MEDICARE PRIVATE 

HEALTH PLANS

Selected Current Issues

Statement of James Cosgrove 

Director, Health Care

Testimony 

Before the Subcommittee on Health, 

Committee on Ways and Means, House 

of Representatives

For Release on Delivery 

Expected at 9:30 a.m. EDT

Friday, September 21, 2012

GAO-12-1045T

United States Government Accountability Office

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United States Government Accountability Office

Highlights of GAO-12-1045T, a testimony

before the Subcommittee on Health, 

Committee on Ways and Means, House of 

Representatives

September 2012

MEDICARE PRIVATE HEALTH PLANS

Selected Current Issues

Why GAO Did This Study

As of August 2012, approximately 

13.6 million Medicare beneficiaries 

were enrolled in MA plans or Medicare 

cost plans—two private health plan 

alternatives to the original Medicare 

fee-for-service program. This testimony

discusses work GAO has done that 

may help inform the Congress as it 

examines the status of the MA 

program and the private health plans 

that serve Medicare beneficiaries. It is 

based on key background and findings 

from three previously issued GAO 

reports on (1) the MA quality bonus 

payment demonstration, 

(2) D-SNPs, and (3) Medicare cost 

plans. This information on cost plans 

was updated, based on information 

supplied by CMS, to reflect the status 

of cost plans in March 2012.

What GAO Recommends

In a March 2012 report on the MA 

quality bonus payment demonstration, 

GAO recommended that HHS cancel 

the MA quality bonus demonstration. 

HHS did not concur with this 

recommendation. In a September 2012 

report on D-SNPs, GAO recommended 

that D-SNPs improve their reporting of 

services provided to beneficiaries and 

that this information be made public. 

HHS agreed with these 

recommendations.

What GAO Found

In March 2012, GAO issued a report on the Centers for Medicare & Medicaid 

Services’ (CMS) Medicare Advantage (MA) quality bonus payment 

demonstration—a demonstration CMS initiated rather than implementing the 

quality bonus program established under the Patient Protection and Affordable 

Care Act (PPACA). Compared to the PPACA quality bonus program, CMS’s 

demonstration increases the number of plans eligible for a bonus, enlarges the 

size of payments for some plans, and accelerates payment phase-in. CMS stated

that the demonstration’s research goal is to test whether scaling bonus payments 

to quality scores MA plans receive increases the speed and degree of annual 

quality improvements for plans compared with what would have occurred under 

PPACA. GAO reported that CMS’s Office of the Actuary estimated that the 

demonstration would cost $8.35 billion over 10 years—an amount greater than 

the combined budgetary impact of all Medicare demonstrations conducted since 

1995. In addition, GAO also found several shortcomings of the demonstration 

design that preclude a credible evaluation of its effectiveness in achieving CMS’s 

stated research goal. In July 2012, GAO sent a letter to the Secretary of Health 

and Human Services (HHS), the head of the agency of which CMS is a part, 

stating that CMS had not established that its demonstration met the criteria in the 

Social Security Act of 1967, as amended, under which the demonstration is being 

performed.

In September 2012, GAO issued a report on Medicare dual-eligible special needs 

plans (D-SNP), a type of MA plan exclusively for beneficiaries that are eligible for 

Medicare and Medicaid. Dual-eligible beneficiaries are costly to Medicare and 

Medicaid in part because they are more likely than other beneficiaries to be 

disabled, report poor health status, and have limitations in activities of daily living. 

GAO found that two-thirds of 2012 D-SNP contracts with state Medicaid agencies 

that it reviewed did not expressly provide for the integration of Medicare and 

Medicaid benefits. Additionally, GAO found that compared to other MA plans, 

D-SNPs provided fewer, but more comprehensive supplemental benefits, such 

as vision, and were less likely to use rebates—additional Medicare payments 

received by many MA plans—for reducing beneficiary cost-sharing. GAO could 

not report on the extent to which benefits specific to D-SNPs were actually 

provided to beneficiaries because CMS did not collect the information. GAO also 

found that plans did not use standardized performance measures, limiting the

amount of comparable information available to CMS.

In December 2009, GAO issued a report on Medicare cost plans, which, unlike 

MA plans, are paid based on their reasonable costs incurred delivering Medicarecovered services and allow beneficiaries to disenroll at any time. GAO found that 

the approximately 288,000 Medicare beneficiaries enrolled in cost plans as of 

June 2009 had multiple MA options available to them. GAO updated this work 

using March 2012 data and found that enrollment in cost plans had increased to 

approximately 392,000 and that 99 percent of Medicare beneficiaries enrolled in 

cost plans had at least one MA option available to them, although generally fewer 

View GAO-12-1045T. For more information, options than in 2009.

contact James Cosgrove at (202) 512-7114 or 

cosgrovej@gao.gov.
 

Page 1 GAO-12-1045T

Chairman Herger, Ranking Member Stark, and Members of the 

Subcommittee:

I appreciate the opportunity to participate in today’s hearing on the status 

of the Medicare Advantage (MA) program and Medicare cost plans—two

private health plan alternatives to the original Medicare fee-for-service 

(FFS) program.1

In an effort to contain costs and encourage Medicare private health plans 

to utilize resources effectively, the Patient Protection and Affordable Care 

Act (PPACA) made changes to how MA plans are paid and introduced 

bonus payments linked to the quality of care that they provide. In 

November 2010, the Centers for Medicare & Medicaid Services (CMS), 

the agency that administers Medicare, announced that instead of 

implementing the PPACA quality bonus payment provisions, it would 

conduct a demonstration of an alternative bonus payment system from

2012 through 2014 in which all plans would participate unless they 

affirmatively opt out. 

As of August 2012, approximately 13.6 million Medicare 

beneficiaries—or about 1 of every 4—were enrolled in these Medicare 

private health plan options. Expenditures for Medicare private health 

plans reached approximately $123.7 billion in 2011. 

PPACA also included provisions that extended the availability of certain 

types of Medicare private health plan options for beneficiaries. 

Specifically, PPACA extended the authorization of special needs plans 

(SNP)—a type of MA plan intended for beneficiaries with special needs, 

such as those dually eligible for Medicare and Medicaid—through 

December 31, 2013. PPACA also extended until January 1, 2013, the 

deadline after which Medicare cost plans in service areas with sufficient 

MA competition may no longer be renewed. Medicare cost plans differ 

from MA plans in that they are paid on the basis of their reasonable costs 

incurred delivering Medicare-covered services. In comparison, MA plans 

are paid a fixed monthly payment per beneficiary and bear financial risk if 

their costs exceed Medicare payments.

 

1

Both MA plans and Medicare cost plans—the term we use to refer to Social Security Act 

§1876 Medicare cost contracts—are generally required to provide the same benefits as 

Medicare FFS. In addition, MA plans may offer benefits not provided under Medicare FFS, 

such as reduced cost sharing or vision and dental coverage. Medicare cost plans may 

also offer optional additional benefits to beneficiaries, but beneficiaries who opt for these 

additional benefits would be responsible for their entire cost.

 
 

Page 2 GAO-12-1045T

We have conducted several analyses that may help inform the Congress 

as it examines the status of the MA program and the private health plans 

that serve Medicare beneficiaries. My remarks today will focus on three of 

these analyses. Specifically, I will discuss key background information 

and findings from our recent work on (1) the MA quality bonus payment 

demonstration, (2) SNPs for dual-eligible beneficiaries, and (3) Medicare 

cost plans. My remarks are based largely on our previously issued work.2

We updated our prior work on Medicare cost plans by including more 

recent data supplied by CMS on the number of Medicare cost contracts, 

enrollment in cost plans, and the number of MA options available to 

beneficiaries enrolled in cost plans. We conducted this performance audit 

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. In addition to these three 

reports, my statement includes information from a legal analysis we 

recently issued on the MA Quality Bonus Payment Demonstration.3

CMS’s quality bonus payment demonstration includes several key 

changes from the quality bonus system established by PPACA.

Specifically, PPACA required CMS to provide quality bonus payments to 

MA plans that achieve 4, 4.5, or 5 stars on a 5-star quality rating system 

developed by CMS.4

 

2

See GAO, Medicare Managed Care: Observations about Medicare Cost Plans, 

In contrast, the demonstration significantly increases 

the number of plans eligible for a bonus, enlarges the size of payments 

for some plans, and accelerates payment phase-in. In announcing the 

GAO-10-185 (Washington, D.C.: Dec. 28, 2009); Medicare Advantage: Quality Bonus 

Payment Demonstration Undermined by High Estimated Costs and Design Shortcomings, 

GAO-12-409R (Washington, D.C.: Mar. 21, 2012); and Medicare Special Needs Plans: 

CMS Should Improve Information Available about Dual-Eligible Plans’ Performance, 

GAO-12-864 (Washington, D.C.: Sept. 14, 2012). See individual reports for details on the 

objectives, scopes, and methodologies.

3

See GAO, Medicare Advantage Quality Bonus Payment Demonstration, B-323170, 

July 11, 2012.

4

Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §§ 3201-02, 124 Stat. 

119, 442, 454 (Mar. 23, 2010), as amended by the Health Care and Education 

Reconciliation Act of 2010, Pub. L. No. 111-152, § 1102, 124 Stat. 1029, 1040 (Mar. 30, 

2010) (hereafter, “PPACA”). 

MA Quality Bonus 

Payment 

Demonstration 
 

Page 3 GAO-12-1045T

demonstration, CMS stated that the demonstration’s research goal is to 

test whether scaling bonus payments to the number of stars MA plans 

receive under the quality rating system leads to larger and faster annual 

quality improvement for plans at various star rating levels compared with 

what would have occurred under PPACA.

In March 2012, we reported that CMS’s Office of the Actuary (OACT) 

estimated that the demonstration would cost $8.35 billion over 10 years—

an amount that is at least seven times larger than that of any other 

Medicare demonstration conducted since 1995 and greater than the 

combined budgetary effect of all those demonstrations.5 The cost is 

largely for quality bonus payments more generous than those prescribed 

in PPACA. Plans are required to use these payments to provide their 

enrollees enhanced benefits, lower premiums, or reduced cost-sharing.6

Our March 2012 report also identified several shortcomings of the 

demonstration’s design that preclude a credible evaluation of its 

effectiveness in achieving CMS’s stated research goal. Notably, the 

bonus payments are based largely on plan performance that predates the 

demonstration. In particular, all of the performance data used to 

determine the 2012 bonus payments and nearly all of the data used to 

determine the 2013 bonus payments were collected before the 

demonstration’s final specifications were published. In addition, under the 

demonstration’s design, the bonus percentages are not continuously 

scaled. For example, in 2014, plans with 4, 4.5, and 5 stars will all receive 

the same bonus percentage. Finally, since all plans may participate in the 

demonstration, there is no adequate comparison group for determining 

whether the demonstration’s bonus structure provided better incentives 

We also found that the additional Medicare spending will mainly benefit 

average-performing plans—those receiving 3 and 3.5-star ratings—and 

that about 90 percent of MA enrollees in 2012 and 2013 would be in plans 

eligible for a bonus payment. As we noted in our report, while a reduction 

in MA payments was projected to occur as a result of PPACA’s payment 

reforms, OACT estimated that the demonstration would offset more than 

70 percent of these payment reductions projected for 2012 alone and 

more than one-third of the reductions for 2012 through 2014.

 

5

GAO-12-409R. 

6

Bonuses under the demonstration increase the size of plan rebates, which are additional 

payments received by many plans.
 

Page 4 GAO-12-1045T

for improving quality than PPACA’s bonus structure. We therefore 

concluded that it is unlikely that the demonstration will produce 

meaningful results.

Given the findings from our program review of the demonstration’s 

features, we recommended in our March 2012 report that the Secretary of 

Health and Human Services (HHS), who heads the agency of which CMS 

is a part, cancel the demonstration and allow the MA quality bonus 

payment system authorized by PPACA to take effect. We further 

recommended that if that bonus payment system does not adequately 

promote quality improvement, HHS should determine ways to modify it, 

which could include conducting an appropriately designed demonstration.

HHS did not agree. It stated that, in contrast to PPACA, the 

demonstration establishes immediate incentives for quality improvement 

throughout the range of quality ratings. Regarding their proposed 

evaluation of the demonstration, HHS did not consider the timing of data 

collection to be a problem and said that the comparison group it would 

use would enable them to determine the demonstration’s impact. We 

continue to believe that, given the problems we cited, the demonstration 

should be canceled.

In addition to our March 2012 report, we sent a letter on July 11, 2012, to 

HHS regarding CMS’s authority to conduct the demonstration.7 In our 

letter, we stated that CMS had not established that the demonstration met 

the criteria set forth in the Social Security Amendments of 1967, as 

amended—the statute under which CMS is conducting the demonstration. 

Specifically, the statute authorizes the Secretary to conduct 

demonstration projects to determine whether changes in payment 

methods would increase the efficiency and economy of Medicare services 

through the creation of additional incentives, without adversely affecting 

quality.8

 

7

GAO, Medicare Advantage Quality Bonus Payment Demonstration.

However, features of the demonstration, particularly those 

8

Section 402(a)(1)(A) authorizes the Secretary to develop and engage in experiments and 

demonstration projects “to determine whether, and if so which, changes in methods of 

payment or reimbursement for health care and services under health programs 

established by the Social Security Act ... would have the effect of increasing the efficiency 

and economy of health services under such programs through the creation of additional 

incentives to these ends without adversely affecting the quality of such services.” 

Relatedly, section 402(b) authorizes the Secretary to waive Medicare payment 

requirements to carry out such demonstrations.
 

Page 5 GAO-12-1045T

regarding the timing of data collection for plan star ratings, call into 

question whether the demonstration includes additional incentives to 

increase the efficiency and economy of Medicare services and raise 

concerns about the agency’s ability to determine whether the payment 

changes under the demonstration result in increased efficiency and 

economy compared to the payment methods in place under PPACA. 

In 2003, Congress authorized the establishment of three types of MA 

coordinated care plans for individuals with special needs: dual-eligible 

special needs plans (D-SNP), which are exclusively for beneficiaries 

eligible for both Medicare and Medicaid; institutional special needs plans 

for individuals in nursing homes, and chronic condition special needs 

plans for individuals with severe or disabling chronic conditions. Of the 

three types of SNPs, D-SNPs are by far the most common, accounting for 

about 80 percent of SNP enrollment as of September 2012. 

The approximately 9 million dual-eligible beneficiaries are particularly 

costly to both Medicare and Medicaid in part because they are more likely 

than other Medicare beneficiaries to be disabled, report poor health 

status, and have limitations in activities of daily living. Furthermore, their 

care must be coordinated across Medicare and Medicaid, and each 

program has its own set of covered services and requirements.

In September 2012, we reported that the 2012 D-SNP contracts with state 

Medicaid agencies that we reviewed varied considerably in their 

provisions for integration of benefits.9 Two-thirds of the 124 contracts 

between D-SNPs and state Medicaid agencies that were submitted to 

CMS for 2012 did not expressly provide for the integration of any benefits.

To carry out the requirement in the Medicare Improvements for Patients 

and Providers Act of 2008 that each D-SNP contract provide or arrange 

for Medicaid benefits to be provided,10

 

9

CMS guidance required that, at a 

minimum, contracts list the Medicaid benefits that dual-eligible

GAO-12-864

10Pub. L. No. 110-275, §164, 122 Stat. 2494, 2571.

SNPs for Dual-Eligible 

Beneficiaries 
 

Page 6 GAO-12-1045T

beneficiaries could receive directly from the state Medicaid agency or the 

state’s Medicaid managed care contractor(s).11

Like other MA plans, D-SNPs must cover all the benefits of fee-forservice, with the exception of hospice, and may offer supplemental 

benefits, such as vision and dental care. In addition, they must develop a 

model of care that describes their approach to caring for their enrollees.

The model of care describes how the plan will address 11 elements, 

including tracking measureable goals, performing health risk 

assessments, providing care management for the most vulnerable 

beneficiaries, and measuring plan performance and outcomes; and 

D-SNPs must offer the benefits that allow them to actualize these 

elements.

In our September 2012 report, we examined the supplemental benefits 

offered by D-SNPs and found that D-SNPs provided fewer supplemental 

benefits than other MA plans. However, the individual services covered 

under vision and dental benefits were generally more comprehensive 

than in other MA plans. Despite offering these supplemental benefits 

somewhat less often than other MA plans, D-SNPs allocated a larger 

percentage of their rebates—additional Medicare payments received by 

many plans—to these benefits than other MA plans. They were able to do 

so largely because they allocated a smaller percentage of rebates to 

reducing cost-sharing.

We could not report on the extent to which benefits specific to D-SNPs 

and described in the model of care were actually provided to beneficiaries 

because CMS did not collect the information. For the 15 models of care 

we reviewed, most did not report—and were not required by CMS to 

report—the number of beneficiaries who received a risk assessment, for 

example, or the number or proportion of beneficiaries who would be 

targeted as “most vulnerable.” However, of the models of care we 

reviewed, past completion rates for risk assessment varied widely among 

the 4 plans that provided this information. None of the models of care we 

reviewed reported the number of beneficiaries that were expected to 

receive add-on services, such as social support services, that were 

intended for the most-vulnerable beneficiaries. 

 

11Only new and expanding D-SNPs are required to contract with state Medicaid agencies 

in 2012. Beginning in 2013, all D-SNPs must contract with state Medicaid agencies. CMS 

stated in its 2013 training materials that contracts must specify how Medicare and 

Medicaid benefits are integrated and coordinated.
 

Page 7 GAO-12-1045T

We found that plans do not use standardized performance measures in 

their models of care, limiting the amount of comparable information 

available to CMS. Although the D-SNPs are required to report how they 

intend to evaluate their performance and measure outcomes, CMS does 

not stipulate the use of standard outcome or performance measures, 

making it difficult to use any data it might collect to compare D-SNPs’ 

effectiveness or evaluate how well they have done in meeting their goals.

Furthermore, without standard measures, it would not be possible for 

CMS to fully evaluate the relative performance of D-SNPs.

We concluded that there was little evidence available on how well 

D-SNPs are meeting their goals of helping dual-eligible beneficiaries to 

navigate two different health care systems and receive services that meet 

their individual needs. Consequently, we recommended in our September 

2012 report that CMS require D-SNPs to state explicitly in their models of 

care the extent of services they expect to provide, require D-SNPs to 

collect and report to CMS standard performance and outcome measures, 

systematically analyze these data and make the results routinely 

available to the public, and conduct an evaluation of the extent to which 

D-SNPs have provided sufficient and appropriate care to their enrollees.

HHS agreed with our recommendations and in its comments on a draft of 

our report, said that it plans to obtain more information from D-SNPs.

CMS is embarking on a new demonstration in up to 26 states with as 

many as 2 million beneficiaries to financially realign Medicare and 

Medicaid services so as to serve dual-eligible beneficiaries more 

effectively. CMS has approved one state demonstration—

Massachusetts—and continues to work with other states. If CMS 

systematically evaluates D-SNP performance, it can use information from 

the evaluation to inform the implementation and reporting requirements of 

this major new initiative.

In contrast to MA plans, which have a financial incentive to control their 

costs, a small number of Medicare private health plans—called cost 

plans—are paid on the basis of their reasonable costs incurred delivering 

Medicare-covered services. Medicare cost plans also differ structurally 

from MA plans in several ways. For example, cost plans, unlike MA plans, 

allow beneficiaries to disenroll at any time. Despite their enrollment only 

totaling under 3 percent of Medicare private health plan enrollment, 

industry representatives stated that cost plans fill a unique niche by 

providing a Medicare private health plan option in rural and other areas

that traditionally have had few or no MA plans. Under current law, new 

Medicare Cost Plans
 

Page 8 GAO-12-1045T

cost contracts are not being entered into and contracts with existing cost 

plans cannot be extended or renewed after January 1, 2013 if sufficient 

MA competition exists in the service area.12

In our December 2009 report on cost plans, we examined the MA options 

available to beneficiaries in these plans and found that all of the 

approximately 288,000 Medicare beneficiaries enrolled in cost plans as of 

June 2009 had multiple MA options available to them.

Additionally, in general, 

organizations that offer cost plans and MA plans in the same area must 

close their cost plan to new enrollment.

13 We also found 

that, of the 22 cost plan contracts, 7 were closed to new enrollment in 

2009. We recently updated this work with March 2012 data and found that 

the number of cost plan contracts decreased from 22 in 2009 to 20 in 

2012, with 6 of the 20 contracts being closed to enrollment.14 Despite this 

slight reduction in the number of contracts, enrollment in cost plans 

increased by 36 percent during this time.15 Of the approximately 392,000 

Medicare beneficiaries enrolled in cost plans in March 2012, we found 

that over 99 percent of cost plan enrollees continue to have at least one 

MA option in March 2012; however, they generally have fewer MA options 

than in June 2009 (see table 1).16

 

12Social Security Act, §1876(h)(5).

This decrease in MA options for 

beneficiaries enrolled in cost plans is consistent with the overall decrease 

in MA plans over this period, as well as with CMS’s efforts to simplify MA 

13GAO-10-185

14Between 2009 and March 2012, 1 new cost contract was closed to new enrollment. Of 

the 7 cost plans contracts that were closed to enrollment in 2009, 5 remain closed to 

enrollment, 1 contract is no longer in operation, and 1 has since become open to new 

enrollment. All 7 of the cost plan contracts that were closed to enrollment in 2009—

including 1 contract that has since become open to enrollment—had lower enrollment in 

March 2012 than they did at the end of 2009.

15This increase in enrollment was primarily due to increases in two plans in the Midwest—

one operated by Blue Cross Blue Shield of Minnesota, which exclusively serves enrollees 

in Minnesota and gained over 65,000 enrollees, and another operated by Medica 

Insurance Company, which primarily serves enrollees in Minnesota, North Dakota, South 

Dakota, and Wisconsin and gained 54,000 enrollees.

16We conducted our analysis of MA options at the contract level. Within each contract, an 

organization may offer one or more plans with different benefit packages. The percentage 

of beneficiaries enrolled in cost plans with access to a given number of MA options would 

be greater if we conducted the analysis at the plan level.
 

Page 9 GAO-12-1045T

plan offerings by eliminating potentially duplicative plans and those with 

low enrollment.

Table 1: Medicare Cost Plan Summary Statistics, June 2009 and March 2012

June 2009 March 2012

Number of contracts 22 20

Enrollment 287,796 392,048

Number of contracts closed to new enrollment 7 6 

Percentage of beneficiaries enrolled in cost plans 

with access to at least

1 Medicare Advantage (MA) option 100% 99%

5 MA options 99% 80%

10 MA options 89% 25%

15 MA options 57% 1%

Source: GAO analysis of CMS data.

Note: We conducted our analysis of MA options at the contract level. Within each contract, an 

organization may offer one or more plans with different benefit packages. The percentage of 

beneficiaries enrolled in cost plans with access to a given number of MA options would be greater if 

we conducted the analysis at the plan level.

As part of our 2009 report on cost plans we also described the concerns 

of officials from Medicare cost plans about converting to MA plans. We 

found that the most-common concerns cited by these officials from 

organizations that offered Medicare cost plans were potential future 

changes to MA payments that may then necessitate closing the plan, 

difficulty assuming financial risk given their small enrollment, and potential 

disruption to beneficiaries during the transition.

For future contacts regarding this testimony, please call James Cosgrove 

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 statement. Other individuals who made key contributions 

include Phyllis Thorburn, Assistant Director; Alison Binkowski; 

Krister Friday; Gregory Giusto; and Eric Wedum.

Contact and 

Acknowledgments

(291084)
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