The significant differences in official long-term projections, including projections of the program’s unfunded liability, reflect the differences in agency assumptions, particularly about the likelihood of the continuation of current law. The Medicare Trustees and the Congressional Budget Office (CBO) are required to make projections under current law, which assumes, for example, that the large Medicare Part A payment reductions are sustainable and that the projected 29.4 percent reduction in Medicare physician payment will be implemented in 2012. The Office of the Actuary in the Centers for Medicare and Medicaid Services (CMS) makes projections based on the premise that key elements of current law are simply “unworkable.” See John D. Shatto and M. Kent Clemens, “Projected Medicare Expenditures Under an Illustrative Scenario with Alternative Payment Updates to Medicare Providers,” Centers for Medicare and Medicaid Services, Office of the Actuary, May 13, 2011, at https://www.cms.gov/ReportsTrustFunds/downloads/2010TRAlternativeScenario.pdf (September 19, 2011).
Annual Statistical Supplement, 2011
Beginning January 1, 2006, upon voluntary enrollment in either a stand-alone PDP or an integrated Medicare Advantage plan that offers Part D coverage in its benefit, subsidized prescription drug coverage. Most FDA-approved drugs and biologicals are covered. However, plans may set up formularies for their drug coverage, subject to certain statutory standards. (Drugs currently covered in Parts A and B remain covered there.) Part D coverage can consist of either standard coverage or an alternative design that provides the same actuarial value. (For an additional premium, plans may also offer supplemental coverage exceeding the value of basic coverage.) Standard Part D coverage is defined for 2006 as having a $250 deductible, with 25 percent coinsurance (or other actuarially equivalent amounts) for drug costs above the deductible and below the initial coverage limit of $2,250. The beneficiary is then responsible for all costs until the $3,600 out-of-pocket limit (which is equivalent to total drug costs of $5,100) is reached. For higher costs, there is catastrophic coverage; it requires enrollees to pay the greater of 5 percent coinsurance or a small copay ($2 for generic or preferred multisource brand and $5 for other drugs). After 2006, these benefit parameters are indexed to the growth in per capita Part D spending (see Table 2.C1). In determining out-of-pocket costs, only those amounts actually paid by the enrollee or another individual (and not reimbursed through insurance) are counted; the exception is cost-sharing assistance from Medicare’s low-income subsidies (certain beneficiaries with low incomes and modest assets will be eligible for certain subsidies that eliminate or reduce their Part D premiums, cost-sharing, or both) and from State Pharmacy Assistance Programs. A beneficiary premium, representing 25.5 percent of the cost of basic coverage on average, is required (except for certain low-income beneficiaries, as previously mentioned, who may pay a reduced or no premium). For PDPs and the drug portion of Medicare Advantage plans, the premium will be determined by a bid process; each plan’s premium will be 25.5 percent of the national weighted average plus or minus the difference between the plan’s bid and the average. To help them gain experience with the Medicare population, plans will be protected by a system of risk corridors, which allow Part D to assist with unexpected costs and to share in unexpected savings; after 2007, the risk corridors became less protective. To encourage employer and union plans to continue prescription drug coverage to Medicare retirees, subsidies to these plans are authorized; the plan must meet or exceed the value of standard Part D coverage, and the subsidy pays 28 percent of the allowable costs associated with enrollee prescription drug costs between a specified cost threshold ($250 in 2006, indexed thereafter) and a specified cost limit ($5,000 in 2006, indexed thereafter).
2011 MLN Matters Articles
F & J Deductible Announcements
Medicare supplemental (Medigap) Plan F can be sold with a high deductible option. Before June 1, 2010, Medigap Plan J could also be sold with a high deductible. Effective January 1, 2016, the annual deductible amount for these two plans is $2180, the same amount as for 2015. The deductible amount for the high deductible version of plans F and J represents the annual out-of-pocket expenses (excluding premiums) that a beneficiary must pay before these policies begin paying benefits. CMS updates the deductible amount for plans F and J each year, after release of the August Consumer Price Index for all Urban Consumers (CPI-U) figures by the Bureau of Labor Statistics, which generally occurs in mid-to late September.
What’s in Store for Medicare’s Part B Premiums and Deductible in 2016, and Why?
The absence of a COLA affects the amount of the Medicare Part B premium charged to enrollees because it triggers the broader application of a provision in the Social Security law known as the hold-harmless provision. In a year where the Social Security COLA is insufficient to cover the amount of the Medicare Part B premium increase for an individual, the law prohibits an increase in the Part B premium that would result in a reduction in that individual’s monthly Social Security benefits from one year to the next. (For an example of how the hold-harmless provision works in a typical year with a Social Security COLA, see Appendix B.) The hold-harmless provision affects a different number of beneficiaries each year, depending on the level of their Social Security benefits, the size of the COLA, and the increase in the Medicare Part B premium. In years with no COLA, a majority of beneficiaries are protected by the hold-harmless provision.