Schoen Cathy, Davis Karen, Buttorf Christine, Willink Amber
New York Academy of Medicine.
Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health.
Issue Brief (Commonw Fund). 2018 Oct 1;2018:1-14.
Out-of-pocket expenses are capped for enrollees in Medicare Advantage (MA) plans but not for beneficiaries in traditional Medicare, which also requires a high deductible for hospital care. The need for supplemental Medigap coverage adds to traditional Medicare’s complexity and administrative costs. Shortfalls in financial protection also make it difficult to offer traditional Medicare as a choice for people under age 65, as some have proposed.
Describe alternative benefit designs that would limit out-of-pocket costs for traditional Medicare’s core services, assess their cost, and illustrate financing mechanisms.
Analysis of a $3,500 ceiling on annual out-of-pocket expenses for Parts A and B benefits and options for replacing Part A hospital cost-sharing with a $350 or $100 copayment per admission.
Estimates of the costs of the reforms are $36–$44 per beneficiary per month, assuming no behavioral or supplemental coverage changes. This could be financed by a $9–$11 increase in premiums combined with a 0.3-to-0.4-percentage-point increase in the Medicare payroll tax (split between employer and employees). Medicaid costs would decrease, while employers, retirees, and Medigap enrollees would see reduced premiums.
The reforms would improve affordability and put traditional Medicare on a more equal footing with MA plans. They would also make it easier to open traditional Medicare to people under age 65.
医疗保险优势（MA）计划参保人的自付费用有上限，但传统医疗保险受益人的自付费用没有上限，而且传统医疗保险在住院治疗方面还需要高额免赔额。补充性医保缺口保险的需求增加了传统医疗保险的复杂性和管理成本。财务保障方面的不足也使得按照一些人的提议，将传统医疗保险作为65岁以下人群的一种选择变得困难。
描述能够限制传统医疗保险核心服务自付费用的替代福利设计，评估其成本，并说明融资机制。
分析对A部分和B部分福利设定每年3500美元的自付费用上限，以及用每次住院350美元或100美元的共付额取代A部分住院费用分摊的选项。
假设行为或补充保险没有变化，改革成本估计为每位受益人每月36 - 44美元。这可以通过将保费提高9 - 11美元，同时将医疗保险工资税提高0.3至0.4个百分点（由雇主和雇员分摊）来融资。医疗补助成本将下降，而雇主、退休人员和医保缺口保险参保人的保费将降低。
这些改革将提高可承受性，使传统医疗保险与MA计划处于更平等的地位。它们还将使向65岁以下人群开放传统医疗保险变得更容易。
