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entitled 'Medicare Advantage: Enrollment Increased from 2010 to 2011 
while Premiums Decreased and Benefit Packages Were Stable' which was 
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United States Government Accountability Office:
GAO: 

Report to Congressional Requesters: 

October 2011: 

Medicare Advantage Benefits: 

Enrollment Increased from 2010 to 2011 while Premiums Decreased and 
Benefit Packages Were Stable: 

GAO-12-93: 

GAO Highlights: 

Highlights of [hyperlink, http://www.gao.gov/products/GAO-12-93], a 
report to congressional requesters. 

Why GAO Did This Study: 

Enrollment and spending in Medicare Advantage (MA) plans—the private 
plan alternative to the Medicare fee-for-service (FFS) program—have 
more than doubled since 2004. MA plans generally receive larger 
payments from Medicare than what these plans would require to provide 
the original Medicare FFS benefit package. Plans must use this 
additional money to reduce cost sharing, reduce premiums, and offer 
additional benefits. The Patient Protection and Affordable Care Act, 
enacted in 2010, required that the Centers for Medicare & Medicaid 
Services (CMS)—the agency within the Department of Health and Human 
Services (HHS) that administers Medicare—make changes in how Medicare 
pays MA plans. These changes, once fully implemented, are expected to 
reduce MA enrollment and payments, and lead to less generous benefit 
packages. GAO was asked to examine trends in MA from 2010 to 2011. This 
study assesses the extent to which the following changed from 2010 to 
2011: (1) MA enrollment, (2) MA premiums and cost-sharing requirements, 
and (3) the additional benefits offered by MA plans. GAO analyzed data 
for the most common types of MA plans, accounting for about 71 percent 
of both the 11.1 million MA beneficiaries in April 2010 and the 11.8 
million MA beneficiaries in April 2011. GAO used MA enrollment data to 
identify enrollment trends. GAO also analyzed data on MA plans’ 
projected revenue requirements and benefit packages. GAO assessed the 
reliability of the data by interviewing CMS officials, conducting logic 
tests, and comparing results to published sources. 

What GAO Found: 

Enrollment in the MA plans GAO analyzed increased by about 6 percent—
from 7.9 million to 8.4 million beneficiaries—from April 2010 through 
April 2011. There was substantial variation by plan type in enrollment 
levels and how they changed from 2010 to 2011. Enrollment in health 
maintenance organizations (HMO), which account for about two-thirds of 
total MA enrollment in 2011, increased by about 9 percent, from about 
5.2 million beneficiaries to about 5.6 million beneficiaries. Local and 
regional preferred provider organizations (PPO), which comprise a much 
smaller portion of total MA enrollment, experienced the highest 
percentage growth in enrollment—local PPOs increased by 38 percent and 
regional PPOs increased by 58 percent. In contrast, private fee-for-
service (PFFS) plans experienced a 54 percent decline in enrollment, 
which was likely due to requirements that most PFFS plans establish 
provider networks beginning in 2011. Even with the increase in 
enrollment from April 2010 through April 2011, the number of MA plans 
decreased from 2,307 to 1,964, and this was due primarily to a decrease 
in PFFS plan offerings, from 435 plans to 239. 

The average monthly premium for beneficiaries in MA plans decreased 
from $28 in 2010 to $24 in 2011, about a 14 percent reduction. The 
extent of the reduction and the premium amount varied substantially 
among plan types. For example, the average monthly premium for 
beneficiaries in PFFS plans fell from $33 in 2010 to $26 in 2011, about 
21 percent, while the average monthly premium for beneficiaries in HMOs 
fell from $25 in 2010 to $23 in 2011, about 8 percent. In information 
MA plans submitted to CMS prior to the contract year, MA plans 
projected that their cost-sharing requirements would be about half of 
the level in Medicare FFS in both 2010 and 2011. In both years HMOs had 
the lowest cost-sharing requirements—40 to 42 percent of the Medicare 
FFS average, while regional PPOs had the highest cost-sharing 
requirements—about 76 to 77 percent of the Medicare FFS average. In 
addition, from 2010 to 2011, the percent of MA beneficiaries in plans 
with limits on beneficiaries’ out-of-pocket health care costs increased 
from 74 percent to 100 percent. This increase is not surprising given 
that, effective in 2011, CMS requires all MA plans to have such limits, 
called out-of-pocket maximums. In contrast, Medicare FFS does not have 
an out-of-pocket maximum. 

MA beneficiaries generally received coverage for additional benefits at 
similar levels in 2010 and 2011. For example, at least 64 percent of 
beneficiaries were in plans providing benefits such as hearing and 
vision in both 2010 and 2011. There were some changes, however, in the 
percentage of beneficiaries with certain benefits. For example, the 
percentage of MA beneficiaries with coverage for vision services 
decreased from 84 percent to 79 percent, while the percentage of MA 
beneficiaries with outpatient blood benefits beyond what Medicare FFS 
covers increased from 87 to 91 percent. 

GAO obtained comments on a draft of this report from HHS. 

View [hyperlink, http://www.gao.gov/products/GAO-12-93] or key 
components. For more information, contact James Cosgrove at (202) 512-
7114 or cosgrovej@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

MA Plan Enrollment Increased by about 6 Percent from 2010 to 2011: 

Average MA Premiums Decreased from 2010 to 2011, and Projected Cost 
Sharing Was Stable: 

MA Plans' Coverage of Additional Benefits Was Generally Similar in 2010 
and 2011: 

Agency Comments: 

Appendix I: MA Beneficiaries Receiving Coverage for Additional Benefits 
by Plan Type, 2010 and 2011: 

Appendix II: Comments from the Department of Health and Human Services: 

Appendix III: GAO Contact and Staff Acknowledgments: 

Table: 

Table 1: Percent of MA Beneficiaries in Plans that Offered Additional 
Benefits in 2010 and 2011, by Plan Type: 

Figures: 

Figure 1: MA Enrollment in 2010 and 2011, by Plan Type: 

Figure 2: Average Premium Charged by MA Plans in 2010 and 2011, by Plan 
Type: 

Figure 3: Average Projected Cost Sharing for MA Beneficiaries Compared 
to Their Cost Sharing in Medicare FFS, 2010 and 2011: 

Figure 4: MA Beneficiaries' Out-of-Pocket Maximum by Plan Type, 2010 
and 2011: 

Figure 5: MA Beneficiaries in Plans that Offered Additional Benefits, 
2010 and 2011: 

Abbreviations: 

CMS: Centers for Medicare & Medicaid Services: 

FFS: fee-for-service: 

HHS: Department of Health and Human Services: 

HMO: health maintenance organization: 

MA: Medicare Advantage: 

MedPAC: Medicare Payment Advisory Commission: 

PPACA: Patient Protection and Affordable Care Act: 

PFFS: private fee-for-service: 

PPO: preferred provider organization: 

PSO: provider-sponsored organization: 

SNP: special needs plan: 

[End of section] 

October 31, 2011: 

The Honorable Max Baucus: 
Chairman: 
Committee on Finance: 
United States Senate: 

The Honorable Tom Harkin: 
Chairman: 
Committee on Health, Education, Labor and Pensions: 
United States Senate: 

Enrollment and spending in Medicare Advantage (MA) plans have more than 
doubled since 2004 and accounted for about 11.1 million beneficiaries 
and $115 billion in 2010.[Footnote 1] The MA program is Medicare's 
private plan alternative to the original Medicare fee-for-service (FFS) 
program in which MA plans provide health care coverage to Medicare 
beneficiaries. MA plans generally receive larger payments from Medicare 
than what these plans would require to provide the original Medicare 
FFS benefit package. Plans must use this additional money to reduce 
premiums, reduce cost sharing, and offer additional benefits. 

The Patient Protection and Affordable Care Act (PPACA), enacted in 
2010, required changes in how MA plan payments are set.[Footnote 2] The 
Congressional Budget Office projected that these changes would reduce 
Medicare payments to MA plans by $136 billion[Footnote 3] and decrease 
enrollment by about 35 percent through 2019. [Footnote 4] In addition, 
the Office of the Actuary of the Centers for Medicare & Medicaid 
Services (CMS) within the Department of Health and Human Services (HHS) 
determined that the reduction in payments to MA plans required by PPACA 
would eventually lead to MA plans offering benefit packages that are 
less generous than what is currently provided to 
beneficiaries.[Footnote 5] However, it is uncertain what impact, if 
any, these payment changes have had thus far on MA plan enrollment, the 
premiums and cost sharing they require from beneficiaries, and the 
additional benefits they offer. You asked us to examine these issues. 
This study assesses the extent to which the following changed from 2010 
to 2011: (1) MA enrollment, (2) MA premiums and cost-sharing 
requirements, and (3) the additional benefits offered by MA plans. 

To assess the extent to which MA enrollment changed from 2010 to 2011, 
we used MA enrollment data for April of each year that we obtained from 
CMS. We focused our analysis on the following types of MA plans: health 
maintenance organizations (HMO), local preferred provider organizations 
(PPO), regional PPOs, and private fee-for-service (PFFS) 
plans.[Footnote 6] We excluded one type of MA plan--medical savings 
accounts, which accounted for about 600 beneficiaries in 2010 and about 
1,500 beneficiaries in 2011, because they operate differently than 
other MA plans.[Footnote 7] In addition, we excluded plans that only 
provided Medicare Part B benefits and plans that restricted enrollment 
to members of an employer group or to beneficiaries with certain health 
conditions or needs--called special needs plans (SNP).[Footnote 8] 
After implementing these exclusions, our analysis included about 71 
percent of both the 11.1 million MA beneficiaries in April 2010 and the 
11.8 million MA beneficiaries in April 2011. 

To assess the extent to which MA premiums and cost-sharing requirements 
changed from 2010 to 2011, we used two data sources: (1) Bid Pricing 
Tool data, which contain information MA plans submitted to CMS on their 
projected revenue requirements for providing Medicare-covered services 
to enrolled beneficiaries; and (2) data on plan benefit packages. We 
used the bid data to calculate MA plans' average premium. For purposes 
of this report, the term MA plan premium applies to health benefits and 
excludes Part D coverage, unless otherwise noted. We also used the bid 
data to calculate plans' projected total cost sharing for beneficiaries 
as a percentage of projected cost sharing for these beneficiaries had 
they remained in Medicare FFS. Because our cost-sharing analysis is 
based on plans' projections for 2010 and 2011, our results may differ 
from plans' actual experience during these years. We obtained 
information on plans' out-of-pocket maximums from the benefit package 
data.[Footnote 9] For plans with an out-of-pocket maximum for in-
network services and also one for combined in-and out-of-network 
services, we used the lower value for this analysis. 

To assess the extent to which the additional benefits MA plans offered 
changed from 2010 to 2011, we analyzed the benefit package data. We 
focused on the categories of additional benefits that were most 
commonly offered by MA plans and that were available to all plan 
beneficiaries.[Footnote 10] We weighted results for all of our analyses 
by each plan's enrollment in April of 2010 or 2011. We assessed the 
reliability of the MA plan enrollment, bid, and benefit package data by 
interviewing CMS officials, conducting logic tests, and comparing our 
results to published sources. 

We conducted this performance audit from February 2011 through October 
2011 in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings based on our audit objectives. 

Background: 

MA plans must offer benefits covered under Medicare FFS, which consist 
of Part A and Part B-covered services, except hospice care. MA plans 
also have the option of offering health benefits, such as dental and 
vision coverage, beyond what is included in the Medicare FFS benefit 
package. MA plans may charge a monthly premium to cover the health 
benefits they offer, although many do not. In addition to health 
benefits, MA plans generally offer Part D prescription drug coverage, 
for which they may charge an additional premium. 

MA plans, like Medicare FFS, can require that beneficiaries pay cost 
sharing when they receive medical services.[Footnote 11] CMS permits MA 
plans to have cost-sharing requirements that differ from Medicare 
FFS.[Footnote 12] However, CMS requires that an MA plan's projected 
total cost sharing, on average, be no greater than the projected amount 
for beneficiaries in Medicare FFS.[Footnote 13] CMS also requires that, 
beginning in 2011, plans establish limits on the amount a beneficiary 
spends on cost sharing in a given year, called out-of-pocket maximums. 
These limits provide financial protection to beneficiaries who 
otherwise would have higher cost-sharing expenses. In contrast to MA 
plans, Medicare FFS does not have an out-of-pocket maximum. 

Medicare pays MA plans a monthly amount to provide health coverage for 
enrolled beneficiaries. CMS determines this amount based on a plan's 
bid--the plan's projected cost of providing Medicare Part A and Part B 
benefits--in relation to a benchmark, which is the maximum amount the 
Medicare program will pay MA plans in a given locality.[Footnote 14] If 
an MA plan's bid exceeds the benchmark, the plan must charge each of 
its beneficiaries an additional premium to make up the difference. If a 
plan's bid is less than the benchmark, 75 percent of the difference is 
returned to the plan as a rebate, which must be used to reduce 
premiums, reduce cost sharing, or provide additional benefits.[Footnote 
15] Because the benchmarks are generally greater than spending in FFS, 
even plans that bid below FFS spending levels in their service areas 
are paid above FFS spending amounts. 

PPACA required CMS to change the way Medicare pays MA plans by revising 
plan benchmarks and rebates and by linking these payments to the 
quality of care that MA plans provide. In 2011, rather than increasing 
benchmarks annually as in previous years, they were frozen at 2010 
levels.[Footnote 16] Revised benchmarks will be phased in over a 2-to 6-
year period beginning in 2012. These benchmarks will be lower, on 
average, and are designed to align more closely with Medicare FFS 
spending.[Footnote 17] PPACA also phases in reduced MA plan rebates 
from 2012 through 2014 and varies rebate amounts based on CMS's 
assessments of plan quality.[Footnote 18] Finally, PPACA required that, 
beginning in 2012, CMS increase payments to MA plans with quality 
ratings above a certain threshold, with higher quality plans receiving 
greater increases and the lowest quality plans receiving no 
increase.[Footnote 19] 

MA Plan Enrollment Increased by about 6 Percent from 2010 to 2011: 

Enrollment in the MA plans we analyzed increased by about 6 percent--
from 7.9 million beneficiaries in April 2010 to 8.4 million 
beneficiaries in April 2011--and enrollment growth varied substantially 
by MA plan type. HMOs, which account for about two-thirds of total MA 
enrollment in 2011, increased by about 9 percent, from about 5.2 
million beneficiaries to about 5.6 million beneficiaries (see fig. 1). 
Local and regional PPOs, which comprise a much smaller portion of total 
MA enrollment compared to HMOs, experienced the highest percentage 
growth in enrollment--local PPOs increased by 38 percent and regional 
PPOs increased by 58 percent. In contrast, PFFS plans experienced a 54 
percent decline in enrollment, which was likely due to requirements 
that most PFFS plans establish provider networks beginning in 
2011.[Footnote 20] 

Figure 1: MA Enrollment in 2010 and 2011, by Plan Type: 

[Refer to PDF for image: vertical bar graph] 

Plan type: All plans; 
2010: Number of beneficiaries in thousands: 7,921; 
2010: Number of plans: 2,307; 
2011: Number of beneficiaries in thousands: 8,364; 
2011: Number of plans: 1,964. 

Plan type: HMO; 
2010: Number of beneficiaries in thousands: 5,155; 
2010: Number of plans: 1,279; 
2011: Number of beneficiaries in thousands: 5,629; 
2011: Number of plans: 1,127. 

Plan type: Local PPO; 
2010: Number of beneficiaries in thousands: 989; 
2010: Number of plans: 527; 
2011: Number of beneficiaries in thousands: 1,361; 
2011: Number of plans: 533. 

Plan type: Regional PPO; 
2010: Number of beneficiaries in thousands: 484; 
2010: Number of plans: 59; 
2011: Number of beneficiaries in thousands: 763; 
2011: Number of plans: 59. 

Plan type: PFFS; 
2010: Number of beneficiaries in thousands: 1,271; 
2010: Number of plans: 435; 
2011: Number of beneficiaries in thousands: 582; 
2011: Number of plans: 239. 

Source: GAO analysis of CMS data on MA enrollment in April 2010 and 
April 2011. 

Notes: The "All plans" category includes PSOs in addition to the other 
types of MA plans shown above. Results are not reported separately for 
PSOs because these plans constituted less than 1 percent of total 
enrollment in 2010 and 2011. We excluded the following types of plans 
from our analysis: employer plans, Part B-only plans, SNPs, Program of 
All Inclusive Care for the Elderly plans, demonstration plans, and cost 
plans. 

[End of figure] 

Despite the increase in enrollment from April 2010 through April 2011, 
the number of MA plans decreased from 2,307 to 1,964. Most of this 
reduction was a decrease in PFFS plan offerings, from 435 plans to 239. 
CMS officials told us that about 75 percent of the beneficiaries in MA 
plans that were not renewed in 2011 were in PFFS plans. The number of 
HMO plans also decreased--from 1,279 in 2010 to 1,127 in 2011, which in 
part may be due to CMS's efforts to simplify MA plan offerings by 
eliminating potentially duplicative plans and those with low 
enrollment.[Footnote 21] According to CMS officials, 84 plans with low 
enrollment were either consolidated with other plans or 
eliminated.[Footnote 22] CMS officials identified and encouraged MA 
plan sponsors to consolidate potentially duplicative plans so that 
beneficiaries would more easily be able to differentiate among MA plans 
offered and select the plan that best meets their needs. 

Average MA Premiums Decreased from 2010 to 2011, and Projected Cost 
Sharing Was Stable: 

The average monthly premium for beneficiaries in MA plans decreased 
from $28 in 2010 to $24 in 2011.[Footnote 23] This was about a 14 
percent reduction in the average monthly premium (see fig. 2).[Footnote 
24] The extent of the reduction and the premium amount varied 
substantially among plan types. For example, the average monthly 
premium for beneficiaries in PFFS plans fell by about 21 percent from 
2010 to 2011, while the average monthly premium for beneficiaries in 
HMOs fell by about 8 percent. In 2011, beneficiaries in local PPOs 
continued to pay over twice as much for their monthly premium as 
beneficiaries in regional PPOs. 

Figure 2: Average Premium Charged by MA Plans in 2010 and 2011, by Plan 
Type: 

[Refer to PDF for image: vertical bar graph] 

Average premium (in dollars). 

Plan type: All plans; 
2010: $28; 
2011: $24. 

Plan type: HMO; 
2010: $25; 
2011: $23. 

Plan type: Local PPO; 
2010: $42; 
2011: $37. 

Plan type: Regional PPO; 
2010: $18; 
2011: $12. 

Plan type: PFFS; 
2010: $33; 
2011: $26. 

Source: GAO analysis of 2010 and 2011 CMS Bid Pricing Tool and 
enrollment data. 

Notes: Results are weighted by plan enrollment in April of each year. 
Average premium amounts are for health benefits and do not include 
premiums for Part D prescription drug coverage. Results are based on 
all plans in the analysis, including plans that do not charge a 
premium. The "All plans" category includes PSOs in addition to the 
other types of MA plans shown above. Results are not reported 
separately for PSOs because these plans constituted less than 1 percent 
of total enrollment in 2010 and 2011. We excluded the following types 
of plans from our analysis: employer plans, Part B-only plans, SNPs, 
Program of All Inclusive Care for the Elderly plans, demonstration 
plans, and cost plans. 

[End of figure] 

MA plans projected that their cost-sharing requirements would be about 
half of the level in Medicare FFS in both 2010 and 2011.[Footnote 25] 
Cost sharing was generally stable across plan types, with at most a 5 
percentage point change from 2010 to 2011, but the level of cost 
sharing varied substantially (see fig. 3). For example, in both years 
HMOs had the lowest cost-sharing requirement--40 to 42 percent of the 
Medicare FFS average--and regional PPOs had the highest cost-sharing 
requirement--76 to 77 percent of the average in Medicare FFS. In both 
2010 and 2011, most of the funding that MA plans used to pay for lower 
cost sharing than Medicare FFS was from Medicare rebates, with the 
remainder coming from additional beneficiary premiums.[Footnote 26] 

Figure 3: Average Projected Cost Sharing for MA Beneficiaries Compared 
to Their Cost Sharing in Medicare FFS, 2010 and 2011: 

[Refer to PDF for image: vertical bar graph] 

Plan type: All plans; 
2010: Percentage of Medicare FFS cost sharing: 48%; 
2010: Projected Medicare FFS cost sharing in dollars: $118; 
2011: Percentage of Medicare FFS cost sharing: 48%; 
2011: Projected Medicare FFS cost sharing in dollars: $121. 

Plan type: HMO; 
2010: Percentage of Medicare FFS cost sharing: 42%; 
2010: Projected Medicare FFS cost sharing in dollars: $123; 
2011: Percentage of Medicare FFS cost sharing: 40%; 
2011: Projected Medicare FFS cost sharing in dollars: $125. 

Plan type: Local PPO; 
2010: Percentage of Medicare FFS cost sharing: 53%; 
2010: Projected Medicare FFS cost sharing in dollars: $110; 
2011: Percentage of Medicare FFS cost sharing: 58%; 
2011: Projected Medicare FFS cost sharing in dollars: $112. 

Plan type: Regional PPO; 
2010: Percentage of Medicare FFS cost sharing: 77%; 
2010: Projected Medicare FFS cost sharing in dollars: $114; 
2011: Percentage of Medicare FFS cost sharing: 76%; 
2011: Projected Medicare FFS cost sharing in dollars: $114. 

Plan type: PFFS; 
2010: Percentage of Medicare FFS cost sharing: 63%; 
2010: Projected Medicare FFS cost sharing in dollars: $106; 
2011: Percentage of Medicare FFS cost sharing: 66%; 
2011: Projected Medicare FFS cost sharing in dollars: $109. 

Source: GAO analysis of 2010 and 2011 CMS Bid Pricing Tool and 
enrollment data. 

Notes: Results are weighted by plan enrollment in April of each year. 
The "All plans" category includes PSOs in addition to the other types 
of MA plans shown above. Results are not reported separately for PSOs 
because these plans constituted less than 1 percent of total enrollment 
in 2010 and 2011. We excluded the following types of plans from our 
analysis: employer plans, Part B-only plans, SNPs, Program of All 
Inclusive Care for the Elderly plans, demonstration plans, and cost 
plans. 

[End of figure] 

From 2010 to 2011, the percent of MA beneficiaries in plans with an out-
of-pocket maximum increased from 74 percent to 100 percent. This 
increase is not surprising given that, effective in 2011, CMS requires 
all MA plans to have an out-of-pocket maximum.[Footnote 27] The 
proportion of MA beneficiaries in plans with out-of-pocket maximums at 
or below $3,400 also increased--from 47 percent in 2010 to 52 percent 
in 2011 (see fig. 4).[Footnote 28] In 2011, MA beneficiaries in 
Regional PPOs and PFFS plans were more likely than MA beneficiaries in 
HMOs or local PPOs to be enrolled in plans with out-of-pocket maximums 
between $3,401 to $6,700. Unlike MA plans, Medicare FFS does not limit 
beneficiaries' out-of-pocket costs. 

Figure 4: MA Beneficiaries' Out-of-Pocket Maximum by Plan Type, 2010 
and 2011: 

[Refer to PDF for image: vertical bar graph] 

Plan type: All Plans; 
2010: Overall out-of-pocket maximum of greater than $6,700: 2%; 
2010: Overall out-of-pocket maximum of $3,401 to $6,700: 25%; 
2010: Overall out-of-pocket maximum of $3,400 or less: 47%; 
2010: No overall out-of-pocket maximum: 26%; 
2011: Overall out-of-pocket maximum of greater than $6,700: 0; 
2011: Overall out-of-pocket maximum of $3,401 to $6,700: 48%; 
2011: Overall out-of-pocket maximum of $3,400 or less: 52%; 
2011: No overall out-of-pocket maximum: 0. 

Plan type: HMO; 
2010: Overall out-of-pocket maximum of greater than $6,700: 2%; 
2010: Overall out-of-pocket maximum of $3,401 to $6,700: 12%; 
2010: Overall out-of-pocket maximum of $3,400 or less: 50%; 
2010: No overall out-of-pocket maximum: 36%; 
2011: Overall out-of-pocket maximum of greater than $6,700: 0; 
2011: Overall out-of-pocket maximum of $3,401 to $6,700: 42%; 
2011: Overall out-of-pocket maximum of $3,400 or less: 58%; 
2011: No overall out-of-pocket maximum: 0. 

Plan type: Local PPO; 
2010: Overall out-of-pocket maximum of greater than $6,700: 2%; 
2010: Overall out-of-pocket maximum of $3,401 to $6,700: 31%; 
2010: Overall out-of-pocket maximum of $3,400 or less: 56%; 
2010: No overall out-of-pocket maximum: 11%; 
2011: Overall out-of-pocket maximum of greater than $6,700: 0; 
2011: Overall out-of-pocket maximum of $3,401 to $6,700: 50%; 
2011: Overall out-of-pocket maximum of $3,400 or less: 50%; 
2011: No overall out-of-pocket maximum: 0. 

Plan type: Regional PPO; 
2010: Overall out-of-pocket maximum of greater than $6,700: 2%; 
2010: Overall out-of-pocket maximum of $3,401 to $6,700: 59%; 
2010: Overall out-of-pocket maximum of $3,400 or less: 39%; 
2010: No overall out-of-pocket maximum: 0; 
2011: Overall out-of-pocket maximum of greater than $6,700: 0; 
2011: Overall out-of-pocket maximum of $3,401 to $6,700: 70%; 
2011: Overall out-of-pocket maximum of $3,400 or less: 30%; 
2011: No overall out-of-pocket maximum: 0. 

Plan type: PFFS; 
2010: Overall out-of-pocket maximum of greater than $6,700: 1%; 
2010: Overall out-of-pocket maximum of $3,401 to $6,700: 64%; 
2010: Overall out-of-pocket maximum of $3,400 or less: 30%; 
2010: No overall out-of-pocket maximum: 5%; 
2011: Overall out-of-pocket maximum of greater than $6,700: 0; 
2011: Overall out-of-pocket maximum of $3,401 to $6,700: 79%; 
2011: Overall out-of-pocket maximum of $3,400 or less: 21%; 
2011: No overall out-of-pocket maximum: 0. 

Source: GAO analysis of 2010 and 2011 CMS plan benefit package data and 
enrollment data. 

Notes: Results are weighted by plan enrollment in April of each year. 
The "All plans" category includes PSOs in addition to the other types 
of MA plans shown above. Results are not reported separately for PSOs 
because these plans constituted less than 1 percent of total enrollment 
in 2010 and 2011. We excluded the following types of plans from our 
analysis: employer plans, Part B-only plans, SNPs, Program of All 
Inclusive Care for the Elderly plans, demonstration plans, and cost 
plans. If a plan had two out-of-pocket maximums--one for in-network 
services and one for combined in-and out-of-network services, then we 
used the lower value for this analysis. 

[End of figure] 

MA Plans' Coverage of Additional Benefits Was Generally Similar in 2010 
and 2011: 

The percentage of MA beneficiaries in plans that offered additional 
benefits was generally similar in 2010 and 2011. In both years, at 
least 64 percent of beneficiaries were in plans providing benefits such 
as hearing and vision. There were some changes, however, between 2010 
and 2011 in the percentage of beneficiaries with certain benefits. For 
example, the proportion of MA beneficiaries with vision coverage 
decreased from 84 percent to 79 percent (see fig. 5). Such changes 
could be due to changes in plan offerings, changes in beneficiaries' 
plan selections, or some combination of the two. See appendix I for 
details on changes in the proportion of MA beneficiaries who received 
coverage for additional benefits by plan type. 

Figure 5: MA Beneficiaries in Plans that Offered Additional Benefits, 
2010 and 2011: 

[Refer to PDF for image: vertical bar graph] 

Type of additional benefit: Professional[A]; 
Percentage of beneficiaries: 2010: 100%; 
Percentage of beneficiaries: 2011: 98%. 

Type of additional benefit: Health and education[B]; 
Percentage of beneficiaries: 2010: 97%; 
Percentage of beneficiaries: 2011: 98%. 

Type of additional benefit: Inpatient facility[C]; 
Percentage of beneficiaries: 2010: 97%; 
Percentage of beneficiaries: 2011: 97%. 

Type of additional benefit: International outpatient emergency[D]; 
Percentage of beneficiaries: 2010: 96%; 
Percentage of beneficiaries: 2011: 97%. 

Type of additional benefit: Outpatient blood[E]; 
Percentage of beneficiaries: 2010: 87%; 
Percentage of beneficiaries: 2011: 91%. 

Type of additional benefit: Vision[F]; 
Percentage of beneficiaries: 2010: 84%; 
Percentage of beneficiaries: 2011: 79%. 

Type of additional benefit: Skilled nursing facility[G]; 
Percentage of beneficiaries: 2010: 72%; 
Percentage of beneficiaries: 2011: 68%. 

Type of additional benefit: Hearing[H]; 
Percentage of beneficiaries: 2010: 64%; 
Percentage of beneficiaries: 2011: 64%. 

Type of additional benefit: Dental[I]; 
Percentage of beneficiaries: 2010: 38%; 
Percentage of beneficiaries: 2011: 38%. 

Source: GAO analysis of 2010 and 2011 CMS plan benefit package and 
enrollment data. 

Notes: Results are weighted by plan enrollment in April of each year. 
The "All plans" category includes PSOs in addition to the other types 
of MA plans shown above. Results are not reported separately for PSOs 
because these plans constituted less than 1 percent of total enrollment 
in 2010 and 2011. We excluded the following types of plans from our 
analysis: employer plans, Part B-only plans, SNPs, Program of All 
Inclusive Care for the Elderly plans, demonstration plans, and cost 
plans. 

[A] Professional services benefits may include screenings and 
immunizations beyond what Medicare FFS covers. 

[B] Health and education benefits may include nutritional training, 
smoking cessation, health club memberships, or nursing hotlines. 

[C] Inpatient facility benefits may include additional days beyond what 
Medicare FFS covers. 

[D] International outpatient emergency benefits may include additional 
services beyond what Medicare FFS covers. 

[E] Outpatient blood benefits may include payment associated with pints 
of blood received as an outpatient or as part of a Part B-covered 
service beyond what Medicare FFS covers. 

[F] Vision benefits may include coverage for routine eye exams, contact 
lenses, or eyeglasses (lenses and frames). 

[G] Skilled nursing facility benefits may include waiving the 3-day 
inpatient hospital stay requirement in Medicare FFS. 

[H] Hearing benefits may include coverage for hearing tests, hearing 
aid fittings, and hearing aid evaluations. 

[I] Dental benefits may include oral exams, teeth cleanings, fluoride 
treatments, dental X-rays, or emergency dental services. 

[End of figure] 

Agency Comments: 

We received written comments from HHS on a draft version of this 
report. HHS did not comment directly on our results for 2010 and 2011. 
However, HHS stated that MA premiums would be 4 percent lower, on 
average, in 2012 compared to 2011 but that 2012 benefits would remain 
consistent with those offered in 2011. HHS also stated that MA plans 
projected that enrollment would be 10 percent higher in 2012 than in 
2011. HHS provided technical comments, which we incorporated as 
appropriate. We reprinted the letter from HHS in appendix II. 

As agreed with your offices, unless you publicly announce the contents 
of this report earlier, we plan no further distribution until 30 days 
from the report date. At that time, we will send copies to the 
Secretary of HHS and to interested congressional committees. In 
addition, the report will be available at no charge on the GAO Web site 
at [hyperlink, http://www.gao.gov]. If you or your staff have any 
questions about this report, please contact me at (202) 512-7114 or 
CosgroveJ@gao.gov. Contact points for our Offices of Congressional 
Relations and Public Affairs may be found on the last page of this 
report. GAO staff who made major contributions to this report are 
listed in appendix III. 

Signed by: 

James C. Cosgrove: 
Director, Health Care: 

[End of section] 

Appendix I: MA Beneficiaries Receiving Coverage for Additional Benefits 
by Plan Type, 2010 and 2011: 

Table 1: Percent of MA Beneficiaries in Plans that Offered Additional 
Benefits in 2010 and 2011, by Plan Type: 

Service category: Professional[A]; 
All plans: 2010: 100%; 
All plans: 2011: 98%; 
HMO: 2010: 100%; 
HMO: 2011: 98%; 
Local PPO: 2010: 99%; 
Local PPO: 2011: 95%; 
Regional PPO: 2010: 100%; 
Regional PPO: 2011: 98%; 
PFFS: 2010: 100%; 
PFFS: 2011: 100%. 

Service category: Health and education[B]; 
All plans: 2010: 97%; 
All plans: 2011: 98%; 
HMO: 2010: 98%; 
HMO: 2011: 98%; 
Local PPO: 2010: 97%; 
Local PPO: 2011: 96%; 
Regional PPO: 2010: 95%; 
Regional PPO: 2011: 97%; 
PFFS: 2010: 94%; 
PFFS: 2011: 99%. 

Service category: Inpatient facility[C]; 
All plans: 2010: 97%; 
All plans: 2011: 97%; 
HMO: 2010: 97%; 
HMO: 2011: 96%; 
Local PPO: 2010: 99%; 
Local PPO: 2011: 99%; 
Regional PPO: 2010: 99%; 
Regional PPO: 2011: 99%; 
PFFS: 2010: 96%; 
PFFS: 2011: 97%. 

Service category: International outpatient emergency[D]; 
All plans: 2010: 96%; 
All plans: 2011: 97%; 
HMO: 2010: 97%; 
HMO: 2011: 97%; 
Local PPO: 2010: 93%; 
Local PPO: 2011: 95%; 
Regional PPO: 2010: 100%; 
Regional PPO: 2011: 100%; 
PFFS: 2010: 96%; 
PFFS: 2011: 100%. 

Service category: Outpatient blood[E]; 
All plans: 2010: 87%; 
All plans: 2011: 91%; 
HMO: 2010: 85%; 
HMO: 2011: 90%; 
Local PPO: 2010: 90%; 
Local PPO: 2011: 94%; 
Regional PPO: 2010: 100%; 
Regional PPO: 2011: 98%; 
PFFS: 2010: 87%; 
PFFS: 2011: 92%. 

Service category: Vision[F]; 
All plans: 2010: 84%; 
All plans: 2011: 79%; 
HMO: 2010: 94%; 
HMO: 2011: 90%; 
Local PPO: 2010: 73%; 
Local PPO: 2011: 65%; 
Regional PPO: 2010: 63%; 
Regional PPO: 2011: 46%; 
PFFS: 2010: 60%; 
PFFS: 2011: 50%. 

Service category: Skilled nursing facility[G]; 
All plans: 2010: 72%; 
All plans: 2011: 68%; 
HMO: 2010: 69%; 
HMO: 2011: 64%; 
Local PPO: 2010: 83%; 
Local PPO: 2011: 80%; 
Regional PPO: 2010: 68%; 
Regional PPO: 2011: 65%; 
PFFS: 2010: 77%; 
PFFS: 2011: 76%. 

Service category: Hearing[H]; 
All plans: 2010: 64%; 
All plans: 2011: 64%; 
HMO: 2010: 70%; 
HMO: 2011: 72%; 
Local PPO: 2010: 46%; 
Local PPO: 2011: 44%; 
Regional PPO: 2010: 49%; 
Regional PPO: 2011: 48%; 
PFFS: 2010: 58%; 
PFFS: 2011: 50%. 

Service category: Dental[I]; 
All plans: 2010: 38%; 
All plans: 2011: 38%; 
HMO: 2010: 37%; 
HMO: 2011: 36%; 
Local PPO: 2010: 55%; 
Local PPO: 2011: 47%; 
Regional PPO: 2010: 60%; 
Regional PPO: 2011: 51%; 
PFFS: 2010: 22%; 
PFFS: 2011: 15%. 

Service category: Number of plans; 
All plans: 2010: 2,294; 
All plans: 2011: 1,964; 
HMO: 2010: 1,266; 
HMO: 2011: 1,127; 
Local PPO: 2010: 527; 
Local PPO: 2011: 533; 
Regional PPO: 2010: 59; 
Regional PPO: 2011: 59; 
PFFS: 2010: 435; 
PFFS: 2011: 239. 

Service category: Number of beneficiaries; 
All plans: 2010: 7,903,152; 
All plans: 2011: 8,364,464; 
HMO: 2010: 5,137,525; 
HMO: 2011: 5,629,092; 
Local PPO: 2010: 988,821; 
Local PPO: 2011: 1,360,888; 
Regional PPO: 2010: 484,041; 
Regional PPO: 2011: 762,754; 
PFFS: 2010: 1,270,904; 
PFFS: 2011: 581,644. 

Source: GAO analysis of 2010 and 2011 CMS plan benefit package and 
enrollment data. 

Notes: Results are weighted by plan enrollment in April of each year. 
The "All plans" category includes PSOs in addition to the other types 
of MA plans shown above. Results are not reported separately for PSOs 
because these plans constituted less than 1 percent of total enrollment 
in 2010 and 2011. We excluded the following types of plans from our 
analysis: employer plans, Part B-only plans, SNPs, Program of All 
Inclusive Care for the Elderly plans, demonstration plans, and cost 
plans. 

[A] Professional services benefits may include screenings and 
immunizations beyond what Medicare FFS covers. 

[B] Health and education benefits may include nutritional training, 
smoking cessation, health club memberships, or nursing hotlines. 

[C] Inpatient facility benefits may include additional days beyond what 
Medicare FFS covers. 

[D] International outpatient emergency benefits may include additional 
services beyond what Medicare FFS covers. 

[E] Outpatient blood benefits may include payment associated with pints 
of blood received as an outpatient or as part of a Part B covered 
service beyond what Medicare FFS covers. 

[F] Vision benefits may include coverage for routine eye exams, contact 
lenses, or eyeglasses (lenses and frames). 

[G] Skilled nursing facility benefits may include waiving the 3-day 
inpatient hospital stay requirement in Medicare FFS. 

[H] Hearing benefits may include coverage for hearing tests, hearing 
aid fittings, and hearing aid evaluations. 

[I] Dental benefits may include oral exams, teeth cleanings, fluoride 
treatments, dental X-rays, or emergency dental services. 

[End of table] 

[End of section] 

Appendix II: Comments from the Department of Health and Human Services: 

Department Of Health & Human Services: 
Office Of The Secretary: 

Assistant Secretary for Legislation: 
Washington, DC 20201: 

October 7, 2011: 

James Cosgrove, Director: 
HealthCare: 
U.S. Government Accountability Office: 
441 G Street NW: 
Washington, DC 20548: 

Dear Mr. Cosgrove:

Attached are comments on the U.S. Government Accountability Office's 
(GAO) draft report entitled, "Medicare Advantage: Enrollment Increased 
from 2010 to 2011 while Premiums Decreased and Benefit Packages Were 
Stable" (GAO-12-93). The Department appreciates the opportunity to 
review this report before its publication. 

Sincerely,

Signed by: 

Jim R. Esquea: 
Assistant Secretary for Legislation: 
Attachment: 

General Comments Of The Department Of Health And Human Services (HHS) 
On The Government Accountability Office's (GAO) Draft Report Entitled, 
"Medicare Advantage: Enrollment Increased From 2010 To 2011 While 
Premiums Decreased And Benefit Packages Were Stable" (GAO-12-93): 

The Department recently announced that 2012 Medicare Advantage premiums 
are falling and projected enrollment is rising. On average, Medicare 
Advantage premiums will be 4 percent lower in 2012 than in 2011, and 
plans project enrollment to increase by 10 percent. Of people with 
Medicare, 99.7 percent continue to enjoy access to a Medicare Advantage 
plan, and benefits remain consistent with those offered in 2011. The 
Centers for Medicare and Medicaid Services (CMS) was able to use 
authority provided by the Affordable Care Act to protect beneficiaries 
from significant increases in costs or cuts in benefits in 2012. In 
addition, average premiums are declining for the second year in a row: 
2012 premiums are projected to be 11.5 percent below 2010 premiums.

[End of section] 

Appendix III: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

James C. Cosgrove, (202) 512-7114 or CosgroveJ@gao.gov: 

Acknowledgments: 

In addition to the contact named above, Christine Brudevold, Assistant 
Director; William Black; George Bogart; Elizabeth Morrison; and Kristal 
Vardaman made key contributions to this report. 

[End of section] 

Footnotes: 

[1] Medicare FFS, also known as original Medicare, includes Medicare 
Parts A and B. Medicare Part A covers hospital and other inpatient 
stays. Medicare Part B is optional insurance, which covers hospital 
outpatient, physician, and other services and requires a monthly 
premium. Medicare beneficiaries who enroll in Part B have the option of 
enrolling in an MA plan--which operates under Medicare Part C--to 
receive their Parts A and B benefits. In addition, all Medicare 
beneficiaries may opt to receive prescription drug coverage under 
Medicare Part D either through a separate Part D plan or through an MA 
plan that offers prescription drug benefits. 

[2] See Pub. L. No. 111-148, title III, subtitle C, 124 Stat. 119, 442 
et seq. (2010) (as amended by the Health Care and Education 
Reconciliation Act of 2010, Pub. L. No. 111-152, § 1102, 124 Stat. 
1029, 1040 et seq.) For purposes of this report, references to PPACA 
include the amendments made by the Health Care and Education 
Reconciliation Act of 2010. 

[3] See Congressional Budget Office, H.R. 4872, Reconciliation Act of 
2010 (Final Health Care Legislation), March 20, 2010 (based on MA 
provisions in a combination of prior versions of PPACA and the Health 
Care and Education Reconciliation Act of 2010). 

[4] The Congressional Budget Office projected that, under PPACA, about 
9.1 million beneficiaries would be enrolled in MA plans in 2019--about 
4.8 million fewer than it projected would enroll in the absence of 
PPACA. See Congressional Budget Office, Comparison of Projected 
Enrollment in Medicare Advantage Plans and Subsidies for Extra Benefits 
Not Covered by Medicare Under Current Law and Under Reconciliation 
Legislation Combined with H.R. 3590 as Passed by the Senate, March 19, 
2010 (based on a preliminary estimate of MA provisions in a prior 
version of PPACA combined with draft language for the Health Care and 
Education Reconciliation Act of 2010). 

[5] CMS is the agency that administers the Medicare program. 

[6] We also included provider-sponsored organizations (PSO) in our 
analysis. 

[7] Beneficiaries in a medical savings account plan receive annual 
deposits from CMS into an interest-bearing account to help them cover 
their health care costs until they have reached their plan's 
deductible, after which the plan is responsible for all Medicare-
covered costs. 

[8] We also excluded Program of All Inclusive Care for the Elderly 
plans, which provide social and medical services primarily in adult day 
health centers, CMS demonstration plans, and cost plans. 

[9] Thirteen of the 2,307 plans in our analysis for 2010, accounting 
for about 0.2 percent of total enrollment, did not have data on out-of-
pocket maximums in the benefit package data, so we used the out-of-
pocket maximum information in the bid data. All of the 1,964 plans in 
our analysis for 2011 had out-of-pocket maximum information in the 
benefit package data. 

[10] We excluded the 13 plans from our analysis of additional benefits 
in 2010 that did not have this information in the benefit package data. 
The Social Security Act uses the term supplemental benefits; throughout 
this report, we use the term additional benefits to refer to 
supplemental benefits. Our analysis addresses mandatory supplemental 
benefits, which are benefits in addition to the Medicare FFS benefit 
package that must be available to every beneficiary enrolled in the 
plan. We did not analyze optional supplemental benefits, which are 
available to those enrollees who elect and pay for them. 

[11] Beneficiary cost sharing can be in the form of (1) a deductible--
the amount a beneficiary pays for services before the plan or Medicare 
FFS begins to pay; (2) coinsurance--a percentage of the cost for a 
given service that a beneficiary must pay; and (3) copayments--a 
standard amount a beneficiary must pay for a service. 

[12] In 2011, Medicare FFS cost-sharing requirements include a 
deductible of $1,132 for inpatient care--covered under Medicare Part A-
-and a $162 deductible and 20 percent coinsurance for Part B physician 
services. 

[13] Under this total, CMS limits cost sharing to an amount that is 
actuarially equivalent to the Medicare FFS amount for certain services, 
such as inpatient facility and skilled nursing facility. 

[14] MA plans offering Part D prescription drug coverage undergo a 
separate process to determine monthly Medicare payments for Part D 
benefits, including enrollee premiums. This process involves comparing 
a plan's bid for providing Part D benefits to the average bid among 
plans nationally. 

[15] The remaining 25 percent of the difference between an MA plan's 
bid and the benchmark is retained by the government. 

[16] Pub. L. No. 111-148, § 3201, 124 Stat. 119, 442 (as amended by 
Pub. L. No. 111-152, § 1102, 124 Stat. 1029, 1040). The benchmark for 
an MA plan is calculated based on the county-level benchmarks in the 
plan's service area. From 2007 through 2010, CMS generally updated 
county benchmarks annually for local MA plans by the growth of Medicare 
expenditures. Benchmarks for regional MA plans are updated by combining 
the county benchmarks in each region with a weighted average of 
regional plan bids. 

[17] Under the revised methodology, county benchmarks will range from 
95 percent of Medicare FFS spending per beneficiary for MA plans in 
areas with the highest FFS spending levels to 115 percent of FFS 
spending per beneficiary for plans in areas with the lowest FFS 
spending levels. The Medicare Payment Advisory Commission (MedPAC) 
estimated that the revised methodology would reduce the average 
benchmark from an average of 113 percent of Medicare FFS spending per 
beneficiary in 2011 to 101 percent in 2017. MedPAC, Report to the 
Congress: Medicare Payment Policy (March 2011). 

[18] CMS assesses plan quality using a five-star rating scale based on 
measures of clinical quality, patients' reported care experience, and 
contract performance. Once fully phased in, the revised rebates will 
range from 50 percent of the difference between a plan's bid and 
benchmark for plans with the lowest quality ratings to 70 percent of 
the difference for plans with the highest quality ratings. 

[19] On November 10, 2010, CMS announced that it would provide bonus 
payments to MA plans beginning in 2012 through a new demonstration 
project called the Quality Bonus Payment Demonstration. 

[20] The Medicare Improvements for Patients and Providers Act of 2008 
required PFFS plans to establish provider networks beginning in 2011 if 
these plans were in areas with at least two available network-based 
plans (such as HMOs or PPOs). In areas with fewer than two network-
based plans, most PFFS plans will continue to have the option of 
operating without networks if they pay providers at Medicare FFS rates 
or higher. Pub. L. No. 110-275, §162, 122 Stat. 2494, 2569. 

[21] CMS identified potentially duplicative plans by determining if 
plans of similar plan types offered by a given MA organization had 
meaningful differences in the projected level of beneficiaries' out-of-
pocket costs. CMS considered two plans of the same sponsor and plan 
type as potentially duplicative if the difference in beneficiaries' 
projected out-of-pocket costs was less than $20. 

[22] CMS officials said that most of these plans, which include SNPs 
and in total accounted for about 16,000 MA beneficiaries, were 
consolidated rather than eliminated. CMS considered plans to have low 
enrollment if they had fewer than 500 beneficiaries for non-SNP plans 
and fewer than 100 for SNPs. According to CMS, the agency maintains a 
flexible approach in enforcing these thresholds to ensure that 
geographic areas have a suitable number of plan options. CMS noted that 
it also considers the specific populations served by the plan and 
locality needs, among other factors that may cause the plan to have low 
enrollment. 

[23] Beneficiaries in MA plans also continue to pay the Part B premium; 
however, MA plans may use their rebates to reduce beneficiaries' Part B 
premiums. In 2011, for most Medicare beneficiaries, the Medicare Part B 
monthly premium was between $96.40 and $115.40. 

[24] The total MA plan premium--including the premium for Part D 
prescription drug coverage--for the over 90 percent of beneficiaries in 
our analysis who were in MA plans with Part D coverage, decreased from 
$41 in 2010 to $36 in 2011. 

[25] Medicare FFS cost sharing takes different forms. In 2011, Medicare 
FFS required a deductible payment of $1,132 before it began paying for 
an inpatient stay, and $162 before it began paying for any Part B 
services. For certain benefits Medicare FFS requires coinsurance, such 
as 20 percent of the total payment for physician visits, while for 
other benefits Medicare FFS requires copayments, such as $283 per day 
for days 61 through 90 of an inpatient stay in 2011. 

[26] Based on MA plans' projections, we estimated that about 69 percent 
of the funding MA plans used to reduce cost sharing or provide 
additional benefits in 2010 was from their rebates, and in 2011 it was 
about 73 percent. 

[27] In 2011, HMOs and PFFS plans were required to establish mandatory 
out-of-pocket maximums of no more than $6,700. Local PPOs were required 
to establish in-network out-of-pocket maximums of no more than $6,700 
and catastrophic out-of-pocket maximums of no more than $10,000. 
Regional PPOs could determine their own in-network and catastrophic 
limits. Beginning in 2012, regional PPOs will have the same out-of-
pocket maximum requirement as local PPOs. 

[28] In 2010 and 2011, CMS gave plans with out-of-pocket maximums of 
$3,400 or below greater flexibility in the design of their cost-sharing 
requirements than plans with higher out-of-pocket maximums. For 
example, in 2011, plans with out-of-pocket maximums higher than $3,400 
could not charge beneficiaries more than $1,613 for a 6-day inpatient 
facility stay, while plans with out-of-pocket maximums at or below 
$3,400 could charge beneficiaries up to $2,016 for a 6-day inpatient 
facility stay. 

[End of section] 

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