October 2019 | Data Note Medicare Advantage 2020 Spotlight: First Look Gretchen Jacobson, Meredith Freed, Anthony Damico, Tricia Neuman Executive Summary Medicare Advantage plans have taken a large and growing role in the Medicare program over the past decade, with more than 22 million Medicare beneficiaries (34%) enrolled in Medicare Advantage plans in 2019, a private plan alternative to the traditional Medicare program. This brief provides an overview of the Medicare Advantage plans that will be available for 2020, based on an analysis of data from the Centers for Medicare and Medicaid Services (CMS). Findings include:  Number of Plans. ES Figure Nationwide, 3,148 Medicare The average Medicare beneficiary has access to 28 Medicare Advantage plans will be Advantage plans in 2020, an increase from prior years Average Number of Medicare Advantage Plans Available to Beneficiaries, 2010-2020 available for individual enrollment for the 2020 plan 33 year – an increase of 414 28 plans since 2019. The 24 20 21 24 20 18 19 19 18 average beneficiary will be able to choose among 28 plans in 2020, up from 24 in 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2019 (ES Figure). The NOTE: Excludes SNPs, EGHPs, HCPPs, and PACE plans. SOURCE: Kaiser Family Foundation analysis of CMS’s Landscape files for 2010 – 2020. number of Special Needs Plans (SNPs) will also increase from 717 plans in 2019 to 855 plans in 2020.  Variation in Number of Plans. The number of Medicare Advantage plans will vary greatly across counties in 2020, from 31 plans, on average, in metropolitan counties to 16 plans, on average, in non- metropolitan counties. More than 60 plans will be available in six counties (in OH and PA), while no plans will be offered in 77 counties (accounting for less than 1% of beneficiaries) in 2020.  Number of Firms. The average beneficiary will be able to choose from plans offered by seven firms in 2020, similar to 2019. Four percent of all Medicare beneficiaries will have a choice of plans offered by two or fewer firms while 24 percent will be able to choose from plans offered by 10 or more firms.  Market Entrants and Exits. Thirteen insurers will be entering the Medicare Advantage market for the first time, and one insurer will be exiting in 2020. In all, well over 100 firms will offer Medicare Advantage plans in 2020.  Extra Benefits. Nearly all beneficiaries (97%) have access to a Medicare Advantage plan that provides dental, fitness, vision, and hearing benefits, which are not covered by traditional Medicare. Many beneficiaries also have access to some transportation assistance (92%) and a meal benefit (96%), but some benefits are less frequently available, such as in-home support (54%), bathroom safety (49%), telemonitoring services (29%), and support for caregivers of enrollees (12%). Plan Offerings in 2020 Number of Plans Figure 1 More Medicare Advantage plans are available in 2020 than in any Total Number of Plans. In total, other year 3,148 Medicare Advantage Number of Medicare Advantage plans generally available by plan type, 2007-2020 Other plan types 3,148 plans will be available 2,830 Regional PPOs PFFS plans 86 Local PPOs 2,734 41 52 2,623 nationwide for individual 118 43 107 51 2,314 HMOs 2,317 74 50 44 958 2,098 1,974 2,074 2,014 1,945 2,001 2,034 696 enrollment in 2020 – a 15 59 2,011 102 87 49 46 812 104 42 801 100 93 81 413 116 101 51 48 93 85 49 59 54 180 120 69 43 57 47 48 569 452 525 220 201 percent increase (414 more 412 522 512 504 548 511 465 461 469 335 plans) from 2019 and the largest 1,754 2,011 1,451 1,566 1,249 1,218 1,242 1,275 1,351 1,387 1,165 1,195 number of plans ever available 1,104 1,114 (Figure 1; Appendix Table 1). 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 These numbers exclude NOTE: Excludes SNPs, EGHPs, HCPPs, and PACE plans. Other category includes cost plans and Medicare MSAs. SOURCE: Kaiser Family Foundation analysis of CMS’s Landscape Files for 2007 – 2020. employer or union-sponsored group plans and Special Needs Plans, which are only available to select populations. Similar to prior years, HMOs continue to account for about two-thirds (64%) of all plans offered in 2020. The growth in number of plans varies across states and counties, with the preponderance of the growth in plans occurring in California and Florida (61 more and 42 more plans, respectively; data not shown). Indiana and Puerto Rico will have 5 fewer plans available in 2020 than in 2019, while Utah will have 2 fewer plans, and Maryland and Hawaii will each have one fewer plan available in 2020 than in 2019. While many employers and unions also offer Medicare Advantage plans to their retirees, no information about these plans is made available by CMS to the public during the Medicare open enrollment period because these plans are not available to the general Medicare population. Special Needs Plans (SNPs). Figure 2 More SNPs will be available in More than 850 Special Needs Plans will be offered in 2020 2020 than in any year since they Number of Special Needs Plans (SNPs), by plan type, 2010-2020 Institutional 855 were authorized, increasing from Chronic or Disabling Conditions 150 717 Dual Eligibles 717 plans in 2019 to 855 plans 644 630 125 68 564 578 165 545 548 550 in 2019, a 19 percent increase 68 500 61 57 69 83 97 127 66 214 132 409 (Figure 2). The SNP market may 140 60 113 152 152 139 122 be an especially attractive 87 540 465 362 373 401 market because potential 337 262 321 351 339 342 overpayments to plans may be 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 largest for those plans that are NOTE: Includes only Special Needs Plans. SOURCE: Kaiser Family Foundation analysis of CMS’s Landscape Files for 2010 – 2020. serving the sickest beneficiaries. The rise in SNPs for people who require an institutional-level of care (I-SNPs) has been particularly notable, more than doubling from 69 plans in 2016 to 150 plans in 2020. I-SNPs may be attractive to insurers because they tend to have much lower marketing costs than other plan types since they are often the only available option for people to receive their Medicare benefits in certain retirement communities and nursing homes. The number of SNPs for people dually eligible for Medicare and Medicare Advantage 2020 Data Spotlight: First Look 2 Medicaid (D-SNPs) has also greatly increased over the past five years (58% increase since 2016), suggesting insurers’ continue to be interested in managing the care of this high-need population. Most SNPs for people with chronic conditions (C-SNPs) will continue to target people with diabetes, heart disease, or lung conditions in 2020, as has been the case since the inception of SNPs. In 2020, three firms will offer C-SNPs for people with dementia (up from two firms in 2019) and one firm will continue to offer a C-SNP for people with mental health conditions in California. Four firms will continue to offer C- SNPs for people with end-stage renal disease (similar to 2019) and two firms will offer C-SNPs for people with HIV/AIDS (similar to 2019). Number of Plans Available to Beneficiaries. In 2020, the average Medicare beneficiary will have access to 28 Medicare Figure 3 Advantage plans available for The average Medicare beneficiary has access to 28 Medicare individual enrollment, the Advantage plans in 2020, an increase from prior years highest number of plans Average Number of Medicare Advantage Plans Available to Beneficiaries, 2010-2020 available to the average 33 beneficiary since 2011 (Figure 28 24 24 20 20 21 18 18 19 19 3). Among the 28 Medicare Advantage plans available to the average Medicare 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 beneficiary, 24 of the plans will Metro counties 35 26 22 22 20 20 21 21 23 26 31 Non-metro include prescription drug counties 24 16 13 13 11 10 11 11 12 14 16 NOTE: Excludes SNPs, EGHPs, HCPPs, and PACE plans. coverage (MA-PDs); 90 percent SOURCE: Kaiser Family Foundation analysis of CMS’s Landscape files for 2010 – 2020. of all Medicare Advantage plans offered will include prescription drug coverage in 2020. Variation in the Number of Figure 4 Plans, by Geographic Area. In 131 counties, Medicare beneficiaries can choose from more than 40 On average, beneficiaries in Medicare Advantage plans, including 6 counties with more than 60 plans metropolitan areas will be able in 2020 to choose from more than twice as many Medicare Advantage plans as beneficiaries in non- metropolitan areas (31 plans versus 16 plans, respectively). In ten percent of counties (accounting for 40% of 0 plans 1 – 5 plans 6 – 10 plans 11 – 20 plans 21 – 30 plans 31 – 40 plans ≥ 41 plans 77 counties 404 counties 608 counties 1,222 counties 513 counties 184 counties 131 counties beneficiaries), beneficiaries can NOTE: Excludes SNPs, EGHPs, HCPPs, and PACE plans, and plans in Puerto Rico and territories. SOURCE: Kaiser Family Foundation analysis of CMS’s Landscape Files for 2020. choose from more than 30 plans in 2020, including four counties in Ohio (Mahoning, Medina, Trumbull, and Summit) and two counties in Pennsylvania (Bucks and Lancaster) where more than 60 plans will be available (Figure 4). In contrast, in 6 percent of counties (accounting for 1% of beneficiaries), beneficiaries can choose from two or fewer Medicare Advantage plans, including 59 counties in which only one plan will be available to beneficiaries. The number of counties with no Medicare Advantage plans will decline from 115 in 2019 to 77 in 2020. Medicare Advantage 2020 Data Spotlight: First Look 3 Additionally, no Medicare Advantage plans are available in territories other than Puerto Rico, similar to previous years. Access to Medicare Advantage Plans, by Plan Type As in recent years, virtually all Medicare beneficiaries (99%) will have access to a Medicare Advantage plan as an alternative to traditional Medicare, including almost all beneficiaries in metropolitan areas (99.9%) and the vast majority of beneficiaries in non-metropolitan areas (97%). In non-metropolitan counties, a smaller share of beneficiaries will have access to HMOs (81% in non-metropolitan versus 99% in metropolitan counties) or local PPOs (86% in non-metropolitan versus 95% in metropolitan counties), and a slightly larger share of beneficiaries will have access to regional PPOs (77% in non-metropolitan counties versus 72% in metropolitan counties). Number of Firms Figure 5 The average Medicare Almost one-quarter of beneficiaries can choose among Medicare Advantage plans offered by 10 or more firms beneficiary will be able to Distribution of Beneficiaries by the Number of Firms Offering Medicare Advantage Plans, 2020 choose from plans offered by 7 No Firms One Firm 1% The average 1% firms, on average, in 2020, 2-3 Firms 8% beneficiary can choose among 10 or More Medicare Advantage similar to 2019 (Figure 5). Firms plans offered by 24% 4-5 Firms 7 firms Almost one-quarter of 20% beneficiaries (24%) will be able 8-9 Firms 15% 6-7 Firms to choose from plans offered by 31% 10 or more firms. Fourteen firms Total Number of Medicare Beneficiaries = 66 Million will offer Medicare Advantage NOTE: Excludes SNPs, EGHPs, HCPPs, and PACE plans. Numbers may not sum to 100% due to rounding. SOURCE: Kaiser Family Foundation analysis of CMS’s Landscape and Penetration Files for 2020. plans in six counties: Los Angeles, Orange, Riverside, and San Bernardino counties in California, Cook County (Chicago) in Illinois, and Summit County (Akron) in Ohio. In each of these metropolitan counties, per capita spending for traditional Medicare and the share of beneficiaries enrolled in Medicare Advantage plans are much higher than the national average. In contrast, in 146 counties, most of which are rural counties with relatively few Medicare beneficiaries, only one firm will offer Medicare Advantage plans in 2020, a reduction from 194 such counties in 2019. UnitedHealthcare and Humana, Figure 6 the two firms with the most Humana’s Medicare Advantage plans will be available in 83% of counties and UnitedHealthcare’s will be available in 60% of counties Medicare Advantage enrollees, in 2020 have large footprints across the Both UnitedHealthcare and Humana country, offering plans in most offering plans (53% of counties) Humana offering plans (83% of counties) counties. UnitedHealthcare is UnitedHealthcare offering plans (60% of counties) offering plans in 60 percent of Neither company offering plans (11% of counties) counties, Humana is offering plans in 83 percent of counties, and both firms are offering plans in more than half of all counties NOTE: Excludes SNPs, EGHPs, HCPPs, and PACE plans, and plans in Puerto Rico and territories. SOURCE: Kaiser Family Foundation analysis of CMS’s Landscape Files for 2020. (53%) in 2020 (Figure 6). More Medicare Advantage 2020 Data Spotlight: First Look 4 than 8 in 10 (85%) of Medicare beneficiaries have access to at least one Humana plan and 82 percent have access to at least one UnitedHealthcare plan. New Market Entrants and Exits Medicare Advantage continues to be an attractive market for insurers, with 13 firms entering the market for the first time in 2020, collectively accounting for about 7 percent of the growth in the number of plans available for general enrollment and about 5 percent of the growth in SNPs (Table 1). Ten new entrants will be offering HMOs available for individual enrollment. Five of the new entrants will be offering SNPs; three firms will be offering D-SNPs and two firms will be offering I-SNPs, including one firm (MoreCare) that will also be offering a C-SNP for people with HIV/AIDS. All of the new entrants are offering plans in one of ten states (FL, IL, LA, MI, NC, NY, SC, TN, TX, and VA). Similar to prior years, some of the new entrants, such as Oscar and Troy Medicare, are funded by venture capital firms, joining about a dozen other venture capital-funded firms offering Medicare Advantage plans in 2020. While well over 100 insurers offered Medicare Advantage plans in 2019, only one insurer will be exiting the market in 2020, a sign that the vast majority of plans in the Medicare Advantage market are profitable. The exiting insurer had about 8,000 enrollees in Puerto Rico in 2019. Table 1. Entrants and Exiting Insurers in Medicare Advantage Markets, by Plan Type and Plan Locations, 2020 Plans for Individual Special Needs Plans Total Enrollment (SNPs) States in Which Number Company Name Plans Are of Plans HMOs Other D-SNPs C-SNPs I-SNPs Offered Offered New Entrants ApexHealth, Inc. 13 X X NC, SC, TN, and VA Clarion Health 1 X FL Community Health 1 X TX Choice Dignity Health Plan 1 X LA El Paso Health 1 X TX Advantage Experience Health, Inc. 1 X NC Mary Washington X 2 VA Medicare Advantage MoreCare 4 X X X IL Oscar 2 X NY and TX PHP Medicare 6 X MI Reliance Medicare X 2 MI Advantage Troy Medicare 1 X NC Zing Health 1 X IL Exiting Insurers Constellation Health 8 X X X PR Note: D-SNPs are plans for people dually eligible for Medicare and Medicaid; C-SNPs are plans for people with certain chronic conditions; and I-SNPs are plans for people that require an institutional level of care. Source: Kaiser Family Foundation analysis of CMS Landscape Files for 2019 and 2020. Medicare Advantage 2020 Data Spotlight: First Look 5 Premiums The vast majority of Medicare Advantage plans for individual enrollment (90%) will include prescription drug coverage (MA-PDs), and 49 percent of these plans will charge no premium, other than the Part B premium, similar to 2019. More than nine out of ten beneficiaries (93%) will have access to a MA-PD with no monthly premium in 2020. However, in three rural states (AK, MT and WY), beneficiaries will not have access to a zero-premium MA-PD, and in four other states (MD, SD, ID, and ND), less than half of beneficiaries will have access to a zero-premium MA-PD. The average premium for MA-PDs (not weighted by enrollment) will be $36 per month in 2020, down from $40 per month in 2019. Medicare Advantage enrollees typically choose low premium plans, and enrollment-weighted premiums are often lower than the average premium across plans. Extra Benefits Medicare Advantage plans may provide extra benefits that are not offered in traditional Medicare, and can use rebate dollars (including bonus payments) to help cover the cost of these extra benefits. Beginning in 2020, Medicare Advantage plans can offer extra benefits that are not primarily health related. Plans may also restrict the availability of these extra benefits to certain subgroups of beneficiaries, making different benefits available to different enrollees. Further research is needed to assess the comprehensiveness of coverage for these extra benefits, and the extent to which the benefits are only available to certain subgroups of enrollees. Availability of Extra Benefits in Plans for General Enrollment. More than 80 percent of plans provide some dental, vision, hearing, or fitness benefits (Figure 7); nearly 6 in 10 plans (58%) provide all of these four benefits in 2020. One-third Figure 7 of plans (33%) provide some Most Medicare Advantage plans provide fitness and vision transportation benefit in 2020, benefits but much fewer provide in-home or caregiver support and almost half (46%) provide a meal benefit, such as a 88% 87% 83% 46% cooking class, nutrition 93% education, or meal delivery. Fitness Dental Eye exams Hearing aids Meal Benefit Benefit Benefit and glasses Less than 10 percent of plans provide bathroom safety devices (6%), in-home support 33% 6% 4% 4% 2% (4%), telemonitoring (4%), or Transportation Bathroom In-Home Telemonitoring Caregiver Safety Support Support support for caregivers of NOTE: Dental includes plans that only provide preventive benefits, such as cleanings. Excludes SNPs, EGHPs, HCPPs, and PACE plans. SOURCE: Kaiser Family Foundation analysis of CMS’s Landscape files for 2020. enrollees (2%). Availability of Extra Benefits in Special Needs Plans. SNPs are designed to serve a disproportionately high-need population, and a somewhat larger percentage of SNPs than plans for other Medicare beneficiaries provide their enrollees with transportation benefits (84%) and meal benefits (60%). Similar to plans available for general enrollment, a relatively small share of SNPs provide bathroom safety devices (7%), in-home support (13%), telemonitoring (10%), and support for caregivers (8%). Medicare Advantage 2020 Data Spotlight: First Look 6 Access to Extra Benefits. Nearly all Medicare beneficiaries have access to a Medicare Advantage plan with some extra benefits not covered by traditional Medicare, with 97% having access to some dental, fitness, vision, and hearing benefits in 2020. The vast majority of beneficiaries also have access to transportation assistance (92%) and a meal benefit (96%), but far fewer have access to in-home support (54%), bathroom safety (49%), telemonitoring services (29%), and support for caregivers of enrollees (12%). Discussion More Medicare Advantage plans will be offered in 2020 than any other year. Thirteen insurers will be entering the Medicare Advantage market for the first time, and only insurer will be exiting the market, suggesting that the Medicare Advantage market remains an attractive, profitable market for insurers. As in prior years, some (mostly non-metropolitan) counties are less attractive to insurers, with fewer firms and plans available. Overall, less than 1 percent of beneficiaries will not have access to a Medicare Advantage plan in 2020, similar to prior years. With more firms offering SNPs and the number of SNPs rapidly growing, there may be greater focus on how well high-need, vulnerable beneficiaries are being served by Medicare Advantage plans, including SNPs as well as plans for general enrollment. As Medicare Advantage enrollment continues to grow, insurers seem to be responding by offering more plans and choices to the people on Medicare. Gretchen Jacobson, Meredith Freed, and Tricia Neuman are with KFF. Anthony Damico is an independent consultant. Medicare Advantage 2020 Data Spotlight: First Look 7 Appendix Table 1. Availability of Medicare Advantage Plans and Insurers, by State, 2020 Average Average Share of Beneficiaries with Total Number Number of Number of Access to at Least 1 Plan State of Plans Plans Available Insurers to Beneficiaries Offering Plans All Plans HMOs Local PPOs Nationwide 3,148 28 7 99% 95% 93% Alabama 55 18 5 100% 95% 100% Alaska 0 0 N/A 0% 0% 0% Arizona 77 30 9 100% 97% 97% Arkansas 50 22 7 100% 99% 89% California 281 31 10 98% 97% 66% Colorado 63 26 7 100% 86% 95% Connecticut 29 26 6 100% 100% 100% Delaware 11 10 4 100% 100% 100% DC 7 7 4 100% 100% 100% Florida 296 35 8 100% 99% 99% Georgia 94 27 7 100% 87% 97% Hawaii 19 12 6 100% 100% 100% Idaho 56 23 5 93% 93% 96% Illinois 116 32 10 100% 98% 93% Indiana 84 20 6 100% 100% 100% Iowa 47 12 4 100% 91% 96% Kansas 60 17 5 100% 70% 82% Kentucky 66 17 5 100% 99% 100% Louisiana 53 20 7 100% 100% 100% Maine 40 24 8 100% 100% 100% Maryland 25 9 4 100% 90% 71% Massachusetts 58 30 6 100% 99% 97% Michigan 79 36 6 100% 100% 100% Minnesota 79 31 7 100% 100% 99% Mississippi 30 12 4 100% 76% 85% Missouri 79 21 5 100% 90% 97% Montana 14 5 3 100% 79% 86% Nebraska 30 13 5 94% 82% 82% Nevada 40 21 7 100% 97% 94% New Hampshire 34 28 6 100% 100% 100% New Jersey 58 24 6 100% 100% 100% New Mexico 29 15 6 100% 68% 100% New York 178 40 10 100% 100% 100% North Carolina 82 17 6 100% 94% 95% North Dakota 22 13 3 100% 0% 51% Ohio 140 47 10 100% 100% 100% Oklahoma 40 17 4 100% 77% 94% Oregon 85 24 7 100% 93% 100% Pennsylvania 160 47 8 100% 100% 100% Rhode Island 16 16 4 100% 100% 100% South Carolina 76 28 8 100% 100% 100% South Dakota 24 14 4 100% 27% 81% Tennessee 76 24 7 100% 100% 100% Texas 152 27 9 100% 93% 94% Utah 28 15 6 100% 98% 94% Vermont 13 11 2 100% 100% 100% Virginia 93 17 5 100% 97% 93% Washington 127 28 7 98% 93% 90% West Virginia 35 20 5 100% 100% 100% Wisconsin 101 25 7 100% 99% 92% Wyoming 5 2 1 100% 3% 3% Note: Excludes SNPs, EGHPs, HCPPs, and PACE plans. Nationwide totals include Puerto Rico and other territories. Source: Kaiser Family Foundation analysis of CMS Landscape File, 2019. Medicare Advantage 2020 Data Spotlight: First Look 8