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Contract Termination and Insurance Enrollment Among Medicare Advantage Beneficiaries

Importance

Approximately one-fifth of Medicare Advantage (MA) contracts terminated their participation in the MA program between 2011 and 2020. Little is known about subsequent insurance choices following a termination.

Objective

To examine the insurance destinations of MA enrollees and the characteristics of enrollees who switch into traditional Medicare (TM) after a contract termination.

Design, Setting, and Participants

This cross-sectional study examined MA program data of MA beneficiaries in the Medicare Master Beneficiary File from 2016 to 2018. Statistical analysis was performed from June 2023 to April 2024.

Exposures

Beneficiary characteristics, including age, sex, race and ethnicity, dual eligibility; hospital, nursing home, and home health utilization; and contract characteristics, including plan type, vertical integration, premium, and MA star rating.

Main Outcome and Measures

The main outcome was switching to TM in the year immediately after termination. We also evaluated the characteristics of contracts among those who remained in MA.

Results

A total of 117 681 beneficiaries were included in this analysis (64 654 [54.9%] female; 409 [0.4%] American Indian or Alaska Native; 2817 [2.4%] Asian; 76 725 [16.8%] Black; 11 131 [9.5%] Hispanic; 81 226 [69.0%] White; and 2373 [2.0%] other race or ethnicity; 27 078 [23.0%] dual-eligible; mean [SD] age, 71.2 [10.4] years). Following a contract termination, 20.1% (95% CI, 19.9%-20.4%) of enrollees switched to TM, including 32.7% (95% CI, 32.4%-33.1%) of dual-eligible beneficiaries and 16.4% (95% CI, 16.2%-16.5%) of non-dual-eligible beneficiaries. In nonterminated contracts, the concurrent switch rate was 6.2% (95% CI, 6.2%-6.2%) for all, 10.4% (95% CI, 10.4%-10.4%) for dual-eligible beneficiaries and 5.1% (95% CI, 5.1%-5.1%) for non-dual-eligible enrollees. The highest switch rates to TM were among Black enrollees (32.3% [95% CI, 31.7%-32.8%]) and those with prior use of hospital (31.3% [95% CI, 30.7%-31.9%], nursing home, 41.4% [95% CI, 40.4%-42.4%], or home health care (28.3% [95% CI, 27.4%-29.2%]). Beneficiaries who stayed in MA selected higher-rated star plans (mean posttermination contract star rating of 3.8 [95% CI, 3.8-3.8] stars compared with 3.3 [95% CI, 3.3-3.3] stars in the terminated year), but did not pay more in monthly premiums with 66.5% (95% CI, 66.2%-66.8%) paying the same or lower premiums.

Conclusions and Relevance

In this cross-sectional study, 1 in 5 MA beneficiaries switched to TM after a contract termination, with Black beneficiaries and those with more intensive health needs having the highest switch rates. These findings highlight the need to examine consequences of contract terminations and subsequent insurance destinations on access to care and health outcomes, especially among those with marginalized race and ethnicity, those who are dual-eligible, and beneficiaries with higher health care needs.

Comparing Medicare plan selection among beneficiaries with and without a history of cancer

Individuals aging into Medicare must choose among plans that vary in their scope of benefits, access to health care providers, and exposure to out-of-pocket expenses. When faced with complex coverage decisions, it is unclear whether older adults consider their experiences with prior serious illness or current medical conditions. We estimated the association between a self-reported history of cancer and initial plan selection among 3811 Health and Retirement Study participants aging into Medicare between 2008 and 2020. The proportion of individuals with and without a history of cancer who chose Medicare Advantage was similar; however, the probability of selecting traditional Medicare plus supplemental coverage was 8.03 percentage points (95% confidence interval, 2.99-13.07) higher for respondents with a history of cancer compared with those without a history of cancer. Individuals with a history of cancer may have accounted for their previous experiences with high-cost health care services and prioritized plans with robust benefits (eg, greater financial protections). Raising awareness of and enhancing educational resources could ensure that older adults select plans that meet their current and evolving health care needs.

Voice of the Customer: Factors Impacting Beneficiary Choice of Programs in TRICARE

Little is known about how a consumer would choose a health plan if cost was not an option such as in the Military Health System. We sought to identify how to recruit TRICARE beneficiaries into new pilot programs challenged by low recruitment. We developed a semistructured interview guide by adapting a framework established by Klinkman to assess factors in choosing a health plan. Using social media platforms, we recruited TRICARE Prime and Select beneficiaries to participate in key informant interviews from October to December 2022. We conducted inductive thematic analysis to determine key areas of concern. We interviewed a total of 20 TRICARE Prime and Select beneficiaries. The majority were women, above age 40, had a master's degree, a sponsor in the US Army and of senior officer rank. Four overarching themes emerged: (I) patient choice; (II) access to care; (III) quality of care; and (IV) cost. This evaluation of TRICARE beneficiaries explores how to motivate high-quality value-based care in a traditionally fee for service system.

Impact of star ratings on Medicare health plan enrollment: A systematic literature review

BACKGROUND

The Medicare star ratings program was developed by the Centers for Medicare and Medicaid Services in 2007 as an approach to evaluate health plan performance and quality.

OBJECTIVE

This study aimed to identify and narratively describe studies that attempted to quantitatively assess the impact that Medicare star ratings have on health plan enrollment.

METHODS

A systematic literature review (SLR) was conducted of PubMed MEDLINE, Embase, and Google to identify articles that quantitatively assessed the impact of Medicare star ratings on health plan enrollment. Inclusion criteria consisted of studies that conducted quantitative analyses to estimate the potential impact. Exclusion criteria consisted of qualitative studies and studies that did not directly assess plan enrollment.

RESULTS

This SLR identified 10 studies that sought to measure the impact of Medicare star ratings on plan enrollment. Nine of the studies found that plan enrollment increased in accordance with increases in star ratings or that plan disenrollment increased with decreases in star ratings. One study conducted of data before the implementation of the Medicare quality bonus payment found contradictory results from one year to the next, whereas all the studies that assessed data after implementation found increases in enrollment in accordance to increases in star ratings or increases in disenrollment for decreases in star ratings. One concerning finding from some of the articles included in the SLR is that increases in star ratings had less of an impact on enrollment in higher-rated plans for ethnic and racial minorities and older adults.

CONCLUSIONS

Increases in Medicare star ratings led to statistically significant increases in health plan enrollment and decreases in health plan disenrollment. Future studies are needed to assess whether this increase has a causal association or is caused by additional factors outside of or in addition to increases in overall star rating.

Potentially More Out of Reach: Public Reporting Exacerbates Inequities in Home Health Access

Policy Points Public reporting is associated with both mitigating and exacerbating inequities in high-quality home health agency use for marginalized groups. Ensuring equitable access to home health requires taking a closer look at potentially inequitable policies to ensure that these policies are not inadvertently exacerbating disparities as home health public reporting potentially does. Targeted federal, state, and local interventions should focus on raising awareness about the five-star quality ratings among marginalized populations for whom inequities have been exacerbated.

CONTEXT

Literature suggests that public reporting of quality may have the unintended consequence of exacerbating disparities in access to high-quality, long-term care for older adults. The objective of this study is to evaluate the impact of the home health five-star ratings on changes in high-quality home health agency use by race, ethnicity, income status, and place-based factors.

METHODS

We use data from the Outcome and Assessment Information Set, Medicare Enrollment Files, Care Compare, and American Community Survey to estimate differential access to high-quality home health agencies between July 2014 and June 2017. To estimate the impact of the home health five-star rating introduction on the use of high-quality home health agencies, we use a longitudinal observational pretest-posttest design.

FINDINGS

After the introduction of the home health five-star ratings in 2016, we found that adjusted rates of high-quality home health agency use increased for all home health patients, except for Hispanic/Latine and Asian American/Pacific Islander patients. Additionally, we found that the disparity in high-quality home health agency use between low-income and higher-income home health patients was exacerbated after the introduction of the five-star quality ratings. We also observed that patients within predominantly Hispanic/Latine neighborhoods had a significant decrease in their use of high-quality home health agencies, whereas patients in predominantly White and integrated neighborhoods had a significant increase in high-quality home health agency use. Other neighborhoods experience a nonsignificant change in high-quality home health agency use.

CONCLUSIONS

Policymakers should be aware of the potential unintended consequences for implementing home health public reporting, specifically for Hispanic/Latine, Asian American/Pacific Islander, and low-income home health patients, as well as patients residing in predominantly Hispanic/Latine neighborhoods. Targeted interventions should focus on raising awareness around the five-star ratings.

A digital divide in the COVID-19 pandemic: information exchange among older Medicare beneficiaries and stakeholders during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic resulted in unprecedented challenges for older adults. Medicare enrollment was already an overwhelming process for a high fraction of older adults pre-pandemic. Therefore, the purpose of this qualitative study was to gain understanding from community organizations and stakeholders about their pre-pandemic and during-pandemic experiences while adapting to continue offering insurance advice to seniors, what resources are available to seniors, and what needs to be done to help seniors make higher quality insurance choices in the Medicare program. In addition, we wanted to explore how the COVID-19 pandemic may have changed the ways that these stakeholders interacted with Medicare beneficiaries.

METHODS

We employed a qualitative strategy to gain a deep understanding of the challenges that these organizations may have faced while offering advice/counseling to older adults. We accomplished this by interviewing a group of 30 stakeholders from different states.

RESULTS

Every stakeholder mentioned that some older adults have difficulty making Medicare decisions, and 16 stakeholders mentioned that their system is complex and/or overwhelming for older adults. Twenty-three stakeholders mentioned that Medicare beneficiaries are often confused about Medicare, and this is more noticeable among new enrollees. With the onset of the pandemic, 22 of these organizations mentioned that they had to move to a virtual model in order to assist beneficiaries, especially at the beginning of the pandemic. However, older adults seeking advice/meetings have a strong preference for in-person meetings even during the pandemic. Given that the majority of the beneficiaries that these stakeholders serve may not have access to technology, it was difficult for some of them to smoothly transition to a virtual environment. With Medicare counseling moving to virtual or telephone methods, stakeholders discussed that many beneficiaries had difficulty utilizing these options in a variety of ways.

CONCLUSIONS

Findings from our interviews with stakeholders provided information regarding experiences providing Medicare counseling pre- and during-COVID-19 pandemic. Some of the barriers faced by older adults included a complex and overwhelming system, a strong preference for in-person meetings among beneficiaries, challenges with technology, and an increased risk of information overload and misinformation. While bias may exist within the study and sample, given that technology-savvy beneficiaries may not seek help from organizations our study participants work in, they show how the current Medicare system may impact vulnerable older adults who may need support with access to high-speed internet and digital literacy.

Variations in Medicare Advantage Switching Rates Among African American and Hispanic Medicare Beneficiaries With Alzheimer's Disease and Related Dementias, by Sex and Dual Eligibility

OBJECTIVES

The objective of this study was to identify rates of switching to Medicare Advantage (MA) among fee-for-service (FFS) Medicare beneficiaries with Alzheimer's disease and related dementias (ADRD) by race/ethnicity and whether these rates vary by sex and dual-eligibility status for Medicare and Medicaid.

METHODS

Data came from the Medicare Master Beneficiary Summary File from 2017 to 2018. The outcome of interest for this study was switching from FFS to MA during any month in 2018. The primary independent variable was race/ethnicity including non-Hispanic White, non-Hispanic African American, and Hispanic beneficiaries. Two interaction terms among race/ethnicity and dual eligibility, and race/ethnicity and sex were included. The model adjusted for age, year of ADRD diagnosis, the number of chronic/disabling conditions, total health care costs, and ZIP code fixed effects.

RESULTS

The study included 2,284,175 FFS Medicare beneficiaries with an ADRD diagnosis in 2017. Among dual-eligible beneficiaries, adjusted rates of switching were higher among African American (1.91 percentage points [p.p.], 95% confidence interval [CI]: 1.68-2.15) and Hispanic beneficiaries (1.36 p.p., 95% CI: 1.07-1.64) compared to non-Hispanic White beneficiaries. Among males, adjusted rates were higher among African American (3.28 p.p., 95% CI: 2.97-3.59) and Hispanic beneficiaries (2.14 p.p., 95% CI: 1.86-2.41) compared to non-Hispanic White beneficiaries.

DISCUSSION

Among persons with ADRD, African American and Hispanic beneficiaries are more likely than White beneficiaries to switch from FFS to MA. This finding underscores the need to monitor the quality and equity of access and care for these populations.