with a Medicare Advantage plan, including participants with a dual-eligible Special Needs Plan (D-SNP), reported issues with doctors accepting their health insurance policy. D-SNPs are a specific type of Medicare Advantage plan designed for this population to better coordinate care, though these plans can also look different across states in terms of their levels of coordination. For example, some D-SNPs offer Medicaid and Medicare benefits through different organizations, while some have plans through the same parent company.

Frustration with using some supplemental benefits

Some Medicare Advantage enrollees also voiced frustration with using some supplemental benefits, particularly dental coverage, because cost sharing was higher than expected and due to network restrictions. Network restrictions for extra benefits were also challenging for dual-eligible participants who had a Medicare Advantage plan.

Many people are attracted to Medicare Advantage plans because they offer extra benefits that traditional Medicare does not offer, such as dental, vision, and hearing coverage. However, some participants raised concerns with the costs of these benefits, challenges using these benefits, or finding a provider who covered these services. Like accessing providers covered by Medicare Advantage plans, many Medicare Advantage plans have networks of providers who cover supplemental benefits, or the enrollee will be required to pay more to see someone out-of-network, such as for dental benefits.

Frustration with high cost of certain medications

Some participants were also frustrated by the high cost of certain medications, particularly for those who need specific drugs to manage chronic conditions.

In recent years, many Medicare beneficiaries have experienced high out-of-pocket costs for their prescription drugs. Changes as part of the Inflation Reduction Act, including a $35 monthly copay on insulin that went into effect in 2023, as well as limits on out-of-pocket prescription drug spending in Part D beginning in 2024, and a $2,000 cap beginning in 2025, will help some Part D enrollees with their prescription drug costs.

Participants Generally Feel They Made the Right Choice When Selecting a Plan, and Most Participants Have Not Revisited Their Plan Choices

The marketplace of Medicare private plans is based on the idea that beneficiaries will compare their plan options to find plans that best meet their individual needs. CMS encourages beneficiaries to compare and review their plan options each year, which could enable them to receive care at a lower cost, ensure their preferred providers are in network, and that the prescription drugs they take are covered. However, KFF analysis has shown that most beneficiaries do not compare their plan options in each year.

Majority feel they made the right choice

The majority of participants in the focus groups confirmed this behavior – they explained that they felt that their coverage was comprehensive and did not need to reevaluate their coverage every year though some wish they had more information before enrolling. Additionally, many participants said they are unlikely to switch plans going forward because selecting a new plan would be too much work, and they did not feel confident they would be better off with another type of coverage. For dual-eligible participants who made a choice about their Medicare coverage, they also generally did not feel the need to switch plans going forward.

But some say they shop around

However, a few of the participants said they do shop around, sometimes every year, to ensure they continue to have the best plan that meets their needs.

Experiences Unique to Dual-Eligible Participants

People with both Medicare and Medicaid, also referred to as dual-eligible individuals or dual eligibles are enrolled in both programs and must meet eligibility requirements for both programs. They receive their primary health insurance coverage through Medicare and some assistance from their state Medicaid program. Together, these two programs help to shield low-income beneficiaries from potentially unaffordable out-of-pocket medical and long-term care costs: Medicaid typically pays the Medicare Part B premium and may also pay for Medicare’s other cost-sharing requirements; Medicaid also helps pay for services that are not covered by Medicare, such as long-term services and supports. While nearly all dually eligible beneficiaries have low incomes and very modest savings, they are otherwise a diverse group in terms of age and physical and mental health.

To capture the unique experiences faced by dual-eligible individuals, we conducted two focus groups that consisted exclusively of these beneficiaries.

Dual-Eligible Participants Had Varying Experiences Signing Up for Medicaid Coverage With Some Participants Choosing Coverage and Others Being Assigned Their Coverage

As mentioned above, people with Medicare have the choice between traditional Medicare or a Medicare Advantage plan, which can include an individual plan open for general enrollment as well as a dual-eligible Special Needs Plan (D-SNP). Dual-eligible individuals who are eligible for full Medicaid may receive those Medicaid benefits through capitated managed care organizations (MCOs) or through fee-for-service (FFS). Options for Medicaid coverage vary depending on the state that the enrollee lives in as do the mechanisms for beneficiary enrollment. Some states provide dual-eligible individuals with the ability to choose their plans, others assign people to a plan, and still others assign enrollees to a plan but offer them the opportunity to disenroll and select a different option.

As a result, participants had varying experiences signing up for Medicaid coverage, often depending on the state they lived in and whether they had enrolled in Medicare or Medicaid first or at the same time.

Making a choice for Medicaid coverage

Some participants had to make a choice for their Medicaid coverage, and many had help from the state choosing their plan.

Some participants did not have a choice

Some participants did not have a choice of their Medicaid coverage, or someone enrolled them in Medicaid coverage – often the state or county chose their Medicaid plan for them.

Some Medicare enrollees did not realize they might also be eligible for Medicaid

Some who were enrolled in Medicare did not realize they might also be eligible for Medicaid, but their state reached out to them to let them know they should apply for Medicaid coverage.

Some Dual-Eligible Participants Were Concerned About the Possibility of Losing Medicaid Coverage Due to the Annual Redetermination Process

Concerns about redetermination process

Because of the importance of the Medicaid program for addressing their health care needs, some dual-eligible participants were concerned about the redetermination process and anxious about the possibility of losing that coverage.

Prior to the COVID-19 pandemic, states were required to renew Medicaid eligibility for dual-eligible individuals at least once per year. Since March 2020, states have provided continuous enrollment in Medicaid in exchange for enhanced federal funding. This continuous enrollment provision and enhanced federal funding were originally in place until the end of the COVID-19 public health emergency (PHE). In December 2022, the Consolidated Appropriations Act, 2023 (CAA) delinked the provision from the PHE and ended continuous enrollment on March 31, 2023. Beginning April 1, 2023, states have restarted disenrollments after conducting a full review of eligibility. As states begin to “unwind” the continuous enrollment provision, many people will likely be found to be no longer eligible for Medicaid. Others could face administrative barriers and lose coverage despite remaining eligible.

Focus group participants generally had not experienced a loss of Medicaid, but some participants mentioned being concerned with losing their Medicaid coverage in the future due to changes in their incomes, assets, or other eligibility requirements. Many were aware of the renewal requirements even though redeterminations had been on hold during the pandemic.

As more people on Medicare are enrolled in Medicare Advantage, CMS, policymakers, researchers, and the public have become more focused on how the program is serving people on Medicare. Participants across the spectrum of coverage noted that they experienced aggressive marketing tactics, including unsolicited phone calls, and felt inundated by Medicare television advertising, often for Medicare Advantage plans, that they believed to be both misleading and unhelpful.

Participants with Medicare found the process of selecting their coverage to be overwhelming and difficult, and often relied on brokers to help them review and understand their coverage options. Few participants used Medicare’s official resources to assist in their decision-making. When choosing their coverage, participants said they valued a variety of factors, including premiums and other costs, access to preferred providers, availability of extra benefits, and coverage of prescription drugs.

Participants in the focus groups – whether in traditional Medicare or Medicare Advantage – emphasized that they are generally satisfied with their Medicare coverage. Participants in Medicare Advantage plans were pleased with their coverage due to the low or no premium costs, as well as the availability of extra benefits, such as dental, vision, hearing, and debit cards. Participants with traditional Medicare and a Medigap policy were happy with their coverage due to the low or no cost-sharing requirements, no network restrictions on seeing their preferred providers, and the ability to control their own health care.

However, some participants, particularly in Medicare Advantage plans, also noted that there are elements of their coverage that caused them frustration, including delays receiving care due to prior authorization and referral requirements as well as facing limitations in seeing their preferred doctors due to limited networks. In recent months, CMS and policymakers have sought to address some of these issues through both legislation and rulemaking, including rules that would streamline the prior authorization process and place additional limitations on Medicare marketing.

Most dual-eligible participants who have both Medicare and Medicaid said they are satisfied with their coverage, whether in Medicare Advantage or traditional Medicare, though some in Medicare Advantage encountered problems finding a provider in their plan’s network. Further, some participants with Medicaid were uniquely concerned about maintaining their Medicaid eligibility and were anxious about losing Medicaid during the annual redetermination process. With Medicaid redeterminations having restarted April 1, states may have begun disenrollments, which could lead to some losing their coverage, though it is unclear how much that would impact focus group participants who generally had not experienced a loss of coverage prior to the pandemic.

In making coverage decisions, participants say they were annoyed by marketing calls and the number of ads marketing Medicare plans on TV, and generally ignored them. Few participants said they intend to review or switch their coverage. While focus group participants were generally satisfied with their Medicare coverage, most were also confused and frustrated by the complexity of the program and lacked confidence in their own ability to compare and choose a source of coverage to best meet their individual needs.

The focus group participants included Medicare beneficiaries ages 65 and older and younger adults with disabilities who make health coverage decisions for themselves and/or their spouse or family member. Some focus groups also consisted of people with both Medicare and Medicaid (also referred to as dual-eligible individuals) as well as adults 64 years old who were not yet enrolled in Medicare. Participants included beneficiaries in traditional Medicare, some with and some without Medigap supplemental coverage, and beneficiaries enrolled in Medicare Advantage plans. Because the study focused on decisions around health plans, we excluded beneficiaries with retiree coverage from a former employer or union.

We conducted 7 focus groups with participants from across the country in November 2022, timed to coincide with the Medicare open enrollment period, which starts October 15 and ends December 7 of each year. Each focus group was conducted virtually by Zoom and included 5-8 participants, differing by age, gender, income, race/ethnicity, health status, and type of insurance coverage. Each focus group lasted one hour and forty-five minutes. Two of the seven focus groups consisted of people with Medicare and Medicaid, with one group consisting of adults 65 and older, and the other group adults younger than 65. One focus group included adults 64 years old who were not yet enrolled in Medicare, but who were starting to think about their Medicare coverage options. One focus group was conducted in Spanish. Individuals who were able to participate in the groups needed to know their Medicare coverage, and if applicable, Medicaid coverage, have two hours of time, a quiet space, a computer, and internet. These characteristics alone may not fully represent many people with Medicare, so the perspectives described in this report may not be generalizable to the entire Medicare population. See Appendix Table 1 for demographic details about the participants.

The analysis includes responses from participants across all 7 focus groups. There are also additional responses from dual-eligible participants that emphasize beneficiary experiences unique to this population.

Opioid use disorder (OUD) is a chronic treatable medical condition affecting birthing parents across all racial and ethnic groups, socioeconomic classes, and geographic locations. Without treatment, opioid use in pregnancy can result in serious negative health outcomes for the fetus and the birthing parent such as increased risk for a stillbirth, pregnancy complications including preterm labor, and death. Medications for OUD (MOUD) – including methadone, buprenorphine, and naltrexone – reduce adverse outcomes for both the birthing parent and child. The American College of Obstetricians and Gynecologists (ACOG) recommends the use of medications, especially opioid agonists (more details below), to manage pregnant women with OUD and advises for continued treatment through the postpartum period. Comprehensive care for pregnant and postpartum women with OUD includes standard prenatal and postpartum care, contraceptive counseling, and the co-prescribing of naloxone and overdose training.

As a major source of coverage for maternity care (covering 42% of all births), and covering an even larger share of women with OUD, and the single largest payer for behavioral health services , Medicaid is particularly well positioned to facilitate access to OUD treatment. Drawing on the 2016-2019 Medicaid claims data from the Transformed Medicaid Statistical Information Systems (T-MSIS), this brief looks at the rates of clinically documented OUD in pregnant and postpartum women as well as the percentage of diagnosed women who receive MOUD treatment. The analysis also explores disparities in clinical diagnosis and treatment based on demographics, such as race/ethnicity and age, along with geographical differences. Differences in clinically documented OUD and treatment rates across various demographics and regions offer insight to help inform ongoing policy conversations aimed at improving access to OUD treatment for pregnant and postpartum parents.

Key Takeaways:

• Analysis of Medicaid claims representing births from 2017 and 2018 in 39 states with usable data shows 2.7% of pregnant or postpartum Medicaid enrollees had clinical documentation of opioid use disorder in their medical claims. This is slightly higher than adults overall (2.0%) and lower than the adolescent and nonelderly adult (12+) Medicaid population clinically diagnosed with OUD (3.3%). There was considerable variation in the rates by states, ranging from a low of 0.4% in Nebraska to a high of 12.4% in Vermont.
• On average, 55% of pregnant and postpartum Medicaid enrollees with documented opioid use disorder received medication as part of their care. Medication treatment rates for pregnant or postpartum Medicaid enrollees with a documented OUD varied substantially with a low of 19% in Kansas to a high of 79% in Maine.
• Younger pregnant or postpartum enrollees had a clinically documented OUD rate (1.6%) that was half of those ages 26 to 34 (3.7%) and 35 years and older (3.1%). Younger enrollees received treatment at somewhat lower rates with 48% getting medication compared to over 55% among those who were aged 26 and older.
• In a subset of 24 states with available data, White pregnant or postpartum Medicaid enrollees had clinically documented OUD rates five times more than Black enrollees (5.5% vs 1.1%, respectively). Clinically documented rates were the lowest among Hispanic enrollees (0.6%). Racial and ethnic disparities persist in the receipt of MOUD. Compared to Hispanic and White enrollees, smaller shares of Black enrollees with a documented OUD received MOUD during the perinatal period (53-57% vs. 31% respectively).
• State laws that take a punitive approach toward substance use during pregnancy may contribute to lower OUD identification and lower treatment rates may be attributable in part to Medicaid utilization controls, prior authorization requirements, and burdensome administrative policies.

How are Medications for Opioid Use Disorder (MOUD) Used to Treat Opioid Used Disorder During the Perinatal Period?

Since the 1970s, ACOG has recommended that MOUD, in combination with behavioral health interventions, serves as the standard treatment for opioid addiction during the perinatal period. MOUD provides stabilization by reducing withdrawal symptoms and the negative health outcomes associated with opioid use. There are several different Food and Drug Administration-approved options for MOUD (Table 1). Methadone and buprenorphine are safe and effective in treating OUD in pregnancy and improve the adherence to standard prenatal care. Naltrexone is another treatment option for OUD, but it is rarely prescribed during pregnancy because there are few studies demonstrating its effectiveness, except in limited circumstances. While behavioral health interventions are encouraged as a supplement to MOUD, we do not discuss them in detail in the current analysis.

Without treatment, opioid use in pregnancy can result in serious negative health outcomes such as fetal distress, intrauterine growth restrictions and ultimately, neonatal abstinence syndrome (NAS) or opioid withdrawal at birth. Pregnant and postpartum parents with untreated OUD are also at increased risk for a stillbirth, pregnancy complications including preterm labor, and death. Notably, opioids played a role in 1 in 10 pregnancy-associated deaths in 2016. Although clinical guidelines recommend the use of MOUD for pregnant and postpartum parents with OUD, most go untreated. Prior studies indicate that only 50-60% of pregnant women in the United States receive any MOUD during pregnancy. In addition to this treatment gap, racial and ethnic disparities have been reported in the receipt of MOUD. Pregnant women of color are less likely to receive any medication to treat OUD.

What are the Rates and Characteristics of Pregnant and Postpartum Enrollees with a Clinically Documented OUD?

Among women with a Medicaid funded live birth in 2017 and 2018, 2.7% or 65,092 enrollees had a clinically documented OUD (Figure 1). This is slightly higher than adults overall (2.0%) and lower than the nonelderly adolescent and adult (12+) Medicaid population (3.3%). For this analysis, any diagnosis or prescription code that suggests the presence of an OUD is defined as a “clinically documented OUD.” Although, other Medicaid studies using claims data show similar rates of maternal OUD, research that adjusts for underreporting finds higher rates. Certain factors may lead to underreporting or reluctance to disclose drug use, which in turn can result in an underestimation of OUD in claims data. Stigma and concerns about legal retribution might make pregnant and postpartum women more careful about disclosing their opioid use to clinicians. Providers may be hesitant to record the diagnosis in the records at all due to concerns about whether documentation could violate the privacy rules in place that provide protection for people receiving any form of SUD treatment. For these reasons, this measure should not be used as a metric to define the overall prevalence of OUD among the pregnant and postpartum Medicaid population because not everyone is screened and diagnoses are not always recorded, but it does provide some insight into how often OUD is recognized and possibly treated in clinical settings.

Rates of clinically documented OUD in pregnant and postpartum Medicaid enrollees vary widely from state to state. For instance, Vermont has the highest share of clinically documented OUD (a finding aligning with other KFF work), with 12.4% of pregnant and postpartum Medicaid enrollees having a clinically documented OUD. In contrast, Nebraska records the lowest rate of diagnosed OUD, with fewer than 1% of pregnant and postpartum Medicaid enrollees having a clinically documented OUD (Figure 1). Rates of diagnosed OUD vary across state, not only because of prevalence, but also because of other factors such as provider screening behavior, variation in Medicaid coverage of SUD services and state laws criminalizing maternal drug use.

State laws that take a punitive approach toward substance use during pregnancy may contribute to lower OUD diagnosis and treatment. State legislation pertaining to drug use during pregnancy usually falls into punitive or supportive categories. Punitive laws categorize prenatal drug use as a form of child abuse or neglect and necessitate healthcare professionals report these instances to state child welfare agencies. These laws may deter pregnant people from seeking standard prenatal care, substance use treatment, and increase fear and concern over the potential loss of custody of their children due to the involvement of child welfare agencies. Alternatively, supportive drug use legislations attempt to prioritize pregnant and postpartum people’s access to treatment. Professional groups, such as ACOG and ASAM, oppose the use of policies and practices that criminalize drug use in pregnancy and advocate for comprehensive and evidence-based care.

Larger shares of White pregnant and postpartum Medicaid enrollees and those over the age of 25 had a documented OUD compared to Black and Hispanic pregnant and postpartum enrollees and those age 25 and younger. OUD is documented five times more in the claims of White enrollees, with 5.5% having a clinically documented OUD, compared to around 1% of Black and Hispanic enrollees. In addition, clinically documented OUD was more common among enrollees who were 26 and older (3.7% between 26-34 years old and 3.1% for those 35 years and older), compared to those aged 25 or younger (1.6%) (Figure 2). The rates at which OUD is diagnosed and documented can differ among populations due to several factors. Apart from the actual prevalence of the condition, these variations can stem from unequal access to prenatal care, inconsistencies in how providers screen for the disorder, and heightened stigma for certain groups that may amplify repercussions of admitting drug use.

What Percentage of Pregnant and Postpartum Women with a Clinically Documented OUD Received MOUD Treatment?

Overall, just over half (55%) of enrollees received MOUD as part of their care (Figure 3). Despite a little more than half of pregnant and postpartum Medicaid enrollees with a clinically documented OUD showing receipt of MOUD treatment, this is still likely an overestimate of treatment access. Research suggests that OUD prevalence is likely higher than what is reported in claims data. Yet, the number of people receiving MOUD treatment is probably fairly accurate. Therefore, the percentage of enrollees with opioid use disorder – whether documented in claims data or not – who receive treatment is likely lower than 55%.

State treatment rates of pregnant and postpartum Medicaid enrollees with a documented OUD also vary substantially. States where more than 60% of enrollees with a clinically documented OUD received MOUD included Northeastern states (ME, VT, NH, MA, CT, DE) and WA, NM, WI, and OH. On the other hand, in KS, less than 1 in 5 received MOUD. Please refer to Methods and Appendix 2 for more information.

Rates of MOUD treatment vary across states because of factors such as Medicaid utilization controls and variation in engagement in public health initiatives like the development of perinatal collaboratives focusing on OUD throughout the perinatal period or the receipt of SAMHSA grants. Utilization control measures, like prior authorization, shape the access and availability of MOUD and can be a barrier to care, particularly if prior authorization denial rates are high. These measures include prior authorization, quantity limits, step therapy, and psychosocial treatment requirements. In addition to prior authorization requirements, some states also have additional administrative requirements, which may include random drug screenings or pill counts, mandatory counseling requirements, and maximum daily doses.

Additionally, MOUD utilization and adherence are affected by treatment concerns and scarcity of women- centered programs. Prior research finds that pregnant and postpartum individuals express concerns about lack of autonomy in their decision to initiate MOUD and have felt pressured from clinicians, ultimately impacting their commitment to treatment. Other pregnant and postpartum individuals voice concerns about their infants developing NAS and the increased scrutiny they would receive from healthcare staff. Lastly, postpartum parents have highlighted that treatment environments for MOUD are not accommodating to their unique needs. Because methadone and buprenorphine are subject to federal and state restrictions limiting their accessibility, postpartum parents have highlighted the difficulties in maintaining adherence with competing childcare responsibilities. Other challenges affecting adherence in the postpartum period include cost, transportation, lack of continued healthcare coverage after delivery, and shortage of treatment centers and clinicians providing MOUD. Research has shown that women-centered programs – programs that offer services tailored to women’s unique needs – have higher retention rates and reductions in substance use, and fewer reported barriers to care.

Black women with a diagnosed OUD were less likely to receive MOUD during prenatal or postpartum periods (31%) compared to Hispanic and White women (53-57% respectively). However, treatment rates were similar between White and Hispanic pregnant and postpartum enrollees. Research suggests that structural racism may be associated with lower standards of care, fewer treatment options, and higher rates of prosecution of women of color, especially Black women. Black women who use drugs are more likely to be reported to child welfare agencies and drug tested than other women. These factors may make women of color less likely to disclose opioid use and contribute to lower treatment rates. Additionally, the absence of a diverse healthcare workforce may result in reluctance to seek or continue treatment. Prior studies have also drawn attention to the limited diversity of workforce in outpatient substance use treatment settings. Furthermore, the existing knowledge base may not be reflective of the experiences of women of color, with previous research noting that White women with an OUD made up most of their sample. Regarding age, pregnant and postpartum women 26 years and older (56-57%) with diagnosed OUD were more likely to receive MOUD treatment compared to those 25 years old and younger (48%) (Figure 4).

What Changes have been made at the Federal and State Level to Support Pregnant and Postpartum Individuals Diagnosed with Opioid Use Disorder?

In recent years, state and federal governments have undertaken additional actions to address gaps in treatment, prevention, and recovery of substance use disorder services. In 2018, the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT Act), a bipartisan legislation, was passed that included Medicaid provisions to expand research and services for pregnant women with OUD. At the same time, CMS launched the Maternal Opioid Misuse (MOM) Model Initiative to address fragmentation in the care of pregnant and postpartum Medicaid enrollees with OUD. There are currently 8 states participating in the program and interventions focus on service integration, coordination, and expansion to ultimately improve the cost, quality, and access to OUD services. In 2021, states were given the option to extend Medicaid postpartum coverage to 12 months in the American Rescue Plan Act and most states have implemented or plan to implement a 12-month extension. This 12-month postpartum extension gives postpartum Medicaid enrollees more time to receive care, ensuring longer access to OUD treatment services. More recently, the Consolidated Appropriations Act of 2023 led to the elimination of additional registration requirements for the prescribing of buprenorphine (X waiver) to facilitate access to buprenorphine providers; funding support to expand maternal mental health screening programs; maintenance of maternal mental health hotline; and establishment of a maternal mental health task force.

Looking Ahead

Although federal policies have aimed to improve access to OUD, treatment gaps persist. Most recently, the resumption of Medicaid renewals following a three-year pandemic halt – termed ‘Medicaid unwinding’ – has led to many individuals being dropped from Medicaid, primarily due to procedural rather than eligibility reasons. While some people losing Medicaid may already have another source of coverage or be able to transition to another form of insurance like the Affordable Care Act marketplace, other pregnant and postpartum women who qualify for Medicaid through pathways other than a current or recent pregnancy may experience coverage loss. Such a loss may disrupt treatment for OUD, increasing overdose risks, especially in the midst of the ongoing fentanyl crisis. If Medicaid unwinding coverage losses disproportionately affect people of color, it could intensify existing racial and ethnic disparities in access to MOUD.

Medicaid Claims (T-MSIS) & State Exclusion Criteria  KFF used the 2016-2019 Transformed Medicaid Statistical Information System (T-MSIS): demographic eligibility base (DE) (2017 and 2018) and both header and line files from inpatient (IP), other services (OT), and long-term care, as well as the prescription (RX) line files from 2016-2019. The 2016-2018 files were Release 2 and the 2019 files were Release 1.

We use 39 states in the main analysis and for maternal age. States with “unusable” data based on state-level information available from the DQ Atlas were excluded. We further excluded states whose final sample in this analysis had a difference of 20% or more from the number of Medicaid-covered births in the CDC Wonder Natality Files and state birth reports. For the analysis on race/ethnicity, we used 24 states with race/ethnicity data that was not considered of “high concern” or “unusable” by the DQ Atlas. Data reported in this analysis are from states with useable and sufficient (n > 50) data. Please see Appendix Table 1 for more information on the measures we used from the DQ Atlas, CDC Wonder Natality Files, and state birth reports to assess states’ data quality.

T-MSIS Enrollee Sample Selection  The sample includes pregnant and postpartum Medicaid enrollees that had a live birth in 2017 and 2018. Enrollees were not included if they did not have a live birth within the study period. This analysis defined the prenatal period as 10 months prior to delivery and the postpartum period includes delivery and 60 days post-delivery. After enrollee and data quality exclusions, the sample includes 2,368,069 enrollees with a live birth from 39 states. Among those with a live birth, 65,092 enrollees had a documented OUD. Out of those with a clinically documented OUD, 35,612 received MOUD.

For the analysis on age, there were 970,458 live births among those 25 years old and younger, 1,084,572 live births among those 26-34 years old, and 313,039 live births among those 35 years old and older across 39 states. Out of those with a live birth, there were 15,234 25 years old and younger, 40,143 between 26-34 years old, and 9,715 35 years old and older with a documented OUD. There were 7,277 enrollees 25 years old and younger, 22,926 enrollees between 26-34 years old, and 5,409 enrollees 35 years old and older that had at least one claim for MOUD.

For the analysis on race/ethnicity, there were 633,477 White live births, 324,546 Black live births, and 527,147 Hispanic live births across 24 states. Out of those with a live birth there were 34,899 White enrollees, 3,447 Black enrollees, and 3,279 Hispanic enrollees who had a clinically documented OUD. Among those with a documented OUD, 19,960 White enrollees, 1,074 Black enrollees, and 1,749 Hispanic enrollees that had at least one claim for MOUD. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis. Other groups are considered non-Hispanic.

Identification of OUD and Treatment in T-MSIS  We link header and line files using BENE_ID and CLM_ID. DE files are linked to header and line files using BENE_ID and if BENE_ID is missing, MSIS_ID. To identify OUD diagnoses and MOUD, we used the Behavioral Health Service Algorithm (BHSA) reference codes provided by Urban Institute (Victoria Lynch, Lisa Clemans-Cope, Paul Johnson, Marni Epstein, Doug Wissoker, and Emma Winiski. Behavioral Health Services Algorithm. Version 3. Washington, DC: Urban Institute, 2022.) which uses ICD-9 and ICD-10 diagnosis codes, procedure codes, service codes, and National Drug Codes (NDCs).

The OUD definition that was used for this analysis included all F11 diagnosis codes, procedure codes for naltrexone unique to OUD (G2073, G2074, G2075), procedure codes for methadone maintenance (HZ91ZZZ, HZ81ZZZ, H0020, G2078, G2067), buprenorphine procedure and NDC codes, and other procedure codes unique to OUD (HZ82ZZZ, HZ92ZZZ, M1032, M1033, M1034, M1035, M1036). One or more occurrence of these codes was coded as an OUD. Modifications to the BHSA algorithm include the removal of NDC codes that were not specific to OUD. Approximately, 2% of pregnant and postpartum Medicaid enrollees had only an Rx prescription and were considered to have an OUD diagnosis.

MOUD treatment included enrollees with at least one of the following: procedure codes for methadone maintenance (HZ91ZZZ, HZ81ZZZ, H0020, G2078, G2067), buprenorphine procedure and NDC codes, and other procedure codes unique to OUD (HZ82ZZZ, HZ92ZZZ, M1032, M1033, M1034, M1035, M1036), procedure codes for naltrexone unique to OUD (G2073, G2074, G2075), and naltrexone NDC codes among those with an OUD diagnosis. Naltrexone is also used for the treatment of alcohol use disorder (AUD) and we did not include those that did not have a corresponding OUD diagnosis code. As previously mentioned, we used reference codes from the Behavioral Health Services Algorithm developed by the Urban Institute.

KFF estimates that there are over 4 million people using Medicaid home- and community-based services (HCBS), which include medical and supportive services that assist people with the activities of daily living (such as eating, bathing, and dressing) and instrumental activities of daily living (such as preparing meals, managing medications, and housekeeping). They are provided to people who need such services because of aging, chronic illness, or disability and may include personal care, adult daycare, home health aide services, transportation, and supported employment. Medicare generally does not cover HCBS and in 2020, Medicaid spent $162 billion on HCBS—a majority of the $245 billion in total HCBS spending. Although all states offer some HCBS through Medicaid, most services are optional for states, and states may cover different services for different types of Medicaid enrollees. To be eligible for Medicaid HCBS, individuals must have limited financial resources and significant functional impairments.

During the COVID-19 pandemic, people who use HCBS were at heightened risk of serious illness or death from exposure to COVID-19 and were disproportionately likely to need hospital or nursing facility care when HCBS were unavailable, but there were fewer workers available and willing to provide services. Recognizing those challenges, the federal government provided states with new authorities to maintain access to HCBS during the public health emergency (PHE), which was in place from 2020 until May 11, 2023. Family caregivers played a critical role in helping to mitigate the consequences of workforce shortages and many states used the new authorities to support and pay family caregivers.

Drawing from KFF’s 50-state survey of state Medicaid HCBS officials, conducted between May and August of 2023, this issue brief describes how states used the PHE authorities to strengthen their HCBS programs, changes as the PHE ends, and the role of family caregivers in providing HCBS. Key take-aways include:

• States used PHE authorities to strengthen their HCBS programs by expanding access to services and investing in the HCBS workforce, and while some of those changes are transitioning into permanent policies, others are ending as the PHE authorities expire.
• The most commonly expiring policies will result in the end of virtual evaluations of eligibility and care needs in 23 states, lower utilization limits in 21 states, and reinstated prior authorization in 18 states; changes that may make it harder for Medicaid enrollees to access HCBS or may reduce the amount of HCBS they are able to use (Figure 1).
• Most states now allow family caregivers to be paid for providing personal care, but such payments are most common under waiver programs, which are offered at the states’ discretion and may limit enrollment to people with certain types of disabilities, may cap enrollment or spending at specified levels, and may use waiting lists when the number of people seeking services exceeds the number of waiver slots available.
• In 11 states, payments to family caregivers who are legally responsible for the person they are caring for will be ending and payments to other types of family caregivers will end in 5 states. With ongoing workforce shortages, families may have difficulty finding paid workers to take over their responsibilities when the policies expire.

How did states use public health emergency authorities to support Medicaid HCBS during the pandemic?

In a 2023 survey of states’ Medicaid HCBS programs, all responding states reported using PHE authorities to strengthen their programs by addressing eligibility and enrollment processes, increasing the availability of services, and addressing workforce challenges (Figure 2, Appendix Table 1). Responding states include the District of Columbia and all states except for Florida. The most common changes included allowing virtual evaluations of people’s eligibility for HCBS or the level of care needed (49 states), increasing payment rates to providers (45 states), allowing spouses and parents of minor children or other legally responsible relatives to be paid providers (37 states), increasing utilization limits on existing services (35 states), and allowing other family members or friends to be paid providers (27 states).

States made these changes using several types of authorities when responding to the COVID-19 PHE, including disaster-relief state plan amendments, 1115 waivers, and Appendix K changes to 1915(c) waivers. When the PHE ended on May 11, 2023, changes made through a disaster-relief state plan amendment or 1115 waiver also ended unless they had been moved to a permanent authority. Changes made using the Appendix K authority will expire within 6 months of the PHE ending (November 11, 2023) unless the state incorporates those changes into section 1915(c) waiver programs.

Although nearly all states are making some of their changes permanent, many other PHE-era policies are ending as the authorities expire. Among states responding to the survey, all states except for Kentucky and New Jersey plan to keep at least one of the policies that they enacted during the PHE. Some policies have already been made permanent—most commonly, increased payment rates (33 states), virtual evaluations of eligibility or level of care (20 states) and allowing family caregivers to be paid providers (17 states). Other policies are currently being transitioned from temporary to permanent authorities, with 13 states currently in the process of transitioning a policy allowing spouses, parents of minor children, or other legally responsible relatives to be paid providers. In other cases, the policies enacted during the PHE are ending, with 23 states ending virtual evaluations of eligibility or level of care, 21 states ending higher utilization limits, and 18 states reinstating prior authorization.

As the public health emergency authorities end, how are states supporting family caregivers?

The availability of payments for and support of family caregivers increased during the PHE and even as PHE authorities end, nearly all states allow payments to family caregivers for at least one of their HCBS programs (Figure 3, Appendix Table 2). Payments for family caregivers are generally allowed for the provision of personal care, which may be offered through several different types of Medicaid HCBS programs. Personal care may be provided through waivers such as 1115 or 1915(c) programs, through the Medicaid state plan, or a combination of both. Waiver services tend to encompass a wider range of benefits than the state plan benefit, but waivers are usually restricted to specific groups of Medicaid enrollees based on geographic region, income, or type of disability; and are often only available to a limited number of people, resulting in waiting lists. In 2023, all 50 states and DC offered HCBS through at least one waiver and 34 states offered personal care as a state plan benefit.

States were more likely to allow family caregivers to be paid if they were not legally responsible for the person receiving care and if the person receiving care was enrolled in an HCBS waiver. Among the 50 states with HCBS waivers that responded to the survey, 41 states allow payments to spouses, parents of minor children, and other legally responsible relatives and 49 states allow payments for other family members and friends (those who are not legally responsible relatives). Among the 34 states providing personal care through the Medicaid state plan, 12 states allow payments to legally responsible relatives and 23 states allow payments to other family members and friends. Those numbers include states that allow payments to family caregivers on an ongoing basis and states that only authorized such payments through a PHE authority. The totals also include states that allow payments for family caregivers under at least one of their waivers, but most states have more than one waiver, and such payments may not be permitted under all waivers.

Payments to legally responsible relatives are more likely to end after the PHE authorities expire than are payments to other family and friends. For the state plan benefit, the number of states only paying family members under a PHE authority was 6 states for legally responsible relatives (Alaska, Idaho, Louisiana, Minnesota, New Hampshire, and Oklahoma) and 2 states for other family members and friends (Missouri and New Hampshire). For waiver programs, the number of states that only allowed payments for family caregivers under a PHE authority for any waiver program in the state was 8 states for legally responsible relatives (Alaska, Georgia, Idaho, Iowa, New Jersey, Rhode Island, Vermont, and Virginia) and 3 states for other family and friends (Kansas, New Jersey, and Vermont). Because most states have different policies for different waivers, a larger number of states will have payments to family caregivers ending for specific waiver programs as shown in the next figure.

Payments to family caregivers are most common for people with intellectual or developmental disabilities and people who are ages 65 and older or with physical disabilities (Figure 4, Appendix Table 3). Most state waiver programs are limited to people with specific types of disabilities—most commonly, intellectual or developmental disabilities (48 states) and people who are ages 65 and older or have physical disabilities (45 states). Among the states with waivers for people with intellectual or developmental disabilities, 18 states allow payments to legally responsible relatives and 43 states allow payments to other family and friends. Among the states with waivers for people who are ages 65 and older or with physical disabilities, 18 states allow payments to legally responsible relatives and 17 states allow payments to other family and friends.

Several states report that payments to family caregivers will end when the PHE authorities expire. Payments to legally responsible relatives were allowed under the PHE but will be ending in 9 states with waivers for people with intellectual and developmental disabilities, in 7 states with waivers for people who are ages 65 and older or with physical disabilities, in 2 states for people with traumatic brain or spinal cord injuries, and in 2 states for children who are medically fragile or technology dependent. (These numbers are higher than the numbers reported overall in Figure 3 because many states allow payments for family caregivers indefinitely for some waivers but only temporarily for other waivers.)

Nearly all states now provide support for family caregivers—who may be paid or unpaid—and most states offer more than one type of support (Figure 5, Appendix Table 4). Almost all (49) states offer at least one family caregiving support in their HCBS programs, and 39 states offer more than one family caregiving support. These supports frequently include respite care (49 states), caregiver training (33 states), and caregiver counseling/support groups (24 states). For all types of waivers, respite care was the most frequently reported support offered and caregiver counseling or support groups was the least frequently reported.

What challenges might Medicaid enrollees who use HCBS face as the PHE ends?

As the PHE authorities expire, there may be additional barriers to accessing HCBS in some states. Although many states are working to make the PHE changes permanent, 23 states will cease evaluating eligibility virtually, 2 states will reduce financial eligibility, 3 states will reduce functional eligibility, and 2 states will reduce the number of waiver slots. Concurrently, 21 states will reinstate utilization limits and 18 states will reinstate prior authorization. Some of those changes will reduce the number of people who are eligible for HCBS or reduce the amount of HCBS eligible enrollees may use.

New HCBS-related administrative barriers could exacerbate the challenges Medicaid enrollees are already experiencing from the unwinding of the pandemic-era continuous enrollment provision, which has resulted in 6.5 million Medicaid enrollees losing coverage as of September 15, 2023. Between February 2020 and March 2023, states received enhanced federal Medicaid funding for keeping people continuously enrolled in Medicaid, and states are now redetermining eligibility for all Medicaid enrollees. Although most people who use HCBS are unlikely to have income or employment changes that render them ineligible for Medicaid, they must still demonstrate their continued eligibility, and some could lose coverage for procedural reasons.

Beyond administrative hurdles, the end of the PHE authorities may place further strain on the HCBS workforce and on family caregivers who provide HCBS. Many of the PHE authorities were enacted in response to HCBS workforce shortages that were exacerbated by the COVID-19 pandemic. As the pandemic era ends, employment in the long-term services and supports sectors continues to remain below pre-pandemic levels and it is unclear whether HCBS workforce shortages will become worse.

In states where payments for family caregivers are ending for some HCBS programs, family members will need to either find new paid workers or will continue to provide care but be unpaid for those services. This situation will be most common for legally responsible relatives who are caring for people with intellectual or developmental disabilities. In states where payments for family caregivers are continuing, such caregivers may experience changes in states’ requirements related to training, documentation, or the maximum number of hours for which they are paid as policies transition to permanent.

Challenges for family caregivers and the HCBS workforce reflect broader challenges in providing care to the many people who use long-term services and supports (LTSS) in both HCBS and institutional settings. The pandemic affected health care workers in all settings but particularly among workers who provide LTSS. As of June 2023, employment levels were still more than 11% below pre-pandemic levels for workers in skilled nursing care facilities and 3% below pre-pandemic levels for workers in elderly care facilities. Recognizing the significance of the LTSS workforce shortage, the Biden Administration has undertaken several steps to bolster the workforce which include issuing major new rules aimed at strengthening the workforce. In HCBS settings, a recent proposed rule on Medicaid access would require states to demonstrate that their payment rates for HCBS are “adequate to ensure a sufficient direct care workforce to meet the needs of beneficiaries and provide access to services.” The rule would also require states to demonstrate that at least 80% of total payments for certain HCBS were compensation to direct care workers. In institutional settings, a recent proposed rule on nursing facility staffing would require facilities to meet minimum staffing requirements and would require states to report on what percentage of Medicaid payments were compensation to direct care workers. Those rules highlight the commitment to supporting LTSS workers, but ultimately, there are only so many people available to provide LTSS and it is likely that challenges will persist.