How We Calculate the Out-of-Pocket Costs (OOPC) Data
The Centers for Medicare & Medicaid Services (CMS) used the events or incidents of health care
usage reported by individual people with Medicare from the Medicare Current Beneficiary Survey (MCBS).
Each person included in the MCBS self-reported their health status, and health care utilization.
We also matched the reported use of health care to the individual claims history to make sure we included
Medicare covered services as well as services not covered by Medicare.
CMS combined 2004 and 2005 MCBS data to create statistically valid and reliable cost estimates.
Of the 11,089 people with Medicare in the 2004 MCBS file, information for 6,708 was used in
calculating out-of-pocket costs. Of the 11,510 people with Medicare in the 2005 MCBS file,
information for 6,823 was used in calculating out-of-pocket costs. Data from both years was
combined to create a nationally representative cohort of 13,531 people with Medicare.
We excluded individuals for certain reasons including if they did not participate in both
Medicare Parts A & B for the full 12 months of the year or if they were in a long-term care
facility for any part of the year. We wanted to focus on people in Original Medicare so that
we could link both MCBS survey results and the Medicare claims data for the same period.
We also excluded certain categories of individuals whose claims are paid differently or for
whom we would not have a full complement of data. We created 5 health status categories (excellent, very good, good, fair,
poor). We also created 3 high
cost diagnostic conditions: diabetes, congestive heart failure, heart attack.
For each of the 5 health status categories and 3 diagnostic conditions we calculated
estimated average monthly out-of-pocket costs for health plan. CMS used the actual
Medicare claims payment experience and the MCBS self-reported health care utilization to
determine total health care utilization for each of the 13,531 people with Medicare. CMS then
computed the out-of-pocket costs based on the benefits covered and co-payments/coinsurance for
each health care service. For the Medicare Advantage out-of-pocket costs projections, CMS used
the data entered into the Plan Benefit Packages (PBP) to compute out-of-pocket costs. For the Original Medicare Plan
and Medigap, CMS applied coinsurance and deductibles to Medicare payment amounts.
CMS made the following basic assumptions related to the out-of-pocket cost estimates for the Original
Medicare Plan and Medicare Advantage Plans:
People with Medicare:
- Do not have any other insurance other than Medicare (no supplemental insurance).
- Enrolled in Part B when first eligible.
- Go to providers who accept Medicare assignment.
- People with Medicare have Original Medicare and the selected Medigap policy. Only include the standardized policies at the State level. (Medicare SELECT is not included.) Use exempted State policies offered by Massachusetts, Minnesota, and Wisconsin.
- Using industry representative and most recently available Medigap premiums.
Medicare Advantage Plans:
- Use Calendar Year 2010 Plan Benefit Packages to define the
out-of-pocket cost estimates.
- Use cost shares for in-network physicians.
- Use minimum co-payments if stated as a minimum/maximum range.
- Use deductibles and plan maximum limits, as applicable.
- Costs for Optional Supplemental benefits are not included.
- Prescription drugs:
- MCBS drug events are mapped into RXCUI codes to apply a particular plan’s
tier-formulary based cost sharing. Use Prescription Drug Event (PDE) claims data (2008) for average drug prices.
Relevant deductibles and premiums are also taken into account.
- For Medicare Medical Savings Account Plans (MSA plans)--the CMS annual contribution amount is assumed to be used
for Medicare-covered expenses towards meeting the deductible. Any remainder is applied to Medicare eligible expenses
(non-covered inpatient or SNF care, dental, and/or prescription drugs). Cost shares are zero once the deductible is
met—except for any remaining non-covered expenses.
Medicare and Non-Medicare covered services in the out-of-pocket cost calculations for Original Medicare, Medigap
and Medicare Advantage Plans are:
- Inpatient Hospital Acute Care,
- Inpatient Psychiatric Hospital/Facility,
- Prescription Drugs,
- Dental, and
- Skilled Nursing Facility.
For Original Medicare, Medigap, and Medicare Advantage Plans without prescription drug coverage, full drug costs
assuming no insurance, are calculated. The calculations also use PDE coverage prices.
Medicare covered services only included in the out-of-pocket cost calculations for Original Medicare, Medigap and
Medicare Advantage Plans are:
- Durable Medical Equipment (Prosthetics/Orthotics),
- Ambulatory Surgical Center,
- Cardiac Rehabilitation,
- Diagnostic Lab,
- Comprehensive Outpatient Rehabilitation Facility,
- Emergency Room,
- Eye Exams and Eye Wear,
- Hearing Exams,
- Medical Supplies,
- Mental Health,
- Occupational Therapy,
- Outpatient Hospital,
- Other Health Care Professionals,
- Pap Smears,
- Physical Therapy,
- Physician Specialist,
- Primary Care Physician Services,
- Renal Dialysis,
- Radiation Therapy,
- Screening Mammography,
- Substance Abuse (not calculated),
- Therapeutic Radiation,
- Urgent Care,
- X-Rays and complicated X-Ray procedures such as MRI.
Some services are excluded from the out-of-pocket cost
calculations. For example, some Medigap policies cover additional benefits that were not included in the
out-of-pocket cost estimates such as:
- Foreign Travel Emergency to cover emergency medical care when you travel outside the United States (Medigap
policies: B, C, D, F, and G).
- Medicare Part B Excess Charges to cover the difference between the doctor's actual charge and Medicare's
approved amount. This would apply if you go to a doctor who does not accept assignment and bills you more
than Medicare's approved amount. (Medigap policies: F and G).
Medicare Advantage plans offer a wide range of benefits, some of which were not included in the out-of-pocket
costs estimates. Some examples of benefits not included in the out-of-pocket cost estimates for Medicare Advantage
- Foreign Travel Emergency to cover emergency medical care when you travel outside the United States.
- Routine physical exams.
- Hearing services not usually covered by Medicare.
- Vision services not usually covered by Medicare.
- Prevention screening services not covered by Medicare.
- Chiropractic services not usually covered by Medicare.
- Podiatry services not usually covered by Medicare.
Note to Researchers, Medicare providers, and Others:
A more in-depth explanation of the exact methodology is available on www.cms.gov.
Click here to view more information.