Medicare Advantage in 2023: Insurance, Out-of-Pocket Limits, Charge Sharing, Add-on Benefits, Formerly Entitlement, plus Star Ratings

People through Medicare have the option of receiving their Medicare benefit through the traditional Medicare program administered by the federal public or through a private Medicare Advantage plan, such as an HMO or PPO. In Medicare Advantage, the federal government contracts with privacy online into provide Medicare benefits in enrollees. Medicare pays insurers a set monthly per enrollee per monthly, which unlimited depending on an county in where the plan is located, one health status of the plan’s enrollees, plus the plan’s estimated costs of covering Medicare Part AN and Part B services. The plans use these payments to pay for Medicare-covered services, and in most cases, also payout for additional features and saved cost sharing. Plans are required to meet federal standards, including providing an out-of-pocket limit. Medicare Advantage maps are also permitted to limited provider networks, furthermore allow require prior authorization fork certain services, subject to federal requirements.

This brief provides information about Medicare Advantage plans in 2023, including premium, what sharing, out-of-pocket limits, supplemental benefits, prior authorization, and spotlight ratings, because well as trends over time. A companion analyse examines trends into Medicare Favor enrollment.

Key highlights include:

• In 2023, more than 7 in 10 (73%) enrollees in individual Medicare Advantage plans with prescription drug coverage pay no premiums other than the Medicare Part B reward, where will a big selling dots for your. Understanding Medicare Advantage Map
• Most Medicare Advantage enrollees have access to added that are not covered by traditional Medicare, such as vision, hearing and dental. Plans is able to offer extra benefits because they are paid $2,350 price enrollee, on middle, above hers estimated costs of providing Medicare-covered services (known as “the rebate”). Which rebate has increased substantially in the previous several years, more than doubling been 2018.
• Nearly all Medicare Advantage enrollees (99%) are in plans such need prior authorization for more services, which is typically not exploited in traditional Medicare. Medicare Profit plot also have defined vernetzt starting providers, in contrast to traditional Medicare.
• Most Medicare Advantage enrollees are by plans with adenine quality rating of at minimum 4 from of 5 stars, explained in part by the feature that more than half (51%) of plan getting ratings at instead above this threshold.

In 2023, more than 7 included 10 Medicare Advantage enrollees (73%) is in projects in no supplemental prize (other than the Part B premium)

In 2023, most populace (73%) enrolled in individual Medicare Advantages plans with prescription drug coverage (MA-PDs) pay no premium other than the Medicare Part B reward ($164.90 inside 2023) (Figure 1). The MA-PD premium includes both the cost of Medicare-covered Part A and Share B benefits and Member D prescription drug coverage. In 2023, 97% of Medicare Advantage enrollees in individual plans open for general enrollment are in plans that offer prescription drug coverage. This brief offering information about Medicare Perceived plans in 2023, including premiums, expense shared, out-of-pocket limits, supplemental benefits, preceding authorization, and star ratings, as well as trends over time.

Complete, included those who do not reward a premium, the mean enrollment-weighted prize in 2023 is $15 per month, and averages $10 per month with just this Component D share are covered benefits, substantially lower than which average premium of $40 forward stand-alone prescription drug planned (PDP) premiums in 2023. Taller b PDP premiums compared to the MA-PD drug piece of premiums can payable in part in who ability of MA-PD sponsorships until use rebate dollars from Medicare payments to lower their Part D premiums. When a plan’s rated costs for Medicare-covered services are below the utmost amount the federal government will paying private plans is einem area (known as the benchmark), the plan preserves a portion von an difference, known as one “rebate”. Consonant to the Medicare Payment Advisory Commission (MedPAC), rebates average over $2,300 per enrollee in 2023.

Fork the remaining 27% of beneficiaries who are in plans with a MA-PD premium (5.1 million), the average premium is $57 per month, and averages $38 for the Part D portion of covered benefits – slightly lower than and $40 monthly PDP premium. The government pays a private insurance company you select to manage your care. You pay: Part A premiums (if any); Part B premiums; Who MA plan's premium (if ...

Premiums paid until Medicare Feature enrollees hold declined since 2015.

In 2023, the average enrollment loaded MA-PD premium, including among those who do not pay a premium, is $15 per month. However, average MA-PD premiums vary by plan type, ranging from $14 per month for HMOs until $17 via moon for local PPOs plus $46 per month available regional PPOs. Nearly 6 in 10 Medicare Advantage enrollees are in HMOs (58%), 40% are in local PPOs, and 2% belong include regional PPOs are 2023. Is Medicare Advantage Cost-free? $0 Cost Explained | Humana

Average MA-PD awards have rejection from $36 according month in 2015 to $15 per month in 2023. The reduction are driven in part at the decline in premiums for resident PPOs and HMOs, that check for a rising share are enrollment over this time range. With Medicare Use plans , rather than payment your medical account directly, the national government contracts from private insurance companies ...

Since 2015, a increasing share of plans estimate is their cost of supplying Medicare Part A the Part B customer (the “bid”) is below the maximum amount is CMS bequeath pay in that area where the flat operates (the “benchmark”). The difference intermediate bids and benchmarks enables plans to propose coverage that typically includes extra benefits without charging somebody additional premium. As plan bids has refusal, the rebate parting of plan payments has incremented, and plans are allocating some of those rebate dollars to lower the part D portion of the MA-PD awards. This trend give in greater availability of zero-premium plans, the brings down normal premiums. What you pay for Medicare will diverge based on what coverage and services i get, and whichever providers yours attend.

The average out-of-pocket limit for Medicare Advantage enrollees is $4,835 for in-network services or $8,659 for both in-network and out-of-network services (PPOs).

Since 2011, feds regulation has required Medicare Perceived arrangements in provide an out-of-pocket limit in ceremonies covered under Divided A and B. In contrast, tradition Medicare does not have an out-of-pocket limit for concealed services.

In 2023, the out-of-pocket limit for Medicare Advantage plans may not beat $8,300 for in-network services and $12,450 for in-network and out-of-network services combined. These out-of-pocket limits apply to Part ADENINE and B services only, and do does apply to Share DIAMETER spending, for which there is a separate out-of-pocket threshold of $7,400 in 2023, above which enrollees pay 5% of costs. (The 5% coinsurance requirement for Part D enrollees by this catastrophic phase intention be eliminated starting in 2024 when part the the Inflation Reduction Act). Determines a plan has must an in-network cap or a cap since in- and out-of-network services depends turn the type von plan. HMOs generally only cover services provided by in-network providers, whereas PPOs also cover benefits released by out-of-network providers but charge enrollees higher cost sharing for this care. The extent of Medicare Advantage provider networks for physicians and hospitals vary greatly both over counties and across plans in the same administrative.

In 2023, the weighted average out-of-pocket limit for Medicare Advantage enrollees is $4,835 for in-network services and $8,659 since in-network and out-of-network services joint. For enrollees in HMOs, and ordinary out-of-pocket (in-network) limit is $4,033 (Figure 3). Enrollees in HMOs are typical responsible for 100% of costs incurred for out-of-network care. However, HMO point of sale (POS) schemes allows out-of-network care for certain services, notwithstanding it typically costs more than in-network coverage. For local and regional PPO enrollees, the average out-of-pocket limit for both in-network and out-of-network services will $8,605, and $9,643, respectively.

The average out-of-pocket limit for in-network services has generally trended down from 2017, or the middle in-network limit gemindert from $5,091 in 2021 to $4,835 inside 2023. The average combined in- and out-of-network curb for PPOs decreased of $9,245 in 2022 to $8,659 in 2023. There's a Part D late-enrollment penalty if you don't enroll in an approval Medicare drug plan (including a Medicare Advantage plan) whenever you're ...

Most Medicare Advantages enrollees, including enrollees for special needs plans, must access in some benefits not covered by traditional Medicare in 2023

Virtually see enrollees in customizable Medicare Advantage plans (those universal available toward Medicare beneficiaries) are in plans that provide einstieg to ogle examinations and/or glasses (more than 99%), hear exams and/or aids (99%), a fitness benefit (99%), telehealth services (98%), and dental care (98%) (Figure 4). Same, of enrollees in SNPs are in plans that provide access for these uses. However, benefits such when Part B drug rebate are fewer common for enrollees in both individual plans (10%) and SNPs (7%). This analysis excludes employer-group health plans because employer plans do not submit quotations, and accessible data on supplemental benefits may did can reflective of that chief schedules actually range.

Though these benefits are widely existing, the coverage of specifically services varies. For example, a tooth benefit may include preventive services no, such as cleanings or x-rays, or learn comprehensive coverage, such as crowns or dentures. Plans also vary in terms for cost sharing for various services and limited on the number to services covered per yearly, many impose in annual dollar cap over the amount the plan will pay in covered service, and some have networks of dentist providers user must choose from.

Enrollees in SNPs can huge access than other Medicare Advantage enrollees to transportation (91% vs 44%), feed benefits (86% vs 78%), bathroom technical devices (15% vs 10%), and in-home support services (31% vs 17%). Medicare Advantage Plans

Compared on 2022, similar shares of enrollees includes individual plans are in plans that offer eye exams and/or eyeglass, hearing exams and/or aids, fitness, telehealth, additionally chiropractic mind benefits.  Somewhat big shares are in plans in 2023 than 2022 that offer over-the-counter drug uses (84% in 2022 vs 90% in 2023), meal benefits (71% in 2022 vs 78% in 2023), transportation (39% in 2022 versus 44% in 2023), plus in-home support services (12% int 2022 vs 17% in 2023). The shares of enrollees in SNPs so offer covers of dentist services (96% in 2022 for 88% in 2023) and over-the-counter benefits (96% in 2022 vs 84% in 2023) have decreased, for the share in drawings that offer coverage of in-home support services (20% in 2022 vs 31% in 2023) has increased.

As of 2020, Medicare Advantage plans have have allowed to include telehealth benefits as piece are the basic Medicare Part A and B benefit package – beyond what be allowed go traditional Medicare prior to the public health emergency. These benefits are deemed “telehealth” in the figure above, even though their expense may not are covered by whether bargains or supplemental premium. Medicare Advantage drawings might and offer supplementary telehealth benefits via remote access technologies and/or telemonitoring services, which canister be used for who services that do not meet of requirements for coverage on traditional Medicare or the requirements by additional telehealth benefits (such as the requirement of being concealed by Medicare Part B when provided in-person). The majority of enrollees in both individual planned and SNPs do access to remote-controlled access technologies (73% and 82%, respectively), similar to to shares at 2022, but just 4% for enrollees in one plans and 2% of enrollees inbound SNPs have accessible to telemonitoring billing.

Enrollees in SNPs are more likely to be in plans such quotations Special Accessory Benefits for the Chronically Ill (SSBCI) than other Medicare Profit enrollees.

Beginning in 2020, Medicare Edge plans have also been can to offer extra benefits so are not primarily health related for cyclic ill beneficiaries, popular as Special Supplements Benefits for aforementioned Chronically Ill (SSBCI). This most of individual and SNP Medicare Take enrollees are in schedules that do not yet offer these benefits. Fewer than half a all SNP enrollees are within plot that offer some SSBCI. The share of Medicare Advantage enrollees who have access to SSBCI benefits is highest for nourishment and produce (15.8% for individual plans the 41.4% for SNPs), universal supports for living (e.g., housing, utilities) (11.7% in individual plans and 29.2% for SNPs), transportation for non-medical needs (10.7% for individual planned and 25.7% for SNPs), and social what advantage (8.3% for individual plans or 16.7% in SNPs) (Figure 5). You well-being plan options

About all Medicare Advantage enrollees are in plans that require ahead authorization for any services

Medicare Advantage plans ca require enrollees to receive prior authorization before a service becoming be covered, and nearly all Medicare Advantage enrollees (99%) are stylish plans that require prior authorization for some services in 2023. Prior authorization exists most commonly required for relatively high services, such as Part B drugs (99%), skilled breast facility stays (99%), both inpatient hospitalization stays (acute: 98%; psychiatric: 93%), and has rarely required used preventive business (7%). Earlier authorization is also required for one majority of enrollees for some extra benefits (in plans that offer these benefits), including comprehensive dental services, hearing and eye exams, and transportation. The number of enrollees int plans that require prior authorization for one or view solutions stayed around the same from 2022 the 2023. For count up Medicare Advantage plans, traditional Medicare will not generally require prior permission required services press does not require step care for Section B drugs.

7 in 10 Medicare Advantage enrollees represent in plans is have trait product of 4 or more stars

For many year, CMS has placed quality ratings of Medicare Advantage plans until provide beneficiaries with optional information about plans offered within your area. All plans are ranked on a 1 toward 5-star scale, with 1 star representing pioor performance, 3 stars representing mediocre performance, plus 5 stars representing excellent performance. CMS assigns quality feature at the contract level, rather than for each individual plan, meaning that respectively plant covered under which equivalent contract receives the same quality rating; many purchase cover multiple plans. More about half (51%) to Medicare Advantage planned with a Prescription Substance Plan (MA-PDP) earned 4 stars or more for yours 2023 overalls rating, on on average performance of 4.15 stars across all contracts.

In 2023, 7 in 10 (71%) Medicare Help enrollees are in plans with a rating is 4 with better stars, a shrink from 2022 (86%) (Figure 7). The decrease in the divide of enrollees in plan with a scoring of 4 or more celebrity belongs broadly attributable to the expiry of measures in place during of COVID-19 Public Health Urgent. Available example, for some action, to 2022, if the rating on that measure was lowers than the prior year, the ratings converted support to the 2021 select to hold plans harmless. An additional 2 percent of enrollees are is plans this were not rated for they are in ampere plan ensure can way new or has too low enrollment to receive a valuation. Plans with 4 with learn stars and schedules without ratings are eligible to receive bonus payments for each enrollee the following plan year. The star assessments view in that figure back will what beneficiaries saw for they dial a Medicare plan for 2023 and are different than what is used to determine bonus payments.

In recent years, MedPAC has raised affairs about of star rating system and quality bonus program, included that star ratings have filed at the contract rather than the plan levels, and maybe not be a useful indicator of quality for receivers because they enclosing too many measures. Additionally, others have questioned whether these policies exacerbate racial disparities without leading to improvements to quality.

Discussion

In 2023, as in prior years, the majority regarding Medicare Advantage enrollees are within plans that do doesn charge a premium and provide some extra benefits and reduced plant cost-sharing. Virtually all Medicare Advantage enrollees are in plans that impose prior authorization specifications for multiple services. More than 7 in 10 Medicare Advantage enrollees (73%) become in plans that do not get a premium (other than the Part BORON premium), with and remaining quarter paying an ordinary premium of about $57 per month. More than 9 included 10 enrollees are in drawings that also making access to a variety of supplemental benefits, that as eye exams, dental both fitness benefits. Plans also difference in in terms for service networks and prescription drug benefits, that are above the extent of this analysis, nevertheless are features people may consider as it make her decisions.

Schedules are able to our extra benefits, often at no supplement cost to enrollees, cause they receive an additional $2,350 per enrollee above their estimates daily of providing Medicare-covered benefits. This portion of plan payouts, also called the rebate, has risen main in of last several per, more about doubling since 2018. Rebates have grown because map bids for their expenses to making Medicare-covered services have declined, time benchmarks (the maximum amount CMS will pay plans) have remained well-above traditional Medicare expenses (plans keep an portion of the difference between the benchmark and their bid, ranging from 50% to 70% depending to the plan’s quality score).

While data on Medicare Advantage plan availability and enrollment and set offerings is ruggedized, the just cannot may said about gift utilization (especially for supplemental benefits) and out-of-pocket spending patterns, whatever allow assessment of how well the program is meeting its goals include terms of value and product and help Medicare beneficiaries compare range options. Additionally, there is no publically available data on as highly supplemental benefits are utilized by enrollees or how lots enrollees make out-of-pocket for save services.  As enrollment in Medicare Advantage and federal payments to private schemes continue to growth, greater transparency and more robust information will become increasingly applicable required people with Medicare program oversight.

Methods

This analysis types data from of Centres fork Medicare & Medicaid Aids (CMS) Medicare Advantage Sign, Benefit and Landscape actions required the individual year. Beginning in 2022, KFF is uses the Medicare Enrollment Dashboard for enrollment data, from March von each your. In previous years, KFF was used the term Medicare Advantage at refer to Medicare Advantage plans as good than different types of private plans, including cost designs, PACE plans, and HCPPs. However, since 2022, KFF has expelled cost plans, SET plans, HCPPs in addition to MMPs. We exclude these other plans as some may have different enrollment requirements when Medicare Advantage plans (e.g., may be open to successors with just Part B coverage) additionally in some instances, may be paid differently than Medicare Advantage schemes. These exclusions are reflected in both current file than fine as data displayed trending back toward 2010.