MEDICARE 

ADVANTAGE

CMS Should Use 

Data on Disenrollment 

and Beneficiary 

Health Status to 

Strengthen Oversight

Report to Congressional Requesters

April 2017

GAO-17-393

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-17-393, a report to 

congressional requesters

April 2017

MEDICARE ADVANTAGE

CMS Should Use Data on Disenrollment and 

Beneficiary Health Status to Strengthen Oversight

What GAO Found

Under the Medicare Advantage (MA) program, the Centers for Medicare 

& Medicaid Services (CMS) contracts with private entities to offer 

coverage for Medicare beneficiaries. GAO examined 126 contracts with 

higher disenrollment rates—above the median rate of 10.6 percent in 

2014—and found 35 contracts with health-biased disenrollment. In these 

contracts, beneficiaries in poor health were substantially more likely (on 

average, 47 percent more likely) to disenroll relative to beneficiaries in 

better health. Such disparities in contract disenrollment by health status 

may indicate that the needs of beneficiaries, particularly those in poor 

health, may not be adequately met. 

GAO found that beneficiaries who left the 35 contracts with health-biased 

disenrollment tended to report leaving for reasons related to preferred 

providers and access to care. In contrast, beneficiaries who left the 91 

contracts without health-biased disenrollment tended to report that they 

left their contracts for reasons related to the cost of care.

Disenrollment Reasons Survey Responses for the 126 Medicare Advantage Contracts with 

Relatively High Disenrollment, 2014

CMS does not use available data to examine data on disenrollment by 

health status as part of its ongoing oversight; thus, CMS may fail to 

identify problems in MA contract performance, which poses a risk as 

contracts are prohibited from limiting coverage based on health status. 

CMS’s oversight is inconsistent with internal control standards.

View GAO-17-393. For more information, 

contact James Cosgrove at (202) 512-7114 or 

cosgrovej@gao.gov.

Why GAO Did This Study

In 2016, over 30 percent of Medicare 

beneficiaries were enrolled in the MA 

program. Each year beneficiaries have 

an opportunity to join or leave their MA 

plan. 

GAO was asked to review MA 

disenrollment by health status and 

CMS oversight. This report examines, 

among other issues, (1) the extent of 

any health-biased disenrollment, (2) 

beneficiaries’ reasons for leaving 

contracts with and without health 

biased disenrollment, and (3) how, if at 

all, CMS identifies contracts with 

health-biased disenrollment, for routine 

oversight purposes. 

GAO analyzed 2014 disenrollment 

rates for the 252 MA contracts that had 

a sufficient number of disenrollees and 

met other criteria. For the 126 

contracts with disenrollment rates 

above the median rate, GAO used 

beneficiaries’ projected health care 

costs to identify those in poor health 

and better health. GAO examined data 

from CMS’s Disenrollment Reasons 

Survey to learn why beneficiaries 

reported leaving the 126 contracts with 

relatively high disenrollment rates. 

GAO also interviewed CMS officials 

and compared their oversight to federal 

standards for internal control. 

What GAO Recommends

To strengthen its oversight of MA 

contracts, CMS should examine data 

on disenrollment by health status and 

the reasons beneficiaries disenroll.

HHS concurred with GAO’s 

recommendation. 
Page i GAO-17-393 Medicare Advantage

Letter 1

Methodology 4

Background 7

2014 MA Contract Disenrollment Rates Ranged from 1 to 39 

Percent 9

Health-biased Disenrollment Found in One-Quarter of MA 

Contracts with Higher Disenrollment Rates 11

Contracts with Health-biased Disenrollment Had Lower 

Enrollment, a Greater Proportion of HMOs, and Relatively Low 

Quality Ratings, among Other Differences 12

Beneficiaries Reported Different Reasons for Disenrolling from 

Contracts with and without Health-Biased Disenrollment 16

CMS Does Not Identify Health-biased Disenrollment as Part of Its 

Routine Oversight of MA Contracts 18

Conclusions 20

Recommendation 20

Agency Comments 21

Appendix I Selection of Contracts Included in Our Study 22

Appendix II Comments from the Department of Health and Human Services 24

Appendix III GAO Contact and Staff Acknowledgments 27

Tables

Table 1: Characteristics of 126 Medicare Advantage Contracts 

with Relatively High Disenrollment Rates, 2014 13

Table 2: Percentage of 126 MA Contracts with Relatively High 

Disenrollment Rates That Have Better Than Median 

Performance on MA Five-Star Measures, 2014 15

Figures

Figure 1: Distribution of Disenrollment Rates across 252 Medicare 

Advantage Contracts, 2014 10

Figure 2: 2016 Star Ratings among 126 MA Contracts with 

Relatively High Disenrollment Rates 14

Contents
Page ii GAO-17-393 Medicare Advantage

Figure 3: Disenrollment Reasons Survey Responses for the 126 

Medicare Advantage Contracts with Relatively High 

Disenrollment Rates, 2014 18

Figure 4: Selection Methodology for Medicare Advantage (MA) 

Contracts Included in Our Study 23

Abbreviations

CMS Centers for Medicare & Medicaid Services

HMO health maintenance organization 

MA Medicare Advantage

MAO Medicare Advantage organization 

PFFS private fee-for-service

PPO preferred provider organization 

SNP special needs plan

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Page 1 GAO-17-393 Medicare Advantage

441 G St. N.W.

Washington, DC 20548

April 28, 2017

The Honorable Rosa L. DeLauro

Ranking Member

Subcommittee on Labor, Health and Human Services, Education, and

 Related Agencies

Committee on Appropriations

House of Representatives

The Honorable Sherrod Brown

United States Senate

The Medicare Advantage (MA) program, under which private entities—

known as MA organizations (MAO)—contract with the Centers for 

Medicare & Medicaid Services (CMS) to provide health care coverage to 

Medicare beneficiaries, has grown in recent years.1 MA enrollment has 

increased from 11.1 million in 2010 to 17.6 million in 2016, and the 

program now accounts for nearly a third of all Medicare beneficiaries—

more than in any previous year. Under MAOs’ contracts, beneficiaries 

may typically choose from a wide array of plans that vary in their 

coverage, costs, and provider networks.2 Medicare requires MAOs to 

accept all beneficiaries who want to enroll in a plan, and the program has 

certain protections in place to ensure that the needs of beneficiaries in 

poor health are adequately met.3 For example, MAOs are prohibited from 

limiting or conditioning their coverage or provision of benefits based on 

health status, and CMS may not approve bids for MA contracts with plans 

that have benefit packages that discourage the enrollment of certain 

beneficiaries, such as those with chronic conditions.4 In addition, CMS 

 1

CMS is the agency within the Department of Health and Human Services that

administers the Medicare program.

2

An MAO, such as Aetna, may have one or several contracts with CMS with each contract 

offering different plan benefit packages, such a standard plan or an enhanced plan, which 

provide a different mix of costs and benefits. 

3

For the purposes of this report, we refer to MA enrollees as beneficiaries. 

4

42 U.S.C. § 1395w-22(b)(1)(A); 42 C.F.R. §§ 422.100(f) (2016). CMS enforces such 

antidiscrimination requirements by, for example, monitoring cost sharing for services such 

as cardiac and pulmonary rehabilitation services. 

Letter
Page 2 GAO-17-393 Medicare Advantage

requires that MAOs develop provider networks that ensure adequate 

access to covered services for all beneficiaries.5

Because MAOs can change their plan offerings from one year to the next, 

CMS encourages MA beneficiaries to review their enrollment decisions 

annually and consider which plan best meets their needs. Beneficiaries 

may choose to remain in their current plan, enroll in another plan offered 

under the same MAO contract, enroll in a plan offered under a different 

contract, or enroll in traditional Medicare.6 Each MAO contract is specific 

to a plan type—such as a health maintenance organization (HMO) or a 

preferred provider organization (PPO)—but each contract may include a 

variety of plan benefit packages (referred to as a plan) for beneficiaries to 

select, each with its own unique mix of cost sharing requirements and 

covered benefits.7

Consequently, beneficiaries who choose to enroll in a different plan under 

the same MA contract, have elected to stay in the same type of plan (e.g., 

HMO or PPO) offered by the same MAO. In contrast, beneficiaries who 

choose to enroll in a plan offered under a different contract have elected 

to enroll in a different type of plan or one offered by a different MAO. In 

2014, nearly 12 percent of beneficiaries chose to leave their MA contract, 

due to a number of potential factors. Contract-level disenrollment may 

indicate a well-functioning competitive local MA market with competing 

MAOs seeking to attract beneficiaries to their plans by offering additional 

benefits or lower premiums and cost sharing. Alternatively, disenrollment 

may indicate that beneficiaries encountered access or quality issues. 

These beneficiaries may disenroll, for example, if their preferred provider 

is no longer in the plan’s network or if they believe that their health care 

needs have not been well met.

 5

Part C-Medicare Advantage Application, §§ 2.8; 3.11.A.; See also 42 C.F.R. § 

422.112(a)(1)(i) ( 2016). For additional information on CMS oversight of MA network 

adequacy, see GAO, Medicare Advantage: Actions Needed to Enhance CMS Oversight of 

Provider Network Adequacy, GAO-15-710 (Washington, D.C.: Aug. 31, 2015).

6

In traditional fee-for-service Medicare, Medicare pays providers who submit claims for 

reimbursement after services have been rendered. Beneficiaries pay a premium, 

deductible, and any applicable cost sharing, and may elect to receive covered benefits 

from any Medicare participating provider.

7

HMOs generally restrict beneficiary access to providers in their network. PPOs also have 

networks, but allow beneficiaries access to non-network providers by paying higher cost 

sharing amounts when receiving care from these providers. 
Page 3 GAO-17-393 Medicare Advantage

While disenrollment among some of a contract’s beneficiaries is 

expected, disparities in disenrollment rates between beneficiaries with 

different health care needs can be a sign of potential problems with a 

contract. If MAOs are meeting the needs of all their beneficiaries, we 

would expect that the rates at which beneficiaries disenroll would not vary 

by their health status. However, when beneficiaries in poor health are 

more likely to disenroll than those in better health—which we refer to as 

health-biased disenrollment—it may indicate that those beneficiaries 

could be facing problems with access to care or the quality of services 

provided.8 From an oversight perspective, contracts with health-biased 

disenrollment may not warrant extra CMS scrutiny if relatively few 

beneficiaries choose to leave the contract. However, contracts with both 

high overall rates of disenrollment and health-biased disenrollment may 

indicate potentially problematic contracts.

Given questions about the care beneficiaries in poor health receive in MA, 

you asked us to review MA disenrollment by health status and any related 

CMS oversight. In this report, we examined

1. the extent to which disenrollment rates vary across MA contracts;

2. the extent of any health-biased disenrollment among MA contracts;

3. how the characteristics of those contracts with health-biased 

disenrollment, if any, compare to those of other contracts;

4. the reasons beneficiaries give for leaving those contracts with healthbiased disenrollment, if any, compared with other contracts; and

5. how, if at all, CMS identifies contracts with health-biased 

disenrollment as part of its routine oversight of MA contracts.

 8

Some studies have found that beneficiaries in poor health may be more likely than 

beneficiaries in better health to leave their MA contracts and join traditional Medicare. See 

Momotazur Rahman, et al., “High-Cost Patients Had Substantial Rates of Leaving 

Medicare Advantage and Joining Traditional Medicare,” Health Affairs, vol. 34, no. 10 

(2015); Gretchen Jacobson, et al., “At Least Half of New Medicare Advantage Enrollees 

Had Switched From Traditional Medicare During 2006-11,” Health Affairs, vol. 34, no. 1 

(2015); and Gerald F. Riley, “Impact of Continued Biased Disenrollment from the Medicare 

Advantage Program to Fee-for-Service,” Medicare & Medicaid Research Review, vol. 2, 

no. 4 (2012). 
Page 4 GAO-17-393 Medicare Advantage

To examine variation in MA disenrollment by contract, we examined CMS 

enrollment and disenrollment data for 2014—the most recent year of data 

available at the time of our analysis—for 252 contracts.9 We selected 

these 252 contracts as they had at least 100 disenrollees in poor health 

and 100 disenrollees in better health as well as had at least 50 percent of 

the individual measures in the 2016 MA Five-Star Rating System—which 

largely reflected performance in 2014.10 These contracts accounted for 80 

percent of the 17.5 million beneficiaries enrolled in an MA contract that 

year.11 We calculated the disenrollment rate for each of these contracts 

and designated the 126 contracts above the median rate of 10.6 percent 

as having relatively high disenrollment rates and the 126 contracts below 

the median rate as having relatively low disenrollment rates. (See 

appendix I for more details on the selection of the contracts included in 

our study.)

To determine the extent of health-biased disenrollment, if any, among MA 

contracts, we focused our analysis on the 126 MA contracts with higher

disenrollment rates.12 We used CMS risk score data to identify 

beneficiaries in poor health and beneficiaries in better health. Specifically, 

beneficiaries whose projected spending was at least twice as much as 

that for the average Medicare beneficiary were characterized as being in 

poor health, while the remaining beneficiaries with projected spending 

 9

CMS data on MA enrollment and disenrollment are at the contract level and exclude 

those enrolled in employer-sponsored contracts. These disenrollment data do not account 

for beneficiaries who enrolled in another plan offered under the same contract. The data 

also exclude beneficiaries who involuntarily disenrolled for reasons that included moving 

outside of their contract service area, experienced a contract closure, or death. For 

beneficiaries who switched contracts multiple times during the year, we counted each 

change as a separate disenrollment. 

10There were 480 contracts, with 3.6 million beneficiaries that we excluded from our 

analysis. These contracts had less than 100 disenrollees in poor health or 100 

disenrollees in better health, or contracts for which CMS reported fewer than 50 percent of 

the individual measures in the 2016 MA Five-Star Rating System—which largely reflected 

performance in 2014. 

11Beneficiaries may have been enrolled in more than one contract in 2014 and our 

beneficiary enrollment calculation accounts for the total number of unique enrollments in 

each MA contract. According to CMS, there were 15.9 million beneficiaries enrolled in 

December 2014. 

12We excluded contracts with below median disenrollment as they may not warrant the 

same level of oversight scrutiny as those with higher rates. 

Methodology
Page 5 GAO-17-393 Medicare Advantage

less than that amount were considered to be in better health.13 Using this 

information for each of the 126 contracts, we then calculated 

disenrollment odds ratios to determine the likelihood that beneficiaries in 

poor health disenrolled from the contract compared to beneficiaries in 

better health. For example, an odds ratio of 1.50 signifies that those in 

poor health were 50 percent more likely to disenroll than those in better 

health.14 We deemed contracts with an odds ratio over 1.25—where the 

likelihood that poor health beneficiaries disenrolled was more than 25 

percent greater than that of beneficiaries in better health—as having 

health-biased disenrollment.15 We deemed those contracts with an odds 

ratio of 1.25 or less as lacking health-biased disenrollment.

To examine the characteristics of contracts with and without healthbiased disenrollment, we focused our analysis on the 126 MA contracts 

with higher disenrollment rates in 2014. We analyzed CMS data for 2014 

on a number of contract variables, including enrollment size and the 

number of years of experience in the MA program. In addition, we 

compared the quality ratings of contracts in each group based on data 

from the MA Five-Star Rating System. These data comprise an overall 

star rating for each MA contract as well as each contract’s performance 

scores on up to 47 individual measures—such as controlling blood 

pressure—grouped within 9 domains—such as managing chronic 

 13We used Medicare risk score information on each beneficiary, which is used to set 

payment rates to MA plans. CMS develops risk scores based on demographic and 

diagnosis information that are used project how much it will cost to provide care for each 

beneficiary. The average score is 1; higher scores correspond to higher predicted health 

care costs. For example, a score of 2.0 would indicate a beneficiary has projected 

spending twice the national average. We classified beneficiaries with risk scores of 2.0 or 

higher as having poor health and those with risk scores of less than 2.0 as being in better 

health.

14For example, a hypothetical contract had 500 beneficiaries in poor health, of which 100 

disenrolled and 400 remained in the contract. In this case, for every one beneficiary who 

disenrolled, four remained. Of the 600 beneficiaries in good health in the same contract, 

100 disenrolled. In this case, for every 1 beneficiary who disenrolled, five remained. The 

relationship between these two calculations can be expressed as an odds ratio, which in 

this case would be (1/4) / (1/5) = 1.25.

15An odds ratio over 1.0 indicates some degree of health-biased disenrollment. To ensure 

that we captured contracts with a sizeable amount of health-biased disenrollment, we 

defined those contracts with odds ratio over 1.25 as having health-biased disenrollment. 

Disenrollment odds for each health group were calculated as the number of beneficiaries 

who disenrolled divided by the number who stayed in the contract. 
Page 6 GAO-17-393 Medicare Advantage

conditions.16 We determined the median score for individual performance 

measures for all contracts in the rating system. For both the contracts 

with and without health-biased disenrollment, we then determined the 

percentage of measures within each domain that had better than median 

scores; we characterized these contracts as having relatively high 

quality.17

To examine the reasons beneficiaries chose to disenroll from contracts 

with and without health-biased disenrollment, we analyzed CMS’s 

Disenrollment Reasons Survey reports. The reports are compiled for MA 

contracts based on surveys sent to a representative sample of 

disenrollees to learn about why they elected to leave their plan. CMS 

combined survey responses into one of five composite reasons for 

disenrollment: problems with costs, problems with drug coverage, 

problems getting information on drugs, problems getting needed care, 

and preferred providers not in network.18 For each of the 126 MA 

contracts with higher disenrollment rates, we compared the average 

percentage of respondents who identified each composite reason, for 

contracts with and without health-biased disenrollment.19

To examine how, if at all, CMS identifies contracts with health-biased 

disenrollment as part of its routine oversight of MA contracts, we reviewed 

the agency guidance and data provided to its regional offices and 

interviewed CMS officials. In addition, we compared the set of contracts 

 16For our analysis, we used the 2016 Part C and Part D Star ratings, which we refer to as 

the MA Five-Star Rating System. These ratings largely reflect beneficiaries experience in 

2014. However, about a quarter of the measures reflect a time period that overlaps 2014 

(e.g., 2013-2014) and about 10 percent reflect the first half of 2015. The ratings apply to 

all plans within a given contract. CMS applies different weights to each measure to reflect 

its importance and assigns each contract an overall star rating. For example, CMS 

assigns greater weight to outcome measures, which focus on improvement to a 

beneficiary’s health, with less weight assigned to process measures, which evaluate the 

method by which health care is provided. 

17For some measures—such as the contract’s complaint rate and disenrollment rate—

lower scores represented better performance. In these instances, we defined relatively 

high quality as a score that was at or below the median score for that measure. 

18For example, the composite reason “problems with drug benefits and coverage” 

included problems with desired drugs not being included on the plan’s formulary or 

because the plan refused to pay for a prescribed drug. 

19Response rates varied by contract, and beneficiaries were able to select more than one 

reason for disenrolling from their contract. We only analyzed those contracts with 

responses that CMS determined were reliable. 
Page 7 GAO-17-393 Medicare Advantage

identified by CMS as having potential problems in 2014 with the contracts 

we identified as having health-biased disenrollment. We examined CMS’s 

oversight in the context of relevant standards for internal control in the 

federal government.20

We assessed the reliability of the data from CMS that we analyzed by 

reviewing relevant documentation and examining the data for obvious 

errors. We determined that the data were sufficiently reliable for the 

purposes of our reporting objectives.

We conducted this performance audit from November 2015 to April 2017 

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 and 

conclusions based on our audit objectives.

The MA program—also known as Medicare Part C—is the private plan 

alternative to the traditional Medicare program.21 Instead of paying 

providers’ claims directly, CMS contracts with MAOs to assume the risk of 

providing health benefits to beneficiaries in exchange for fixed monthly 

payments. The payment amounts vary, in part, depending on the relative 

health status of the MAO’s beneficiaries as compared to the health status 

of an average Medicare beneficiary. CMS paid almost $170 billion to 

MAOs in 2015.

MAOs must provide coverage for all traditional Medicare services and 

include a yearly limit on out-of-pocket costs.22 Most plans also include 

prescription drug coverage offered under Medicare Part D. Plans may 

offer more generous benefits, such as less cost sharing and additional 

covered services, such as vision or dental care. To control utilization, 

 20GAO, Standards for Internal Control in the Federal Government, GAO-14-704G 

(Washington, D.C.: September 2014). Internal control is a process effected by an entity’s 

oversight body, management, and other personnel that provides reasonable assurance 

that the objectives of an entity will be achieved.

21MA beneficiaries must pay the Medicare monthly premium. Some plans may charge an 

additional monthly premium, while others may offer a reduction on the Medicare premium.

22MAOs are not required to cover hospice care as hospice services provided to MA 

beneficiaries are covered under traditional Medicare. 

Background
Page 8 GAO-17-393 Medicare Advantage

plans may impose referral requirements and implement care coordination 

programs. MA beneficiaries’ access to providers is generally limited to a 

network of physicians, hospitals, and others that contract with their MAO. 

If a given physician or hospital is not in the MA plan’s network, the 

beneficiary’s out-of-pocket cost to use that physician or hospital may be 

considerably higher than the cost associated with using providers in the 

plan’s network.

Beneficiaries may choose from the plans available in their county, which 

may be provided by multiple contacts. The contracts represent various 

types of plans, including HMOs, PPOs, and private fee-for-service (PFFS) 

plans. HMOs, which according to CMS, accounted for nearly three-fourths 

of MA enrollment in 2016, generally restrict beneficiary access to 

providers in their network. PPOs, which according to CMS, accounted for 

nearly one-fourth of 2016 MA enrollment, also have networks, but allow 

beneficiaries access to non-network providers by paying higher cost 

sharing amounts. In contrast, PFFS plans, which accounted for 1 percent 

of MA enrollment in 2016, generally offer a wider choice of providers.23 A 

subset of HMOs and PPOs are special needs plans (SNP) which provide 

care for beneficiaries in one of three classes of special needs. Medicare 

beneficiaries can enroll in a SNP if they are dually eligible for Medicare 

and Medicaid, require an institutional level of care, or have a severe or 

chronic condition.24

While beneficiaries are generally locked into their MA plan for a year 

(January through December), they may voluntarily leave their plan at 

certain times in the year or if they meet certain criteria. During the annual 

open enrollment period, from October 15 to December 7, MA 

beneficiaries may change their MA plan selection or join traditional 

Medicare. This is followed by the MA disenrollment period, from January 

1 to February 14, when MA beneficiaries may join traditional Medicare 

and are allowed to select a drug plan to go with their new coverage. In 

addition, CMS has special enrollment periods where MA beneficiaries 

may change their enrollment under certain circumstances. For example, 

Medicare beneficiaries can switch to a contract with an overall Five-Star 

rating of 5 from December 8 to the following November 30. In addition, 

 23PFFS plans are required to have networks in service areas where two or more HMOs or 

PPOs operate. In other areas, PFFS beneficiaries are free to use any Medicare provider.

24Dual-eligible beneficiaries are those who are eligible for both Medicare and Medicaid, a 

joint federal-state program that finances health insurance coverage for certain categories 

of low-income or disabled people.
Page 9 GAO-17-393 Medicare Advantage

dual-eligible beneficiaries may change their MA enrollment on the first 

day of any month.

In 2014, disenrollment rates varied widely among the 252 contracts in our 

analysis, ranging from 1 to 39 percent.25 (See fig. 1.) The 126 contracts 

with high disenrollment rates—those with rates above the median rate of 

10.6 percent—accounted for 38 percent of the MA population in our 

study. Moreover, these contracts accounted for over two-thirds of total 

disenrollment in our population. Nineteen percent of this group of 

contracts—24 contracts—had disenrollment rates of 20 percent or 

greater. In contrast, contracts with relatively low disenrollment rates 

accounted for 62 percent of the MA population in our study. Nearly half of 

these contracts had disenrollment rates at or below 5 percent.

 25Enrollment in these 252 contracts ranged from about 1,600 to over 1 million 

beneficiaries.

2014 MA Contract 

Disenrollment Rates 

Ranged from 1 to 39 

Percent
Page 10 GAO-17-393 Medicare Advantage

Figure 1: Distribution of Disenrollment Rates across 252 Medicare Advantage Contracts, 2014

Note: Excluded from our analysis were 480 contracts with fewer than 100 disenrollees in poor health 

and 100 disenrollees in better health, or contracts for which CMS reported fewer than 50 percent of 

the individual measures in the 2016 MA Five-Star Rating System—which largely reflected 

performance in 2014. We used CMS data to identify beneficiaries in relatively poor health—those with 

projected spending at least twice as much as that for the average Medicare beneficiary.
Page 11 GAO-17-393 Medicare Advantage

Among the 126 contracts with higher disenrollment rates, we found that 

35 contracts had health-biased disenrollment—meaning that beneficiaries 

in poor health were substantially more likely to leave their contracts than 

those in better health. These contracts accounted for 15 percent of 

beneficiaries in higher disenrollment contracts, or approximately 810,000 

beneficiaries. For these 35 contracts, on average, beneficiaries in poor 

health were 47 percent more likely to disenroll relative to beneficiaries in 

better health. For individual contracts, this percentage ranged from 27 to 

126 percent.

Among the remaining 91 contracts with higher disenrollment rates, we did 

not find evidence of health-biased disenrollment—meaning that in these 

contracts, beneficiaries in poor health had, on average, odds of 

disenrollment similar to beneficiaries in better health. Specifically, both 

disenrollees in poor health and disenrollees in better health had a 1 in 5 

chance of disenrolling from their contract. In total, the 91 contracts 

accounted for 4.5 million beneficiaries, or 85 percent of the enrollment in 

the MA contracts with higher rates of disenrollment in our review.

Health-biased 

Disenrollment Found 

in One-Quarter of MA 

Contracts with Higher 

Disenrollment Rates

Where did beneficiaries go when they 

chose to leave their MA contract with high 

disenrollment?

The majority-84 percent-switched to another 

MA contract in 2014. The remaining 16 

percent enrolled in traditional Medicare. Such 

a high rate of switching among MA contracts 

may reflect general satisfaction with the MA 

program. However, it may also reflect certain 

barriers disenrollees may face in opting for 

traditional Medicare. For instance, 

beneficiaries may have difficulty obtaining a 

supplemental Medigap insurance policy from 

a private insurer when enrolling in traditional 

Medicare outside of the initial enrollment 

period.a Even MA beneficiaries in relatively 

poor health-those with projected spending at 

least twice as much as that for the average 

Medicare beneficiary-tended to switch MA 

contracts instead of opting for traditional 

Medicare: 79 percent of beneficiaries in poor 

health who disenrolled from their MA plan in 

2014 chose to remain in MA. 

Source: GAO. | GAO-17-393

a

Beneficiaries enrolling in traditional Medicare have

the option of purchasing private supplemental 

insurance to help cover cost sharing amounts. 

Beneficiaries are able to purchase this coverage 

without medical underwriting at certain times. 

However, beneficiaries who enrolled in MA upon 

becoming Medicare eligible and enroll in traditional 

Medicare after 12 months may be subject to medical 

underwriting as part of enrolling in a Medigap plan. 
Page 12 GAO-17-393 Medicare Advantage

We found several notable differences when comparing the characteristics 

of the 35 contracts with health-biased disenrollment with the 91 contracts

without health-biased disenrollment. Specifically, the 35 health-biased 

disenrollment contracts were more likely to have the following:

• Lower enrollment. Sixty-nine percent of health-biased disenrollment 

contracts had fewer than 15,000 enrollees.26 This percentage was 

lower for contracts without health-biased disenrollment—25 percent. 

In addition, a smaller percentage of health-biased disenrollment 

contracts—11 percent—had enrollment that exceed 50,000 

beneficiaries. In contrast, 29 percent of contracts without healthbiased disenrollment had enrollments that large.

• Higher proportion of HMOs. Ninety-one percent of health-biased 

disenrollment contracts were HMOs—which feature closed provider 

networks—while only 9 percent were PPOs. In contrast, for contracts 

without health-biased disenrollment, 70 percent were HMOs and 25 

percent were PPOs.

• Larger share of SNP enrollees. Contracts with health-biased 

disenrollment tended to have a higher proportion of beneficiaries in 

SNPs—which provide targeted care for special needs individuals, 

such as those with chronic conditions. On average, 37 percent of 

these contracts had a majority of their beneficiaries in SNPs 

 26Contracts with health-biased disenrollment had an average of 23,000 beneficiaries, 

while contracts without health bias averaged 50,000 beneficiaries.

Contracts with 

Health-biased 

Disenrollment Had 

Lower Enrollment, a 

Greater Proportion of 

HMOs, and Relatively 

Low Quality Ratings, 

among Other 

Differences

Contracts with Healthbiased Disenrollment Had 

Low Enrollment and a 

Greater Proportion of 

HMOs, among Other 

Differences, Compared 

with Other Contracts
Page 13 GAO-17-393 Medicare Advantage

compared with 21 percent, on average, for the contracts without 

health-biased disenrollment.

• Less time in MA program. The contracts with health-biased 

disenrollment had, on average, fewer years in the MA program 

compared to the contracts without health-biased disenrollment—an 

average of 8 years compared to 12 years, respectively. (See table 1 

for a comparison of the characteristics of contracts with and without 

health-biased disenrollment.)

Table 1: Characteristics of 126 Medicare Advantage Contracts with Relatively High Disenrollment Rates, 2014

Characteristics Percentage of contracts

Contracts with health-biased 

disenrollment (n=35)

Contracts without health-biased 

disenrollment (n=91)

Size of contract

% Small (<=15,000 beneficiaries) 69 25

% Medium (15,001-50,000 beneficiaries) 20 46

% Large (>=50,001 beneficiaries) 11 29

Type of contract

Health maintenance organization 91 70

Preferred provider organization 9 25

Private fee-for-service 0 4

Enrollment in special needs plans (SNP)

% Majority SNP enrollment 37 21

Medicare Advantage experience

Average number of years in program 8 12

Source: GAO analysis of Centers for Medicare & Medicaid Services data. | GAO-17-393

Note: This analysis includes the 126 contracts with 2014 disenrollment rates above the median rate of 

10.6 percent among contracts in our study. We calculated odds ratios for each contract to determine 

the likelihood that beneficiaries in poor health had of disenrolling relative to those in better health. We 

used CMS data to identify beneficiaries in relatively poor health—those with projected spending at 

least twice as much as that for the average Medicare beneficiary. Contracts with odds ratios over 

1.25 were designated as having health-biased disenrollment, and contracts with odds ratios of 1.25 or 

less were considered to be without health-biased disenrollment.
Page 14 GAO-17-393 Medicare Advantage

Our analysis of data from CMS’s MA Five-Star Rating System showed 

that the contracts with health-biased disenrollment generally had lower 

overall quality ratings than contracts without health-biased 

disenrollment.27 (See fig. 2.) Among the 126 contracts with higher 

disenrollment rates, nearly two-thirds of the health-biased contracts had 

three or fewer stars compared to about one-fourth of the contracts without 

health-biased disenrollment. Furthermore, only 11 percent of contracts 

with health-biased disenrollment had four or more stars compared to 32 

percent of the contracts without health-biased disenrollment.

Figure 2: 2016 Star Ratings among 126 MA Contracts with Relatively High 

Disenrollment Rates

Notes: This analysis includes the 126 contracts with 2014 disenrollment rates above the median rate 

of 10.6 percent among contracts in our study. We calculated odds ratios for each contract to 

determine the likelihood that beneficiaries in poor health had of disenrolling relative to those in better 

health. We used CMS data to identify beneficiaries in relatively poor health—those with projected 

spending at least twice as much as that for the average Medicare beneficiary. Contracts with odds 

 27CMS developed the Five-Star Rating System—which includes measures on outcomes 

and patient experience—as a way to gauge whether beneficiaries were getting highquality care from their MAOs. CMS publishes the star ratings each year to assist 

beneficiaries in selecting a plan within a given contract as well as to determine bonus 

payments to MAOs. Forty percent of contracts had four or more stars overall and received 

bonus payments from CMS in 2016.

Contracts with Healthbiased Disenrollment 

Scored Lower on Overall 

Quality and Individual 

Performance Measures 

Than Other Contracts
Page 15 GAO-17-393 Medicare Advantage

ratios over 1.25 were designated as having health-biased disenrollment and contracts with odds 

ratios of 1.25 or less were considered to be without health-biased disenrollment.

CMS’s 2016 MA Five-Star Rating System is used to evaluate contracts on up to 47 quality and 

performance measures. These ratings largely reflect beneficiaries’ experience in 2014. However, 

about a quarter of the measures reflect a time period that overlaps 2014, e.g., 2013-2014 and about 

10 percent reflect the first half of 2015.

In addition, the contracts with health-biased disenrollment scored lower 

than the contracts without health-biased disenrollment across each of the 

nine performance domains in the MA Five-Star Rating System.28 We 

found a smaller share of the 35 contracts with health-biased disenrollment 

had better than median quality scores when compared to the 91 contracts 

without health-biased disenrollment. For example, only 36 percent of the 

contracts with health-biased disenrollment had better than median scores 

on managing chronic (long-term) conditions, which include measures on 

blood pressure and diabetes care. In contrast, 52 percent of the contracts 

without health-biased disenrollment performed above the median on this 

performance domain. (See table 2.)

Table 2: Percentage of 126 MA Contracts with Relatively High Disenrollment Rates That Have Better Than Median 

Performance on MA Five-Star Measures, 2014

Medicare domain Percentage of contracts with better than median performance scores

Contracts with health-biased 

disenrollment (n=35)

Contracts without health-biased 

disenrollment (n=91)

Medicare Advantage (Part C)

Staying healthy: screenings, tests and vaccines 39 50

Managing chronic (long-term) conditions 36 52

Member experience with health plan 18 42

Fewer member complaints; changes in health 

plan’s performance

28 37

Health plan customer service 40 62

Average percentage 32 49

Prescription drug (Part D)

Drug plan customer service 46 65

Fewer member complaints; changes in drug 

plan’s performance

25 31

 28In addition to assigning contracts an overall rating under the MA Five-Star Rating 

System, CMS also evaluates contracts on a range of quality measures and consolidates 

the individual measures into broader domains. These domains include such areas as 

management of chronic (long-term) conditions, complaints, and health plan customer 

service.
Page 16 GAO-17-393 Medicare Advantage

Medicare domain Percentage of contracts with better than median performance scores

Contracts with health-biased 

disenrollment (n=35)

Contracts without health-biased 

disenrollment (n=91)

Member experience with drug plan 36 51

Drug safety and accuracy of drug pricing 34 52

Average percentage 35 50

Overall percentage 34 49

Source: GAO review of Centers for Medicare & Medicaid Services data. | GAO-17-393

Notes: This analysis includes the 126 contracts with 2014 disenrollment rates above the median rate 

of 10.6 percent among contracts in our study. We calculated odds ratios for each contract to 

determine the likelihood that beneficiaries in poor health had of disenrolling relative to those in better 

health. We used CMS data to identify beneficiaries in relatively poor health—those with projected 

spending at least twice as much as that for the average Medicare beneficiary. Contracts with odds 

ratios over 1.25 were designated as having health-biased disenrollment and contracts with odds 

ratios of 1.25 or less were considered to be without health-biased disenrollment.

Using data from the 2016 MA Five-Star Rating System, we determined the median performance 

score across all MA contracts for each measure and determined the proportion contracts that 

performed better than the median score. These ratings largely reflect beneficiaries experience in 

2014. However, about a quarter of the measures reflect a time period that overlaps 2014, e.g., 2013-

2014 and about 10 percent reflect the first half of 2015.

Our review of CMS’s Disenrollment Reasons Survey reports showed that 

beneficiaries who disenrolled from the 35 contracts with health-biased 

disenrollment tended to report that they did so for reasons related to 

provider coverage. In contrast, beneficiaries who disenrolled from the 91

contracts without health-biased disenrollment tended to report that they 

left their contracts for reasons related to the cost of care. (See fig. 3.) 

Specifically, we found the following:

• Beneficiaries who left the 35 contracts with health-biased 

disenrollment commonly reported disenrolling because their preferred 

doctor or hospital was not covered by their MA contract.29 This reason 

was cited by 41 percent of surveyed disenrollees, on average, across 

the contracts with health-biased disenrollment. In contrast, the same 

reason was cited by 25 percent of surveyed disenrollees, on average, 

across the contracts without health-biased disenrollment.

• Beneficiaries in contracts with health-biased disenrollment were more 

likely to report problems obtaining needed care, obtaining information 

 29Beneficiaries may lack accurate information on network providers. A 2016 CMS review 

of 54 Medicare plans’ directories found that nearly half of the online physician listings were 

incorrect. For additional information on CMS oversight of MA network adequacy, see 

GAO-15-710. 

Beneficiaries 

Reported Different 

Reasons for 

Disenrolling from 

Contracts with and 

without Health-Biased 

Disenrollment
Page 17 GAO-17-393 Medicare Advantage

on drugs, and with drug coverage. For example, on average, 27 

percent of surveyed disenrollees from contracts with health-biased 

disenrollment reported difficulty getting needed care. In contrast, 16 

percent of surveyed disenrollees from contracts without health-biased 

disenrollment cited these reasons.

• Beneficiaries who left the 91 contracts without health-biased 

disenrollment were more likely to report financial reasons for 

disenrolling.30 On average, 28 percent of disenrollees from these 

contracts identified problems with costs, compared with 18 percent of 

disenrollees from contracts with health-biased disenrollment. For 

example, when asked whether the presence of another plan that costs 

less was a reason for disenrolling, 45 percent of disenrollees from the 

contracts without health-biased disenrollment cited this reason, 

compared with 27 percent of beneficiaries who left contracts with 

health-biased disenrollment.

 30Financial reasons included “monthly premium went up,” “prescription copayment went 

up,” “found a plan that costs less,” and “could no longer afford plan.”
Page 18 GAO-17-393 Medicare Advantage

Figure 3: Disenrollment Reasons Survey Responses for the 126 Medicare 

Advantage Contracts with Relatively High Disenrollment Rates, 2014

Notes: This analysis includes the 126 contracts with 2014 disenrollment rates above the median rate 

of 10.6 percent among contracts in our study. We calculated odds ratios for each contract to 

determine the likelihood that beneficiaries in poor health had of disenrolling relative to those in better 

health. We used CMS data to identify beneficiaries in relatively poor health—those with projected 

spending at least twice as much as that for the average Medicare beneficiary. Contracts with odds 

ratios over 1.25 were designated as having health-biased disenrollment and contracts with odds 

ratios of 1.25 or less were considered to be without health-biased disenrollment.

Survey response rates varied by contract, and beneficiaries were able to select more than one reason 

for disenrolling from their contract. Reasons are composites of individual questions created by CMS. 

We analyzed those responses that CMS determined were reliable.

CMS does not identify patterns of disenrollment by beneficiary health 

status in its routine oversight of MA contracts. Account managers in the 

10 regional offices are the CMS officials responsible for overseeing these 

contracts. To do so, CMS officials told us they follow a standard 

performance monitoring protocol designed to determine whether the 

contracts adhere to all program requirements and need additional 

scrutiny. As part of their review, the account managers examine a variety 

of contract performance data, including MA Five-Star ratings, beneficiary 

complaint rates, and data on significant changes in drug coverage. 

Overall contract disenrollment rates are included in the MA Five-Star 

CMS Does Not

Identify Health-biased 

Disenrollment as Part 

of Its Routine 

Oversight of MA 

Contracts
Page 19 GAO-17-393 Medicare Advantage

Rating System provided to account managers to identify contracts that 

may need closer scrutiny. However, CMS officials told us these rates do 

not include information on beneficiary health status.31

In addition, CMS’s account managers do not use the information CMS 

collects in the Disenrollment Reasons Survey in their oversight of MA 

contracts. The survey asks beneficiaries about the reasons they have 

disenrolled from their MA plan, and CMS officials told us that that CMS 

develops the survey reports and distributes them to MAOs annually to 

help them facilitate quality improvement efforts. The survey results are 

also made available to the public on CMS’s Medicare Plan Finder website 

so that beneficiaries considering enrollment in an MA plan can learn why 

beneficiaries have chosen to leave a particular plan.

Given the data account managers use in their oversight of MA contracts, 

CMS is unlikely to consistently identify contracts with health-biased 

disenrollment as needing extra scrutiny. As part of its ongoing analysis of 

contract performance data, CMS identified 63 contracts as potentially 

requiring additional scrutiny in 2014. However, this list included only 9 of 

the 35 contracts we identified as having health-biased disenrollment. 

CMS classified 2 of the 9 contracts as potentially requiring what the 

agency describes as “intensive monitoring,” which may include dedicated 

monthly meetings between the account managers and MAO 

representatives to discuss problem areas. CMS identified the other 7 

contracts as requiring some additional monitoring, which may include at 

least one meeting between the account manager and MAO 

representatives.

CMS has available data that its account managers could use to monitor 

contract disenrollment rates by beneficiary health status. Disenrollment 

rates are one of the measures used in the MA Five-Star Rating System; 

we used CMS’s beneficiary risk scores, which are based on demographic 

and diagnosis information, to identify beneficiaries in poor and better 

health; and the Disenrollment Reasons Survey provides information on 

why beneficiaries disenroll from their plans. As we have shown, contracts 

 31CMS officials told us that since disenrollment rates are only 1 of up to 45 quality and 

performance measures in the MA Five-Star Rating System, disenrollment alone would 

have a small effect on contracts’ overall star rating. Furthermore, the officials explained, 

disenrollment rates have a limited effect on whether contracts are identified as warranting 

additional review, as a contract’s star ratings are combined with the other performance 

indicators account managers use in their ongoing oversight. 
Page 20 GAO-17-393 Medicare Advantage

with health-biased disenrollment had lower quality scores, and 

beneficiaries who disenrolled from these contracts more commonly cited 

problems with coverage of preferred doctors and hospitals as well as 

problems getting access to care as leading reasons for disenrolling. As a 

result, the survey data could be used in conjunction with the other 

available data to reveal unique information about contract performance 

that other data do not show.

By not analyzing disenrollment rates for signs of potential health-biased 

disenrollment, CMS account managers may fail to identify problems in 

MA contract performance. This poses a risk to beneficiaries, given that 

MA contracts are prohibited from limiting or conditioning their coverage or 

provision of benefits based on health status and must ensure adequate 

access to covered services for all beneficiaries. CMS’s oversight is also 

inconsistent with federal internal control standards, which call for 

agencies to identify, analyze, and respond to risks.

CMS is responsible for ensuring that all MA contracts offer care that 

meets applicable standards, regardless of beneficiary health status. 

However, as part of its routine oversight, CMS does not examine 

disenrollment rates by health status. Our analysis identified 35 contracts 

in 2014 where MA beneficiaries in poor health were more likely to 

disenroll than those in better health. These contracts with health-biased 

disenrollment had quality scores that were consistently and substantially 

below the scores of contracts without health-biased disenrollment. In 

addition, survey data indicate that beneficiaries who left these contracts 

reported problems with coverage of preferred doctors and hospitals as 

well as problems getting access to care as leading reasons they chose to 

leave their contracts. This type of information on disenrollment and 

beneficiary health status is available to CMS; however, by not leveraging 

it as part of its routine oversight of MA contracts, CMS is missing an 

opportunity to better target its oversight activities toward MA contracts 

that may not be adequately meeting the health care needs of all 

beneficiaries, particularly those in poor health.

To strengthen CMS’s oversight of MA contracts, the Administrator of CMS 

should review data on disenrollment by health status and the reasons 

beneficiaries disenroll as part of the agency’s routine monitoring efforts.

Conclusions

Recommendation
Page 21 GAO-17-393 Medicare Advantage

We provided a draft of this report to HHS for comment. In its written 

comments, which are reprinted in appendix II, HHS concurred with our 

recommendation. HHS noted that it currently uses disenrollment data in 

its review of MA plan quality and performance and will continue to 

consider ways of incorporating disenrollment data in its oversight. HHS 

also provided technical comments, which we incorporated as appropriate.

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 appropriate 

congressional committees and the Secretary of Health and Human 

Services. In addition, the report will be available at no charge on the GAO 

website at http://www.gao.gov.

If you or your staffs 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.

James Cosgrove

Director, Health Care

Agency Comments
Appendix I: Selection of Contracts Included in 

Our Study

Page 22 GAO-17-393 Medicare Advantage

Using data from the Centers for Medicare & Medicaid Services (CMS), we 

examined enrollment and disenrollment in 2014—the most recent year of 

data available at the time of our analysis. Of the 732 Medicare Advantage 

(MA) contracts in 2014, we excluded 480 contracts, with 3.6 million 

beneficiaries, from our analysis. These were contracts with fewer than 

100 beneficiaries in poor health who disenrolled from the contract in 

2014, fewer than 100 beneficiaries in better health who disenrolled from 

the contract in 2014, and contracts for which CMS reported fewer than 50 

percent of the individual measures in the 2016 MA Five-Star Rating 

System—which largely reflected performance in 2014.1 These contracts 

were excluded because they did not have a sufficient number of Five-Star 

ratings, or had low contract enrollment. The remaining 252 contracts 

accounted for 79.7 percent of the 17.5 million beneficiaries enrolled in an 

MA contract in 2014.2 We then ranked the 252 contracts in terms of their 

total disenrollment rate, identifying the 126 contracts with disenrollment 

rates higher than the median of 10.6 percent as having relatively high 

disenrollment.3 In our analysis we focused on these 126 contracts 

because they had relatively high disenrollment as contracts with below 

median disenrollment may not warrant the same level of oversight 

scrutiny as those with higher rates. (See fig. 4.)

 1

We used CMS risk score data to identify beneficiaries in relatively poor health and those 

in relatively better health. Beneficiaries whose projected spending was at least twice as 

much as that for the average Medicare beneficiary were classified as being in poor health, 

while beneficiaries with projected spending less than that amount were considered to be in 

relatively better health.

2

Beneficiaries may have been enrolled in more than one contract in 2014, and our 17.5 

million beneficiary enrollment calculation accounts for the total number of contract 

enrollments. According to CMS, there were 15.9 million unique beneficiaries enrolled in 

2014.

3

Data on contract disenrollment rates account for beneficiaries who disenrolled to join 

traditional Medicare or a plan offered under a different contract; the rates do not include 

beneficiaries who enrolled in another plan offered under the same contract.

Appendix I: Selection of Contracts Included 

in Our Study
Appendix I: Selection of Contracts Included in 

Our Study

Page 23 GAO-17-393 Medicare Advantage

Figure 4: Selection Methodology for Medicare Advantage (MA) Contracts Included in Our Study
Appendix II: Comments from the Department 

of Health and Human Services

Page 24 GAO-17-393 Medicare Advantage

Appendix II: Comments from the Department 

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

of Health and Human Services

Page 25 GAO-17-393 Medicare Advantage
Appendix II: Comments from the Department 

of Health and Human Services

Page 26 GAO-17-393 Medicare Advantage
Appendix III: GAO Contact and Staff 

Acknowledgments

Page 27 GAO-17-393 Medicare Advantage

James Cosgrove, (202) 512-7114 or cosgrovej@gao.gov

In addition to the contact named above, GAO staff who made key 

contributions to this report include Rosamond Katz (Assistant Director), 

Richard Lipinski (Assistant Director), Will Crafton (Analyst-in-Charge),

and Betsy Conklin. Also contributing were Krister Friday and George 

Bogart.

Appendix III: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(100423)
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