Enrollment of Dually Eligible Beneficiaries in
Medicare Part D Plans:
Autoassignment and Choice
Christine Bishop, Ph.D.1
Cindy Parks Thomas, Ph.D. 1
Daniel Gilden, M.S.2
Joanna Kubisiak, M.S.2
AcademyHealth Annual Research Meeting
June 29, 2009
1Schneider
Institutes for Health Policy, Heller School for
Social Policy and Management, Brandeis University
2JEN Associates Inc.
Research Support
Centers for Medicare & Medicaid
Services
Contract No. CMS 500-00-0031/T.O.
#2
Project Officers:
William Clark and Karyn Anderson
2
Background: Autoenrollment/Reassignment

Initial matching to plans: October 2005
♦ Dually-eligible beneficiaries were autoenrolled to benchmark
(premium below average) Prescription Drug Plans (PDPs)
♦ Beneficiary had option to switch to PDP with formulary better
meeting own needs
♦ No Lock In for Duals – can switch any month (unlike others)

New dually-eligible beneficiaries autoenrolled monthly
♦ Newly qualified for both
♦ Previously Medicaid only
♦ Previously Medicare only

Response to market evolution: 2006, 2007
♦ Continuing beneficiaries are reassigned if own PDP premium
falls above benchmark plus de minimis threshold ($2, $1)
♦ Some are moved to a below-benchmark plan offered by same
sponsor (e.g. United Health, Humana)
♦ “Choosers” (past switchers) are not reassigned, but must pay
premium difference if they stay in chosen plan -- of course
may switch any month
3
2005->2006
2006->2007
2007->2008
No longer bench Stay/pay
(no reassign)
Or choose out
Choose out
Previous dual
New dual
Auto-assign
Plan stays
benchmark
Plan stays
benchmark
Stay in
No longer
benchmark
No longer benchmark If chooser:
(reassign same or
Stay/pay
new sponsor)
Or choose out
(reassign same
sponsor)
No longer
benchmark
Plan stays benchmark
(reassign new sponsor)
No longer benchmark If chooser:
(reassign same or
Stay/pay
new sponsor)
Or choose out
4
Importance of Beneficiary Plan Choice


Autoassignment: Assures that All Duals are Enrolled
BUT Formulary restrictions of plans may differ
♦ Covered brands within a class may differ
♦ Prior authorization may be required for brand within protected
class


Beneficiaries should match to plan that covers needed
drugs -- and Medicare supports choice
But DO beneficiaries “choose away” from autoassigned
plan?
♦ Some have no reason to choose away




5
Autoassigned plan meets needs
Some have few drug needs
Some may be less able to choose than others
Impact on Health???
Current Analysis



6
Question 1: How much choice occurred at initial
and key choice points?
Question 2: What factors are associated with
active choosing at these points in time?
(Question 3: How much active choice AFTER
these points for those who are autoassigned?)
Study Populations

Dually eligible for at least one month January
2006 through December 2007
♦ for Medicare
♦ for full Medicaid (by state criteria)
♦ ~7.8 million

Dually eligible at least one month during 2006
linked to Medicare 5% Sample: Medicare data
for 2004-2006
♦ ~275,000
7
Individual Monthly Enrollment Data for 24
Months

CMS PDP Contract file
♦ Plan type (MA or stand-alone) contract number, plan number
♦ Sex, date of birth
♦ Enrollment type





A = autoenrolled by CMS
B = Beneficiary election
C = Part D Facilitated enrollment by CMS
D = System generated enrollment (rollover plan number
change)
Medicaid dual eligibility file
♦ State of eligibility
♦ Dual status (QMB,SLMB,QWDI,QI)
♦ FPL: below or 100%+
♦ Institutional status (yes, no)
8
For 5%, Linked Medicare Data


2005 flags indicating presence of a chronic
illness diagnosis
Original and current reasons for eligibility
♦ Exclude ESRD

9
Race from Medicare enrollment data
How Much Plan Change?
Percent Dually Eligible Beneficiaries With Plan Change by Month
25.0%
20.0%
707,417 Beneficiaries Autoassigned: 13.2%
15.0%
10.0%
408,804 Beneficiaries Changed Plan: 7.6%
5.0%
10
Dec-07
Nov-07
Oct-07
Sep-07
Aug-07
Jul-07
Jun-07
May-07
Apr-07
Mar-07
Feb-07
Jan-07
Dec-06
Nov-06
Oct-06
Sep-06
Aug-06
Jul-06
Jun-06
May-06
Apr-06
Mar-06
Feb-06
0.0%
Question 1: How much Choice at three
Plan Choice Points?

January 2006
♦ Beneficiaries autoassigned in October 2005 had 3
prior months to choose away from autoassigned plan

New beneficiaries coming onto Medicaid
♦ February 2006 – December 2007

Enrollees in plans that lose below benchmark
status (January 2007)
♦ Previous chooser: pay premium difference or switch
♦ Informed beneficiary: choose new plan before 1/07
♦ Do nothing: Autoassigned to a different benchmark
plan
11
First Enrollment: 5 Million Duals Autoassigned October 2005
1.1 Million (21%) Chose Different Plan by January 2006
Unknown,
170,000 , 3%
Autoassigned,
3,780,000 , 76%
12
New duals as of 1/06 are included
Chose: Stand
Alone Plan,
620,000 , 12%
Chose: MA Plan,
450,000 , 9%
13
10,000
1,085,542
-
Dec-07
Nov-07
Oct-07
Sep-07
38,000
43,000
45,000
43,000
45,000
Aug-07
44,000
Jun-07
46,000
45,000
May-07
Jul-07
46,000
48,000
41,000
47,000
38,000
44,000
Apr-07
Mar-07
Feb-07
Jan-07
Dec-06
Nov-06
49,000
20,000
Oct-06
30,000
49,000
40,000
Sep-06
47,000
49,000
47,000
60,000
70,000
Aug-06
Jul-06
Jun-06
May-06
45,000
50,000
Apr-06
60,000
52,000
74,000
80,000
Mar-06
Feb-06
1.1 million beneficiaries became newly dually eligible for Medicaid
and Medicare from February 2006 through December 2007
After May 2006, about half of new dual beneficiaries were
choosing a plan (stand-alone or MA) by first Medicaid
month
100%
8%11% 11%
13%
19% 20% 15% 16% 14% 17% 17% 18%
13%
90%
19%
80%
70%
27%
12% 12%
11%
35%
34%
33%
60%
50%
12%
13% 13% 14% 14% 14%
14%
14%
34% 29% 31%
36% 37%
35% 34%
33%
34% 34%
40%
65%
54% 44%
52%
40% 40%
20%
36% 34% 31% 35% 34% 33% 33%
32%
10%
30%
14
Dec-07
Oct-07
Aug-07
Jun-07
Apr-07
Feb-07
Dec-06
Oct-06
Aug-06
Jun-06
Apr-06
Feb-06
0%
Unknown
Facilitated
Chose MA
Chose Stand-Alone
Autoassigned
Some dual beneficiaries’ plans went Above
Benchmark in January 2007

22% of duals in stand-alone plans in December
2006 had their plans move above benchmark in
January 2007 – 1.02 million beneficiaries
♦ 23% (235,000) of duals in plans going above
benchmark chose a different plan by January 2007
♦ 62% (630,000) were autoassigned in January 2007

Includes specific facilitated shifts within sponsor
♦ 15% (160,000) remained in same plan
♦ A very small handful (5,000) moved to MA plans
15
Sum up re: Question 1
For dual beneficiaries new to Part D or new
to dual eligibility -


16
21% (1.1 million out of 5 million) chose a
different plan as Part D began
30-40% (total of 500,000 of the 1.1 new duals
Feb 06-Dec 07) chose a different plan as they
became newly eligible as duals
23% (235,000 out of 1.02 million) chose a
different plan, rather than accepting an
autoassigned benchmark plan, when they
learned their PDP was going above benchmark
Question 2:
Who was more likely to choose at the choice points?

Choosing perhaps more likely if
♦ Better information – outreach from state
♦ Past diagnoses associated with chronic utilization of
certain brand drugs
♦ Greater drug needs
♦ Better cognitive function
♦ Support from setting of care (e.g. nursing home,
other institution)
♦ Time:


17
As all become familiar with Part D
As more are previously enrolled in Part D
5% Medicare sample







18
Sex
Age categories (same as Aged vs. Disabled)
Institutionalized
Income 100% FPL +
State
Medicare reported race
Diagnosis indicators for certain chronic
conditions (FFS in 2005)
1.88
1.8
1.6
1.4
1.23
1.2
0.98
1.07
0.96
1
0.98
0.98
0.97
0.80
0.71
0.8
0.6
0.4
0.2
Accounting for state and Dx indicator effects
19
Hispanic
Black
Institutional
Resident
Income>FPL
Age 90+
Age 85-89
Age 80-84
Age 75-79
Age 65-69
0
Male
Odds of Having Chosen Plan (Not MA) January 2006
2
Logistic Regression—Aged: Odds of Choosing StandAlone Plan vs. Autoassignment by January 2006
0
Accounting for state and demographic characteristics
hypertension
macular degeneration
Alzheimers
1.04
skin ulcer
1.03
1.05
osteoporosis
urinary incontinence
1.10
1.02
cellulitis
arthritis
1.05
UTI
1.10
1.06
teritis/colitis/diverticulitis
chronic renal failure
1.03
peptic ulcer
0.92
1.03
asthma
COPD
1.02
0.97
bronchitis/emphysema
pneumonia
1.08
1.04
CHF
CVA, stroke
1.04
1.10
atrial fibrilation
0.92
1.14
1.02
1.06
0.2
depression
0.4
1.06
0.6
lipid disorder
0.8
1.03
1
ischemic heart disease
20
1.08
1.2
diabetes
cancer
Odds of Having Chosen Plan (Not MA) January 2006
Logistic Regression: Odds of Choosing Stand-Alone Plan
vs. Autoassignment by January 2006
0.60
0.71
0.71
0.72
1
MA
CT
RI
CA
WI
WA
SC
NC
NY
FL
AL
TN
MO
AZ
KY
UT
MS
LA
SD
OK
OH
KS
PA
NH
IA
CO
TX
NE
MN
ID
GA
AR
OR
ME
ND
Odds of Having Chosen Plan (Not MA) January 2006
2.5
2
1.5
1.21
1.23
1.26
1.27
1.31
1.61
1.63
1.63
1.64
1.77
1.79
1.79
1.83
1.83
1.87
1.88
1.92
2.03
2.13
2.14
3.5
3
2.57
2.65
2.69
2.81
2.85
2.95
2.98
3.04
3.29
3.31
Choice more likely in some states
5
4.5
4
0.5
0
21
Odds of Chosen Plan (Not MA) Mo 1 New Duals
2.5
Odds of New Duals Choosing Stand-Alone Plan
vs. Autoassignment, First Eligible Month
(Full Enrollment Study Group)
2
1.5
1.22
1.04
1.12
1.31
1.27
0.83
0.55
0.63
0.59
Age 55-64
0.81
Age 45-54
1
1.07
1.22
0.5
Institutional
Resident
Age 90+
Age 85-89
Age 80-84
Income>FPL
22
Age 75-79
All coefficients significant at p<.05
Age 65-69
Age 21-44
Age 0-21
Male
0
Odds of Dual Eligible with Plan Moving Above Benchmark Choosing StandAlone Plan or No Change vs. Autoassignment
(Full Enrollment Study Group)
2.50
2.11
1.93
2.00
1.50
1.15
1.12
Age 90+
0.98
1.23
1.17
1.08
Age 85-89
0.98
0.89
1.09
1.02
Age 80-84
1.00
1.021.02
Age 75-79
1.10
1.16
1.13
Choose Stand-Alone Pla
1.08
0.89
0.80
0.50
Income>FPL
Age 65-69
Age 55-64
Institutional Resident
23
Age <55
Male
0.00
No Change
Question 3: Pattern of Choosing After
Autoassigned at Choice Point

“Survival” curves show proportion who remain
autoenrolled after t months
♦ January 2006
♦ Autoassigned after plan goes above benchmark,
January 2007
24
Duals Autoassigned in January 2006
Tended to Remain in Autoassigned Plan
Still Over 80% by Month 24
1
0.9
Proportion Still Autoenrolled
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
0
25
5
10
15
Months
20
Dual beneficiaries autoassigned after old plan
Above Benchmark (Dec 06) tended to stay in new
autoassigned plan
1
0.95
Proportion Still Autoenrolled
0.9
0.85
0.8
0.75
0.7
0.65
0.6
0.55
0.5
26
1
3
5
7
9
11
PRELIMINARY Implications


SOME dual beneficiaries DO choose away from
autoassigned plans
First enrollment (January 2006) (65+): more
likely to choose if
♦ Institution resident
♦ Income 100%FPL+

First enrollment LESS likely to choose if
♦ Black
♦ Hispanic

27
Residents of certain states have higher
probability of choosing
PRELIMINARY Implications (2)

New duals: more likely to choose if
♦ Income 100% FPL+
♦ Age patterns: sequencing of eligibility?

Plan goes above benchmark: more likely to
choose if
♦ Institution resident
♦ Income 100%FPL+

Dually eligible beneficiaries tend to remain
passively enrolled in autoassigned plans –
original or after benchmark change
♦ Low need for Rx drugs?
♦ Satisfied with initial plan?
28
Next steps


Impact of cognitive impairment on choice
Subgroup analysis: duals using selected Rxs in 2005
♦ Autoassigned or chose plans including those brands?
♦ Impacts on health outcomes?

Effects of market change on beneficiary outcomes
♦ Note: more beneficiaries affected by plans moving above
benchmark in January 2008 and January 2009
♦ How many dual beneficiaries are paying premiums?
♦Health Outcomes
29