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PubMed1993

Medicare program; revised designation of states in which Medicare SELECT insurance policies may be issued--HCFA. Notice.

Section 4358(c) of the Omnibus Budget Reconciliation Act of 1990, provides for the designation of 15 States in which Medicare supplemental insurance policies (commonly referred to as "Medigap" policies) may be approved for issuance as Medicare SELECT policies during the period January 1, 1992 through December 31, 1994. This notice announces two revisions in the list of States designated under this authority.

Centers for Medicare and Medicaid Services, U.S.↗
PubMedDate not supplied

Trends in Medicare supplemental insurance and prescription drug coverage, 1996-1999.

Medicare Current Beneficiary Survey (MCBS) Access to Care data indicate a five-percentage-point decline in the share of Medicare beneficiaries having Medigap coverage between 1996 and 1999; this was matched by a commensurate rise in the share enrolled in Medicare HMOs, contributing to an increase in the percentage with drug coverage. During this period, high-income beneficiaries, and to a lesser extent healthier and rural beneficiaries, experienced greater net declines in supplemental coverage and smaller relative gains in drug coverage, compared with others. By fall 1999, 38 percent of beneficiaries lacked drug coverage, based on point-in-time estimates. This is much higher than previous estimates that measured beneficiaries' drug coverage at any time during the calendar year. Many of Medicare's most vulnerable beneficiaries--rural (50 percent), near-poor (44 percent), and oldest old (45 percent)--were most likely to lack drug coverage in the fall of 1999.

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PubMed1999

Out-of-pocket health spending by poor and near-poor elderly Medicare beneficiaries.

OBJECTIVE: To estimate out-of-pocket health care spending by lower-income Medicare beneficiaries, and to examine spending variations between those who receive Medicaid assistance and those who do not receive such aid. DATA SOURCES AND COLLECTION: 1993 Medicare Current Beneficiary Survey (MCBS) Cost and Use files, supplemented with data from the Bureau of the Census (Current Population Survey); the Congressional Budget Office; the Health Care Financing Administration, Office of the Actuary (National Health Accounts); and the Social Security Administration. STUDY DESIGN: We analyzed out-of-pocket spending through a Medicare Benefits Simulation model, which projects out-of-pocket health care spending from the 1993 MCBS to 1997. Out-of-pocket health care spending is defined to include Medicare deductibles and coinsurance; premiums for private insurance, Medicare Part B, and Medicare HMOs; payments for non-covered goods and services; and balance billing by physicians. It excludes the costs of home care and nursing facility services, as well as indirect tax payments toward health care financing. PRINCIPAL FINDINGS: Almost 60 percent of beneficiaries with incomes below the poverty level did not receive Medicaid assistance in 1997. We estimate that these beneficiaries spent, on average, about half their income out-of-pocket for health care, whether they were enrolled in a Medicare HMO or in the traditional fee-for-service program. The 75 percent of beneficiaries with incomes between 100 and 125 percent of the poverty level who were not enrolled in Medicaid spent an estimated 30 percent of their income out-of-pocket on health care if they were in the traditional program and about 23 percent of their income if they were enrolled in a Medicare HMO. Average out-of-pocket spending among fee-for-service beneficiaries varied depending on whether beneficiaries had Medigap policies, employer-provided supplemental insurance, or no supplemental coverage. Those without supplemental coverage spent more on health care goods and services, but spent less than the other groups on prescription drugs and dental care-services not covered by Medicare. CONCLUSIONS: While Medicaid provides substantial protection for some lower-income Medicare beneficiaries, out-of-pocket health care spending continues to be a substantial burden for most of this population. Medicare reform discussions that focus on shifting more costs to beneficiaries should take into account the dramatic costs of health care already faced by this vulnerable population.

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PubMedDate not supplied

Prescription drugs and the elderly: issues and options.

This paper examines the elderly's need for prescription drug insurance, the extent and depth of current coverage supplementary to Medicare, the characteristics of those who have coverage and those who do not, and the problem of adverse selection in individual insurance for prescription drugs. It also discusses the issues that must be resolved in choosing the direction public policy should take if more of the elderly are to be covered and examines the advantages and disadvantages of four illustrative public policy options, ranging from small expansions of Medicaid benefits through "Medigap" regulation to Medicare coverage for all elderly.

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PubMed2004

Increasing medication access to transplant recipients.

Transplant recipients require numerous medications to maintain graft survival and health. Post-transplant medication therapy costs greater than 12000 dollars annually, and the cost of therapy is expected to increase. Although medication costs continue to rise, a substantial portion of Americans lack adequate health insurance or do not have any insurance coverage. To facilitate health, it is imperative that health care providers are familiar with programs that are available to increase prescribed medication access to transplant recipients. The purpose of this manuscript is to provide an overview of common programs available to increase transplant recipients' access to medications. In addition to discussing the consequences of medication non-compliance, this manuscript reviews Medicare, Medigap, Medicaid, Qualified Medicare Beneficiaries, and pharmaceutical manufacturers' medication assistance programs and its use to increase medication access to solid-organ transplant recipients.

Drug Prescriptions↗
PubMed2004

Insurance coverage of prescription drugs and the rural elderly.

CONTEXT: Rural impacts of a Medicare drug benefit will ultimately depend on the number of elderly who are currently without drug coverage, new demand by those currently without coverage, the nature of the new benefit relative to current benefits, and benefit design. PURPOSE: To enhance understanding of drug coverage among rural elderly Medicare beneficiaries and their expenditures for pharmaceuticals. METHODS: Estimates of the extent of coverage, expenditures, and sources of drugs were obtained using data are from the 1997 Medicare Current Beneficiary Survey and the Pharmacy Verification and Household Components of the 1996 Medical Expenditure Panel Survey. FINDINGS: Three-quarters of the urban elderly had some type of drug coverage in 1997 versus 59% of the elderly in rural areas. Urban residents were more likely to have obtained their drug coverage from an employer-sponsored supplemental plan, and rural residents were more likely to have self-purchased Medigap drug coverage. Expenditures and use of drugs by Medicare beneficiaries are greater for those with than without coverage, and differences are invariant with respect to geographic location. Coverage under self-purchased supplemental plans appears less generous than under employer-sponsored plans in both rural and urban areas. Rural and urban elderly are more than twice as likely to receive at least 1 prescribed medication through the mail than the general population. CONCLUSION: A well-designed Medicare drug benefit would be especially beneficial to the rural elderly because relatively more rural elderly currently lack coverage or have less generous coverage than urban beneficiaries. Mail-order distribution may help contain future program expenditures.

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PubMed1996

Medigap reform legislation of 1990: have the objectives been met?

The 1990 medigap reform legislation had multiple objectives: To simplify the insurance market in order to facilitate policy comparison, provide consumer choice, provide market stability, promote competition, and avoid adverse selection. Based on case study interviews with a cross-section of individuals and organizations, we report that most of these objectives have been achieved. Consumers of medigap plans are able to make more informed choices, largely because they can adequately compare policies based on standard benefits. Marketing abuses have apparently declined, as evidenced by a decrease in the number of consumer complaints. Finally, no major detrimental impact on the insurance industry was detected. Beneficiaries still face some confusion in this market, however, such as understanding the rating methodologies used to set premiums and how this may affect their choices. Confusion could increase with the growth of managed care options.

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PubMed2002

Medigap premiums and Medicare HMO enrollment.

OBJECTIVE: Markets for Medicare HMOs (health maintenance organizations) and supplemental Medicare coverage are often treated separately in existing literature. Yet because managed care plans and Medigap plans both cover services not covered by basic Medicare, these markets are clearly interrelated. We examine the extent to which Medigap premiums affect the likelihood of the elderly joining managed care plans. DATA SOURCES: The analysis is based on a sample of Medicare beneficiaries drawn from the 1996-1997 Community Tracking Study (CTS) Household Survey by the Center for Studying Health System Change. Respondents span 56 different CTS sites from 30 different states. Measures of premiums for privately-purchased Medigap policies were collected from a survey of large insurers serving this market. Data for individual, market, and HMO characteristics were collected from the CTS, InterStudy, and HCFA (Health Care Financing Administration). STUDY DESIGN: Our analysis uses a reduced-form logit model to estimate the probability of Medicare HMO participation as a function of Medigap premiums controlling for other market- and individual-level characteristics. The logit coefficients were then used to simulate changes in Medicare participation in response to changes in Medigap premiums. PRINCIPAL FINDINGS: We found that Medigap premiums vary considerably among the geographic markets included in our sample. Measures of premiums from different insurers and for different types of Medigap policies were generally highly correlated across markets. Our models consistently indicate a strong positive relationship between Medigap premiums and HMO participation. This result is robust across several specifications. Simulations suggest that a one standard deviation increase in Medigap premiums would increase HMO participation by more than 8 percentage points. CONCLUSIONS: This research provides strong evidence that Medigap premiums have a significant effect on seniors' participation in Medicare HMOs. Policy initiatives aimed at lowering Medigap premiums will likely discourage enrollment in Medicare HMOs, holding other factors constant. Although the Medigap premiums are just one factor affecting the future penetration rate of Medicare HMOs, they are an important driver of HMO enrollment and should be considered carefully when creating policy related to seniors' supplemental coverage. Similarly, our results imply that reforms to the Medicare HMO market would influence the demand for Medigap policies.

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PubMed2002

Who switches from Medigap to Medicare HMOs?

OBJECTIVE: To determine the factors affecting whether Medigap owners switch to Medicare managed care plans. DATA SOURCES: The primary data were the 1993-1996 Medicare Current Beneficiary Survey (MCBS) Cost and Use Files. These were supplemented by data available from the Centers for Medicare & Medicaid Services (CMS) website. STUDY DESIGN: Individuals on the MCBS files with Medigap coverage in the period 1993-1996 were included in the study. The person-year was the unit of analysis. We used multivariate logistic regression analysis to determine whether or not a Medigap owner switched to a Medicare-managed care plan during a particular year. Independent variables included measures of affordability, need for services, health insurance benefits, sociodemographics, and supply of managed care plans. PRINCIPAL FINDINGS: We did not detect strong evidence that beneficiaries in poorer health were more likely than others to switch from Medigap coverage to Medicare-managed care. In addition, higher Medigap premiums did not appear to induce beneficiaries to switch into managed care. CONCLUSIONS: We examined selection bias in joining managed care plans among the subset of Medicare beneficiaries who have Medigap policies. No strong evidence of selection bias was found in this population. We conclude that there was no evidence that the Medigap market is becoming prohibitively expensive as a result of unfavorable selection.

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PubMed2002

Stability and change in health insurance among older Mexican Americans: longitudinal evidence from the Hispanic established populations for epidemiologic study of the elderly.

OBJECTIVES: This study examined the association between health insurance coverage, medical care use, limitations in activities of daily living, and mortality among older Mexican-origin individuals. METHODS: We analyzed longitudinal data from the Hispanic Established Populations for Epidemiologic Study of the Elderly (H-EPESE). RESULTS: The uninsured tend to be younger, female, poor, and foreign born. They report fewer health care visits, are less likely to have a usual source of care, and more often receive care in Mexico. Conversely, those with private health insurance are economically better off and use more health care services. Over time, the data reveal substantial changes in type of insurance coverage. CONCLUSIONS: The data reveal serious vulnerabilities among older Mexican Americans that result from a lack of private Medigap supplemental coverage.

Activities of Daily Living↗
PubMed1997

Effects of supplemental coverage on use of services by Medicare enrollees.

This article estimates the extent to which private insurance supplements affect use of services by Medicare enrollees. Three types of supplements to Medicare's coverage are examined--Health Maintenance Organizations (HMOs), medigap (MGP) plans, and employment-based indemnity (EBI) plans. While each kind of supplement reduces cost sharing on Medicare-covered services, only HMOs do so without increasing enrollees' overall use of services. Use of services by HMO enrollees is about 4 percent lower than use by similar Medicare enrollees with no insurance supplement. By contrast, use of services by enrollees with MGP coverage is 28 percent higher, and use of services by enrollees with EBI plans is 17 percent higher.

Adolescent↗
PubMed1997

Effects of supplemental coverage on use of services by Medicare enrollees.

This article estimates the extent to which private insurance supplements affect use of services by Medicare enrollees. Three types of supplements to Medicare's coverage are examined--Health Maintenance Organizations (HMOs), medigap (MGP) plans, and employment-based indemnity (EBI) plans. While each kind of supplement reduces cost sharing on Medicare-covered services, only HMOs do so without increasing enrollees' overall use of services. Use of services by HMO enrollees is about 4 percent lower than use by similar Medicare enrollees with no insurance supplement. By contrast, use of services by enrollees with MGP coverage is 28 percent higher, and use of services by enrollees with EBI plans is 17 percent higher.

Adult↗
PubMed1992

Employer-sponsored postretirement health benefits: not your mother's medigap plan.

Using nationally representative data, we report the prevalence of retiree health insurance as a fringe benefit in private and public settings, and take an in-depth look at its content. We examine how it coordinates with Medicare to characterize the "total insurance" of beneficiaries who hold these supplements. Retiree health coverage is now widespread and typical benefits are far more generous than those found in medigap policies, the other major type of Medicare supplement. When a typical retiree plan is overlaid on Medicare, the resulting total insurance benefits are more generous than those held by either the working nonelderly or beneficiaries with a medigap supplement.

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PubMed1992

Multiple sources of Medicare supplementary insurance.

Estimates from the National Medical Expenditure Survey imply that in 1987 only two-thirds of elderly Medicare beneficiaries held the amount and type of insurance that is generally recommended to supplement Medicare, namely, 57.7% with private hospital/medical insurance from one source and 6.6% with only Medicaid. Of the remainder, 19.8% had more than one source of private insurance; slightly more than 1% had one source of extra-cash or disease-specific insurance as their only supplementary coverage; and 12.9% had no supplementary coverage at all. In addition, more than 500,000 Medicaid enrollees had purchased private insurance, despite the comprehensive coverage offered by Medicaid. Although the issue of multiple coverage has been dramatized by stories of poor, very elderly persons who have purchased numerous Medigap plans, beneficiaries who purchase coverage from more than one source are likely to be relatively young, more highly educated, and financially better off.

Age Factors↗
PubMed1992

Persistence in the use of pharmaceuticals by the elderly. Evidence from annual claims.

An analysis of four-and-a-half years of claims data from the Pennsylvania Pharmaceutical Assistance Contract for the Elderly (PACE) program shows a pronounced degree of persistence in annual prescription drug expense by individual enrollees from year to year, particularly among the heaviest users. There is evidence of eventual regression to the mean, but it takes a substantial length of time--far longer than observed for other types of health care used by the elderly. The study findings raise questions about the insurability of drug expenses in non-group Medigap policies.

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PubMed1992

Consumer information and biased selection in the demand for coverage supplementing Medicare.

This study examines how the relationship between health insurance knowledge and the health status of health insurance consumers influences their decisions to purchase insurance coverage. Data from the federal Medicare health insurance program for the elderly in the United States are used. The basic Medicare program provides a limited amount of coverage for health care services obtained from any provider in the private fee-for-service (FFS) market. Beneficiaries of this program may choose to supplement the basic coverage which they receive by two mechanisms: either they may purchase private insurance designed to fill some of the gaps left by the federal program ('Medigap' policies), thereby remaining in the FFS market and preserving their choice of provider, or they may enroll in health maintenance organizations (HMOs), thereby leaving the FFS market and agreeing to use only those providers affiliated with the HMO, and in return receiving broader coverage at little additional out-of-pocket cost. The study was made possible by a unique data set which combines measures of beneficiary knowledge of Medicare coverage with measures of perceived health status, socio-economic characteristics, and insurance coverage choices for a sample of Medicare beneficiaries who participated in an educational workshop about their insurance coverage options. These data were used to estimate a multinomial logistic model of the determinants of insurance choices, where the options included the two listed above and a basic Medicare option. The study explicitly recognizes the interaction between insurance information and health status in health plan choice. These results show that knowledge of coverage does have a differential impact on the decision to purchase health insurance depending on health status. With a high level of knowledge, sicker beneficiaries are less likely to have basic Medicare alone, compared with HMOs or Medigap policies, while healthier beneficiaries are less likely to be enrolled in HMOs, compared with Medigap policies. This finding has important implications for the use of health status measures to adjust capitated payment formulas when knowledgable consumers have the option to enroll in HMOs or remain in the FFS environment. In the absence of health status adjusters for the HMO capitation payments, high levels of coverage knowledge may exacerbate inherent selection bias among these coverage options by healthier and sicker consumers of health insurance.

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PubMed2000

The health plan choices of retirees under managed competition.

OBJECTIVE: To investigate the effect of price on the health insurance decisions of Medicare-eligible retirees in a managed competition setting. DATA SOURCE: The study is based on four years of administrative data from the University of California (UC) Retiree Health Benefits Program, which closely resembles the managed competition model upon which several leading Medicare reform proposals are based. STUDY DESIGN: A change in UC's premium contribution policy between 1993 and 1994 created a unique natural experiment for investigating the effect of price on retirees' health insurance decisions. This study consists of two related analyses. First, I estimate the effect of changes in out-of-pocket premiums between 1993 and 1994 on the decision to switch plans during open enrollment. Second, using data from 1993 to 1996, I examine the extent to which rising premiums for fee-for-service Medigap coverage increased HMO enrollment among Medicare-eligible UC retirees. PRINCIPLE FINDINGS: Price is a significant factor affecting the health plan decisions of Medicare-eligible UC retirees. However, these retirees are substantially less price sensitive than active UC employees and the non-elderly in other similar programs. This result is likely attributable to higher nonpecuniary switching costs facing older individuals. CONCLUSIONS: Although it is not clear exactly how price sensitive enrollees must be in order to generate price competition among health plans, the behavioral differences between retirees and active employees suggest that caution should be taken in extrapolating from research on the non-elderly to the Medicare program.

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