Medicare factors in no cost immunizations for Medicare Advantage plan reimbursements.
It is always a tricky proposition to figure exactly how much Medicare will pay the Medicare Advantage (MA) Plan for each enrolled member. Even though the Medicare beneficiary may pay a zero premium for the Medicare Advantage plan they have selected, the federal government pays the insurance company that administers the Medicare Advantage plan every month just like paying an insurance premium.
How much do Medicare patients spend?
The Centers for Medicare and Medicaid (CMS) start by calculating how much folks spend on Medicare for their Part A (hospital) and Part B (medical) cost sharing each month. These numbers reflect the national actuarial amounts and are used as reference only. Tables and statistic gleaned from the CMS 2013 Call Letter Data Capitation Rates [download id=”40″]
| Monthly Actuarial Value of Medicare | |||
| Cost Sharing Comparison | |||
| per Medicare beneficiary in U.S. – Non ESRD | |||
|
2012 |
2013 |
Change |
|
| Part A |
$40.92 |
$40.99 |
0.20% |
| Part B1 |
$100.20 |
$103.95 |
3.70% |
| Total |
$141.12 |
$144.94 |
2.70% |
| 1. Includes outpatient psychiatric charges. | |||
How much does Medicare spend per person?
They then look at how much Medicare spends on each enrolled person with Original Medicare or traditional Fee-For-Service (FFS). This number is represented by the United States Per Capita Cost estimate (USPCC). From the CMS 2013 Call Letter Data and Capitation Rates:
The Affordable Care Act of 2010 requires the Medicare Advantage benchmark amounts be tied to a percentage of the county FFS amounts. There will be a transition to the percentage of FFS over a number of years. Table 2 below provides the increase in the FFS USPCC which will be used for the county FFS portion of the benchmark.
| Increase in the FFS USPCC Growth Percentage | |
|
Aged + Disabled |
|
| Current projected 2013 |
$767.99 |
| Prior projected 2012 |
$743.54 |
| Percent increase |
3.29% |
|
|
|
All these figures represent a national statistical amount spent on each person enrolled in Medicare. It’s also interesting to see how the national average of per capita Medicare expenses have risen over the years and the future projections as estimated by the Centers for Medicare and Medicaid.
| Historical and future Comparison of | |
| Current Estimates of the USPCC – non-ESRD | |
|
Part A & B |
|
|
Year |
Current Estimate |
|
2003 |
$545.14 |
|
2004 |
$587.77 |
|
2005 |
$628.05 |
|
2006 |
$659.05 |
|
2007 |
$659.41 |
|
2008 |
$689.28 |
|
2009 |
$726.59 |
|
2010 |
$766.79 |
|
2011 |
$793.78 |
|
2012 |
$807.62 |
|
2013 |
$789.26 |
|
2014 |
$811.34 |
|
2015 |
$825.28 |
California County MA reimbursements
CMS gathers this information and breaks it down by county and runs it through a complicated weighted formula to determine a capitation rate by county. Another significant consideration regarding how much a Medicare Advantage Plan will be paid is the plans Star rating. The Star rating is based member surveys and healthcare data of the MA plans past performance. A five star rating is the highest and qualifies plans for highest monthly reimbursement rate from CMS. Data pulled from CMS Statutory Benchmark Data 2013 Spreadsheet which includes all counties in U.S. [download id=”41″]
| California County Rate 2013 ACA RATES | |||
| County |
5 Stars |
4 Stars |
3 Stars |
| ALAMEDA |
$935.85 |
$926.81 |
$917.77 |
| ALPINE |
$1,195.97 |
$1,184.53 |
$1,173.08 |
| AMADOR |
$838.46 |
$830.72 |
$822.99 |
| BUTTE |
$809.88 |
$802.68 |
$795.48 |
| CALAVERAS |
$910.41 |
$901.74 |
$893.07 |
| COLUSA |
$803.90 |
$796.37 |
$788.84 |
| CONTRA COSTA |
$989.07 |
$979.51 |
$969.96 |
| DEL NORTE |
$797.47 |
$790.32 |
$783.17 |
| EL DORADO |
$876.60 |
$860.91 |
$845.22 |
| FRESNO |
$883.64 |
$867.89 |
$852.14 |
| GLENN |
$795.67 |
$788.35 |
$781.04 |
| HUMBOLDT |
$781.92 |
$775.19 |
$768.47 |
| IMPERIAL |
$768.42 |
$761.59 |
$754.76 |
| INYO |
$843.71 |
$835.27 |
$826.84 |
| KERN |
$839.77 |
$831.77 |
$823.77 |
| KINGS |
$789.27 |
$782.02 |
$774.76 |
| LAKE |
$948.18 |
$939.02 |
$929.86 |
| LASSEN |
$825.33 |
$817.08 |
$808.82 |
| LOS ANGELES |
$948.68 |
$939.44 |
$930.20 |
| MADERA |
$879.85 |
$864.77 |
$849.70 |
| MARIN |
$881.80 |
$873.21 |
$864.61 |
| MARIPOSA |
$848.87 |
$840.79 |
$832.70 |
| MENDOCINO |
$801.82 |
$794.69 |
$787.57 |
| MERCED |
$780.39 |
$773.45 |
$766.52 |
| MODOC |
$840.39 |
$832.65 |
$824.91 |
| MONO |
$928.42 |
$919.45 |
$910.47 |
| MONTEREY |
$880.92 |
$872.40 |
$863.89 |
| NAPA |
$961.18 |
$951.90 |
$942.62 |
| NEVADA |
$812.82 |
$805.60 |
$798.37 |
| ORANGE |
$899.06 |
$890.30 |
$881.54 |
| PLACER |
$886.17 |
$870.98 |
$855.79 |
| PLUMAS |
$903.07 |
$894.41 |
$885.75 |
| RIVERSIDE |
$900.90 |
$892.20 |
$883.50 |
| SACRAMENTO |
$860.40 |
$845.65 |
$830.89 |
| SAN BENITO |
$883.64 |
$875.22 |
$866.81 |
| SAN BERNARDINO |
$889.56 |
$880.96 |
$872.37 |
| SAN DIEGO |
$844.23 |
$836.19 |
$828.15 |
| SAN FRANCISCO |
$912.14 |
$895.71 |
$879.29 |
| SAN JOAQUIN |
$864.92 |
$849.67 |
$834.41 |
| SAN LUIS OBISPO |
$785.84 |
$778.85 |
$771.86 |
| SAN MATEO |
$828.43 |
$820.45 |
$812.46 |
| SANTA BARBARA |
$828.82 |
$821.39 |
$813.96 |
| SANTA CLARA |
$906.32 |
$889.84 |
$873.36 |
| SANTA CRUZ |
$825.97 |
$818.10 |
$810.23 |
| SHASTA |
$973.82 |
$964.49 |
$955.15 |
| SIERRA |
$851.32 |
$843.48 |
$835.64 |
| SISKIYOU |
$801.79 |
$794.51 |
$787.23 |
| SOLANO |
$893.37 |
$884.86 |
$876.35 |
| SONOMA |
$877.55 |
$861.59 |
$845.64 |
| STANISLAUS |
$933.79 |
$916.87 |
$899.94 |
| SUTTER |
$771.73 |
$765.09 |
$758.45 |
| TEHAMA |
$815.88 |
$808.11 |
$800.34 |
| TRINITY |
$883.67 |
$875.26 |
$866.84 |
| TULARE |
$837.27 |
$829.55 |
$821.83 |
| TUOLUMNE |
$784.47 |
$777.50 |
$770.53 |
| VENTURA |
$893.94 |
$885.36 |
$876.79 |
| YOLO |
$867.60 |
$852.39 |
$837.19 |
| YUBA |
$819.95 |
$812.49 |
$805.03 |
A Medicare beneficiary enrolled in a regular Medicare Advantage plan in Sacramento County with a three star rating will have the CMS pay the insurance company $830.89 per month or $9,970.68 per year as an insurance premium on their behalf.
Medicare pays more to MA plans with higher benefits for care
The county capitation rate is one of the items insurance companies look at when they are deciding to offer a Medicare Advantage Plan for a particular county. The monthly capitation rate is what they expect to be reimbursed by CMS for each Medicare beneficiary enrolled in one of their plans. This is a highly simplified overview that doesn’t take into account reimbursements for plan members that may have End Stage Renal Disease (ESRD), Program of All-inclusive Care for the Elderly (PACE), or Special Needs Plan (SNP) all of which have higher reimbursement rates. Plan reimbursements are further broken down by half star ratings that I didn’t include in the above table.
A Medicare Advantage Plan needs to be what CMS calls actuarially equivalent to or better than what a Medicare beneficiary would receive in Original Medicare. In other words, the average member of a Medicare Advantage plan should not be expected to spend any more for their healthcare in a MA plan than if they had stayed in Original Medicare.
Part D Plan Reimbursement
The Part D Prescription drug plan national average monthly bid amount for 2013 is $79.64. There are several variables that determine how much Medicare will actually reimburse a statewide Part D prescription drug plan from the structure of the plan to income related adjustments. Suffice it to say, on average, the federal government is paying the prescription drug plans a little over $79 per month per individual enrolled. A further complication is that many Medicare Advantage plans also include the Part D prescription coverage, MA-PD. From CMS Part D and MA Benchmarks 2013 announcement. [download id=”42″]