The health law requires the National Association of Insurance Commissioners to advise the administration about whether seniors would use fewer Medicare services -- and therefore, cost the government less money -- if the most popular Medigap plans were less generous.
"Everything we've looked at has shown that increasing cost-sharing does stop people from seeking medical care," said Bonnie Burns, a training and policy specialist at California Health Advocates who serves on an NAIC committee that has studied the issue for more than a year. "The problem is they stop using both necessary and unnecessary care."
In a draft letter approved unanimously by NAIC's senior issues task force and health insurance committee last week, the commissioners warn that limiting Medigap could backfire and raise Medicare costs when seniors don't receive the medical care they need. The letter, to Secretary of Health and Human Services Kathleen Sebelius, was approved during the association's annual meeting near Washington. The letter will be sent after a third committee is expected to approve it next week.
"Once the letter has cleared the senior issues task force, it's probably a done deal," said Guenther Ruch, a former administrator of the Wisconsin insurance department who, until March, chaired the Medigap subgroup that prepared the letter.
About 9 million Medicare beneficiaries - or one out of five - bought a Medigap policy in 2010, to cover a portion of medical expenses not covered by Medicare. And two-thirds of them purchased the most comprehensive plans that offer "first dollar" coverage, which protects them from paying almost anything out of pocket.
The Obama administration and congressional leaders are considering similar proposals as part of their effort to avoid automatic spending cuts and tax increases in the "fiscal cliff" negotiations. The Congressional Budget Office has estimated that cost-sharing changes could save the Medicare program as much as $53 billion over 10 years.
Medigap policies are popular with seniors because Medicare does not cap out-of-pocket expenses. The policies are not cheap -- the average premium nationwide was $178 a month in 2010 -- but they protect subscribers from unexpected high medical bills. The C and F Medigap plans cover nearly all the out-of-pocket costs that beneficiaries would usually pay. Two-thirds of people who buy Medigap plans have incomes below $40,000 a year - about the same income levels for all Medicare beneficiaries.
"People are buying Medigap because they need the medical treatment," said Dotti Outland, director of regulatory affairs for UnitedHealthcare and a member of the Medigap subgroup. "And they are paying something out of their pocket now. They are paying premiums."
Advocates of increased cost-sharing point to studies showing that seniors with Medigap coverage tend to use more Medicare services than those without it, and they probably get unneeded care, a large share of which the government pays.
The insurance commissioners were supposed to recommend specific cost-sharing changes for these Medigap plans with first-dollar coverage to reduce Medicare spending for unnecessary medical treatment and, as the law says, "encourage the use of appropriate physicians' services." The law requires their recommendations to be based on peer-reviewed studies or current successful managed-care practices.
But after a year and a half of research and discussion, they came up empty-handed.
"None of the studies provided a basis for the design of nominal cost sharing that would encourage the use of appropriate physicians' services," the letter says. "Many of the studies caution that added cost sharing would result in delayed treatments that could increase Medicare program costs later (e.g., increased expenditures for emergency room visits and hospitalizations) and result in adverse health outcomes for vulnerable populations (i.e., elderly, chronically ill and low-income)."
The letter acknowledges that Sebelius might disagree with the NAIC and seek cost-sharing changes regardless.
"If that is your decision, please know that the NAIC stands ready to continue its regulatory role in developing Medicare supplement standards."
Nevada state insurance commissioner Scott Kipper, who chairs the senior issues task force, said the letter conveys "without any doubt that we want to continue to be the organization that HHS turns to on Medigap."
Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.
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