Individuals with Medicare have the choice of receiving their Medicare advantages by way of the standard Medicare program administered by the federal authorities or by way of a non-public Medicare Benefit plan, similar to an HMO or PPO. In Medicare Benefit, the federal authorities contracts with personal insurers to supply Medicare advantages to enrollees. Medicare pays insurers a set quantity per enrollee monthly, which varies relying on the county by which the plan is situated, the well being standing of the plan’s enrollees, and the plan’s estimated prices of masking Medicare Half A and Half B companies.
The plans use these funds to pay for Medicare-covered companies, and generally, additionally pay for supplemental advantages, decreased price sharing and decrease out-of-pocket limits, that are engaging to enrollees. Plans are in a position to provide these further advantages, typically with out charging a further premium for Half D prescribed drugs or supplemental advantages, as a result of they obtain a further $2,329 per enrollee above their estimated prices of offering Medicare-covered companies. This portion of plan funds, additionally known as the rebate, has elevated considerably within the final a number of years, greater than doubling since 2018. On the similar time, Medicare Benefit plans can use price administration instruments, similar to prior authorization necessities, which may impose limitations to receiving care, and restricted networks of suppliers, which may prohibit beneficiary selection of physicians and hospitals. Greater than half (56%) of Medicare Benefit beneficiaries are enrolled in HMO plans that usually don’t cowl out-of-network companies.
This temporary supplies details about Medicare Benefit plans in 2024, together with premiums, out-of-pocket limits, supplemental advantages, and prior authorization, in addition to tendencies over time. A companion evaluation examines tendencies in Medicare Benefit enrollment.
Whereas information on Medicare Benefit plan availability, enrollment and plan choices is strong, the identical can’t be stated about service utilization (particularly for supplemental advantages) and out-of-pocket spending patterns (although a few of this information is beginning to be collected), which might permit evaluation of how properly this system is assembly its targets when it comes to worth and high quality and assist Medicare beneficiaries evaluate protection choices. As enrollment in Medicare Benefit and federal funds to non-public plans proceed to develop, larger transparency and extra complete info will grow to be more and more related for folks with Medicare program oversight.
Highlights for 2024:
In 2024, three quarters (75%) of enrollees in particular person Medicare Benefit plans with prescription drug protection pay no premium apart from the Medicare Half B premium, which is a giant promoting level for beneficiaries, significantly these residing on modest incomes and financial savings.
Most Medicare Benefit enrollees are in plans that provide supplemental advantages not lined by conventional Medicare, similar to imaginative and prescient, listening to and dental. From 2023 to 2024, Medicare Benefit enrollees general didn’t expertise a major loss in advantages regardless of considerations that modifications in Medicare Benefit fee would result in a drastic discount in advantages or enhance in premiums, although there have been small declines within the share of enrollees in plans with entry to some advantages from 2023 to 2024.
Practically all Medicare Benefit enrollees (99%) are in plans that require prior authorization for some companies, which is usually not utilized in conventional Medicare. Prior authorization is most frequently required for comparatively costly companies, similar to expert nursing facility stays (99%), Half B medication (98%), inpatient hospital stays (acute: 98%; psychiatric: 93%) and outpatient psychiatric companies (82%) and is never required for preventive companies (6%).
In 2024, three quarters of Medicare Benefit enrollees (75%) are in plans with no supplemental premium (apart from the Half B premium)
In 2024, most individuals (75%) enrolled in particular person Medicare Benefit plans with prescription drug protection (MA-PDs) pay no premium apart from the Medicare Half B premium ($174.70 in 2024) (Determine 1). The MA-PD premium consists of each the price of Medicare-covered Half A and Half B advantages and Half D prescription drug protection. In 2024, 97% of Medicare Benefit enrollees in particular person plans open for common enrollment are in plans that provide prescription drug protection.
Altogether, together with those that don’t pay a premium, the common enrollment-weighted premium in 2024 is $14 monthly, and averages $9 monthly for simply the Half D portion of lined advantages, considerably decrease than the common premium of $43 for stand-alone prescription drug plans (PDP) in 2024. Larger common PDP premiums in comparison with the MA-PD drug portion of premiums is due partly to the flexibility of MA-PD sponsors to make use of rebate {dollars} from Medicare funds to decrease their Half D premiums. When a plan’s estimated prices for Medicare-covered companies are beneath the utmost quantity the federal authorities can pay personal plans in an space (often called the benchmark), the plan retains a portion of the distinction, often called the “rebate”. In response to the Medicare Fee Advisory Fee (MedPAC), rebates common over $2,300 per enrollee in 2024.
For the remaining 25% of beneficiaries who’re in plans with a MA-PD premium (5.0 million), the common premium is $56 monthly, and averages $36 for the Half D portion of lined advantages.
Premiums paid by Medicare Benefit enrollees have declined since 2015.
Common MA-PD premiums have declined from $36 monthly in 2015 to $14 monthly in 2024. Common MA-PD premiums have declined markedly for native PPOs, declining from $65 monthly in 2015 to $16 monthly in 2024. Premiums for HMOs have additionally declined steadily from $28 monthly in 2015 to $12 monthly in 2024. Solely regional PPOs, which signify a really small and declining share of enrollment, have seen a rise in plan premiums over this time from $36 monthly in 2015 to $55 monthly in 2024. Practically 6 in 10 Medicare Benefit enrollees are in HMOs (56%), 43% are in native PPOs, and 1% are in regional PPOs in 2024. The discount for almost all plans is pushed partly by the decline in premiums for native PPOs and HMOs, that account for a rising share of enrollment over this time interval, in addition to the rise in rebates paid by Medicare to those plans.
Since 2015, a rising share of plans estimate that their price of offering Medicare Half A and Half B companies (the “bid”) is beneath the utmost quantity that CMS can pay within the space the place the plan operates (the “benchmark”). The distinction between bids and benchmarks allows plans to supply protection that usually consists of additional advantages with out charging a further premium. As plan bids have declined, the rebate portion of plan funds has elevated, and plans are allocating a few of these rebate {dollars} to decrease the half D portion of the MA-PD premium. In response to MedPAC, rebates have elevated from a mean of about $900 per enrollee in 2015 to over $2,300 per enrollee in 2024. This development contributes to larger availability of zero-premium plans, which brings down common premiums.
The typical out-of-pocket restrict for Medicare Benefit enrollees is $4,882 for in-network companies and $8,707 for each in-network and out-of-network companies (PPOs).
Since 2011, federal regulation has required Medicare Benefit plans to supply an out-of-pocket restrict for companies lined beneath Components A and B. In distinction, conventional Medicare doesn’t have an out-of-pocket restrict for lined companies.
In 2024, the out-of-pocket restrict for Medicare Benefit plans might not exceed $8,850 for in-network companies and $13,300 for in-network and out-of-network companies mixed. These out-of-pocket limits apply to Half A and B companies solely, and don’t apply to Half D spending. Resulting from a provision within the Inflation Discount Act, there’s a cap in Half D spending of round $3,300 in 2024, and in 2025, Medicare beneficiaries can pay not more than $2,000 out of pocket for prescribed drugs lined beneath Half D.
HMOs typically solely cowl companies supplied by in-network suppliers so usually do not need a restrict for out-of-network companies. Nevertheless, about 5 million Medicare Benefit enrollees are in HMOs which can be Level-of-Service plans (HMOPOS), which permit out-of-network look after sure companies, although they usually price greater than companies acquired in-network. PPOs additionally cowl companies delivered by out-of-network suppliers however cost enrollees larger price sharing for this care. The dimensions of Medicare Benefit supplier networks for physicians and hospitals range vastly each throughout counties and throughout plans in the identical county.
In 2024, the enrollment-weighted common for out-of-pocket limits for Medicare Benefit enrollees is $4,882 for in-network companies and $8,707 for in-network and out-of-network companies mixed. For enrollees in HMOs, the common out-of-pocket (in-network) restrict is $3,965 (Determine 3). Enrollees in HMOs are typically liable for 100% of prices incurred for out-of-network care. For native and regional PPO enrollees, the common out-of-pocket restrict for each in-network and out-of-network companies is $8,634, and $10,728, respectively.
The typical out-of-pocket restrict for in-network companies has typically trended down from 2017 ($5,297), although elevated barely from $4,835 in 2023 to 4,882 to 2024. The typical mixed in- and out-of-network restrict for PPOs barely elevated from $8,659 in 2023 to $8,707 in 2024.
Most Medicare Benefit enrollees, together with enrollees in particular wants plans (SNPs), are in plans that provide some advantages not lined by conventional Medicare in 2024
Nearly all enrollees in particular person Medicare Benefit plans (these typically accessible to Medicare beneficiaries) are in plans that provide primarily well being associated supplemental advantages together with eye exams and/or glasses (greater than 99%), dental care (98%) listening to exams and/or aids (96%), and a health profit (95%) (Determine 4). Equally, most enrollees in SNPs are in plans that provide these advantages. Nevertheless, advantages similar to Half B drug rebate are much less frequent for enrollees in each particular person plans (12%) and SNPs (7%). This evaluation excludes employer-group well being plans as a result of employer plans don’t submit bids, and accessible information on supplemental advantages is probably not reflective of what employer plans truly provide.
Although these advantages are extensively accessible, the scope of particular companies varies. For instance, a dental profit might embody preventive companies solely, similar to cleanings or x-rays, or extra complete protection, similar to crowns or dentures. Plans additionally range when it comes to price sharing for numerous companies and limits on the variety of companies lined per yr, many impose an annual greenback cap on the quantity the plan can pay towards lined service, and a few have networks of dental suppliers beneficiaries should select from.
Enrollees in SNPs have larger entry than different Medicare Benefit enrollees to transportation (91% vs 36%), meal advantages (85% vs 74%), rest room security gadgets (49% vs 31%), and in-home help companies (23% vs 9%). Nevertheless, as famous above, it’s not identified what share of enrollees have used these advantages as a result of information usually are not but accessible.
As of 2020, Medicare Benefit plans have been allowed to incorporate telehealth advantages as a part of the essential Medicare Half A and B profit package deal – past what was allowed beneath conventional Medicare previous to the general public well being emergency, and was prolonged to December 2024. Due to this fact, these advantages usually are not included within the determine above as a result of their price is just not lined by both rebates or supplemental premiums. Medicare Benefit plans may additionally provide supplemental telehealth advantages by way of distant entry applied sciences and/or telemonitoring companies, which can be utilized for these companies that don’t meet the necessities for protection beneath conventional Medicare or the necessities for extra telehealth advantages (such because the requirement of being lined by Medicare Half B when supplied in-person). The vast majority of enrollees in each particular person plans and SNPs are in plans that provide distant entry applied sciences (72% and 78%, respectively), however simply 4% of enrollees in particular person plans and 1% of enrollees in SNPs have entry to telemonitoring companies.
Practically all Medicare Benefit enrollees are in plans that provide imaginative and prescient, dental, and listening to advantages, just like 2023, with the share of enrollees in plans that provide many advantages growing considerably since 2015.
In 2024, there have been modest modifications to the share of enrollees in plans that provide particular advantages in comparison with 2023. Comparable shares of enrollees in particular person plans are in plans that provide eye exams and/or eyeglasses (100% in 2023 and 2024), dental advantages (98% in 2023 and 2024), and listening to exams and/or aids (99% in 2023 vs 96% in 2024) (Determine 5). Smaller shares of enrollees are in plans that provide transportation advantages (44% in 2023 vs 36% in 2024) whereas a bigger share of enrollees is in plans that provide rest room security gadgets (10% in 2023 vs 31% in 2024).
For these in Particular Wants Plans, comparable shares of enrollees are in plans that provide eye exams and/or eyeglasses (97% in 2023 vs 98% in 2024), dental advantages (95% in 2023 and 2024), and listening to exams and/or aids (92% in 2023 vs 93% in 2024). Bigger shares of SNP enrollees are in plans that provide over-the-counter advantages (84% in 2023 vs 96% in 2024) and toilet security gadgets (15% in 2023 vs 49% in 2024).
General, Medicare Benefit enrollees haven’t skilled a major loss in advantages regardless of considerations that modifications in Medicare Benefit fee would result in a drastic discount in advantages or enhance in premiums. Whereas the share enrolled in plans that provide advantages seems to have remained largely steady from 2023 to 2024 and has elevated considerably from 2015 for a lot of advantages, this evaluation doesn’t account for any modifications to the design of advantages, which might be much less strong, even when the advantages are nonetheless provided by the plan, similar to restrictions on eligibility for these advantages, narrower networks of suppliers or much less complete protection.
Enrollees in SNPs usually tend to be in plans that provide Particular Supplemental Advantages for the Chronically In poor health (SSBCI) than different Medicare Benefit enrollees.
Starting in 2020, Medicare Benefit plans have additionally been in a position to provide supplemental advantages that aren’t primarily well being associated for chronically sick beneficiaries, often called Particular Supplemental Advantages for the Chronically In poor health (SSBCI). As well as, Medicare Benefit plans collaborating within the Worth-Primarily based Insurance coverage Design Mannequin may additionally provide these non-primarily well being associated supplemental advantages to their enrollees, however can use totally different eligibility standards than required for SSBCI, together with providing them based mostly on an enrollee’s socioeconomic standing (e.g., LIS eligibility) or whether or not the enrollee lives in an underserved space.
The overwhelming majority of particular person plan enrollees and about half of SNP Medicare Benefit enrollees are in plans that don’t provide these advantages. Nevertheless, whereas the share in plans which can be provided these advantages varies extensively, this typically interprets to an analogous variety of enrollees. For instance, the share of Medicare Benefit enrollees who’re provided SSBCI advantages in 2024 is highest for meals and produce – 15% for particular person plans or about 3.1 million enrollees, whereas 49% of SNP enrollees are provided these advantages, or about 3.3 million enrollees (Determine 6).
The opposite SSBCI advantages which can be mostly provided are common helps for residing (e.g., housing, utilities) (10% in particular person plans and 43% for SNPs) and transportation for non-medical wants (9% for particular person plans and 29% for SNPs). The same share of enrollees in particular person plans (5%) are provided pest management, a social wants profit (e.g., neighborhood applications), and meals past a restricted foundation although the share of enrollees in SNPs who’ve entry to those advantages is larger (17%, 15%, and 12%, respectively). Smaller shares of enrollees are in plans that provide indoor air high quality gear and companies (e.g., air con models) (4% in particular person plans and 12% for SNPs), companies supporting self-direction (e.g., energy of legal professional for well being companies, monetary literacy courses) (3% in particular person plans and 12% for SNPs), complementary therapies (these provided alongside conventional medical remedy) (3% in particular person plans and 12% for SNPs) and structural residence modifications (0.02% for particular person plans and 1% for SNPs).
Along with the ten initially enumerated examples of SSBCI supplied by CMS, plans are additionally in a position to provide “different” additional advantages specified by the plan, together with pet care/service animal provides (5% in particular person plans and 18% for SNPs) and private care (2% in particular person plans and 9% for SNPs)(Determine 6). About 2% of SNP enrollees are in plans that provide roadside and journey help and residential cleansing (lower than 1% in particular person plans), and fewer than 1% are in SNPs or particular person plans that provide hairstyling and wonder care (information not proven), although this isn’t an exhaustive listing of further advantages plans might provide.
Whereas the share of enrollees with plans that provide some SSBCI advantages has elevated since 2021, similar to meals and produce, progress for different advantages has been a lot slower.
Although the share of SNP enrollees in plans with meals and produce advantages, common helps for residing advantages, and transportation for non-medical wants has grown significantly since 2021, the share of enrollment in plans for different SSBCI advantages has grown far more slowly, significantly for enrollees in particular person plans (Determine 7). For instance, the share of SNP Medicare Benefit enrollees with meals and produce advantages in SNPs has greater than doubled from 21% in 2021 to 49% in 2024, whereas for particular person plans, the share of enrollees with these advantages has additionally doubled, however solely from 7% to fifteen%. For common helps for residing advantages, the share of SNP Medicare Benefit enrollees with these advantages has greater than quadrupled from 10% to 43%, whereas for particular person plans, the share has greater than tripled, however solely from 3% to 10%.
Like for different supplemental advantages, the scope of companies for SSBCI advantages varies. For instance, many plans provide a specified greenback quantity that enrollees can use towards a wide range of advantages, similar to meals and produce, utility payments, hire help, and transportation for non-medical wants, amongst others. This greenback quantity is commonly loaded onto a flex card or spending card that can be utilized at collaborating shops and retailers, which may range relying on the seller administering the profit. Relying on the plan, this can be a month-to-month allowance that expires on the finish of every month or rolls over month to month till the top of the yr, when any unused quantity expires.
Practically all Medicare Benefit enrollees are in plans that require prior authorization for a lot of higher-cost companies
Medicare Benefit plans can require enrollees to obtain prior authorization earlier than a service can be lined, and almost all Medicare Benefit enrollees (99%) are in plans that require prior authorization for some companies in 2024 (Determine 8). Prior authorization is most frequently required for comparatively costly companies, similar to expert nursing facility stays (99%), Half B medication (98%), inpatient hospital stays (acute: 98%; psychiatric: 93%) and outpatient psychiatric companies (82%) and is never required for preventive companies (6%). Prior authorization can be required for almost all of enrollees for some additional advantages (in plans that provide these advantages), together with complete dental companies, and listening to and eye exams. The variety of enrollees in plans that require prior authorization for a number of companies stayed across the similar from 2023 to 2024. In distinction to Medicare Benefit plans, conventional Medicare doesn’t typically require prior authorization for companies and doesn’t require step remedy for Half B medication.
Meredith Freed, Jeannie Fuglesten Biniek, and Tricia Neuman are with KFF. Anthony Damico is an impartial guide.
Strategies
This evaluation makes use of information from the Facilities for Medicare & Medicaid Companies (CMS) Medicare Benefit Enrollment, Profit and Panorama recordsdata for the respective yr.
In earlier years, KFF had used the time period Medicare Benefit to confer with Medicare Benefit plans in addition to different varieties of personal plans, together with price plans, PACE plans, and HCPPs. Nevertheless, since 2022, KFF has excluded price plans, PACE plans, HCPPs along with MMPs. We exclude these different plans as some might have totally different enrollment necessities than Medicare Benefit plans (e.g., could also be accessible to beneficiaries with solely Half B protection) and in some instances, could also be paid otherwise than Medicare Benefit plans. These exclusions are mirrored in each present information in addition to information displayed trending again to 2010.
