A Definitive Guide of How the Overall Medicare Process Works

A comprehensive overview of the Medicare journey has been compiled. The research starts with the Medicare basics that are needed to understand the process with an overview of the different types of Advantage plans, including innovators and highly rated companies in the market. Pain points are discussed that pertain to Medicare Advantage, and the overall Medicare process.
The user journey is shared from multiple perspectives, along with how the process works. This section reveals multiple areas of pain points for beneficiaries as well as shares their desires, their perceptions of companies, and what drives their choices. This next section explains why some are waiting to enroll, and why many refuse to review their plans each year.
Finally, demographics for Medicare A& B, Medicare Advantage, and Medicare Part D are presented an analyzed for insights. Overall, it seems that a married partner will choose the plan their spouse is on. Those in lower income brackets will choose Advantage plans more than those who make more money.

Medicare Options

  • When someone first enrolls in Medicare and during certain times of the year, they can choose how they get their Medicare coverage. There are 2 main ways to get Medicare.
  • Original Medicare includes Part A and Part B. If drug coverage is desired, a separate Medicare Drug Plan can be joined (Part D). Patients can use any doctor or hospital that takes Medicare in the US.
  • Medicare A&B will not cover long term care, dental care, eye exams, dentures, cosmetic surgery, acupuncture, hearing aids, and routine foot care.
  • Medicare Advantage, also known as Medicare Part C, is the second way someone can get Medicare. This is an “all in one” plan and an alternative to Original Medicare. These bundled plans include part A, B, and usually Part D. Some of these plans may have lower out-of-pocket costs than Original Medicare. One of the key differences is that patients must use the doctors and hospitals that are in the plan’s network. These plans also sometimes offer additional benefits that Original Medicare does not, like vision, hearing, dental, and more.
  • There is the option each year to keep the current plan or to switch to a different plan.
  • Medicare Advocacy summed up the choices with this statement, “If you want access to almost all health care providers, anywhere in the country, and do not want to have to get permission from an insurance company to see specialists, look to traditional Medicare. IF you are willing to give up access to a full choice of providers for possible lower cost-sharing and some additional benefits, look at Medicare Advantage.

medicare costs

Medicare Part A

  • Medicare Part A is hospital insurance. It covers inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care.
  • Part A is normally free. Some must pay if they did not earn enough Social Security credits.
  • After the deductible is met, the patient pays a co-payment for services.

Medicare Part B

  • Medicare Part B is medical insurance. It covers services from doctors and other healthcare providers, outpatient care, home health care, durable medical equipment, and preventative services.
  • In 2020, the standard premium is $144.60. If the modified adjusted gross income is above a certain threshold, an extra charge is added to this premium. If you receive Social Security, this amount is automatically deducted from your monthly benefit. The individual income threshold is $87,000 or less. If you make more, there is a graduated scale with increased premiums. For reference, the top tier is $500,000 yearly, and the premium is $491.60.
  • After the deductible is met, the patient pays a co-payment for services. This is usually 20%.

Medicare Part D

  • Medicare Part D is drug coverage. This helps cover the cost of prescriptions, and many shots and vaccines. Medicare Part A & B do not provide for drug coverage.
  • These plans are run by private companies and follow rules set forth by Medicare.
  • If you have Medicare Advantage, you most likely will not need this plan.
  • The average part D premium was $32.74 in 2020.

Medigap- Medicare Supplement Insurance

  • Medigap plans can help pay some of the remaining health care costs and are sold by private companies. They can cover deductibles, co-payments, and co-insurance.
  • 13.6 million beneficiaries purchased Medigap policies in 2017, which amounts to about 22.5% of the 59 million people on Medicare.
  • Medicare recipients who participate in Medicare Advantage do not need Medigap insurance.
  • The average Medigap policy was $152 in 2019.
  • There are ten different Medigap plans.

Medicare Part C- Medicare Advantage (MA Plans)

  • The plans set a limit on what you will have to pay out-of-pocket each year for covered services, to help protect from unexpected costs.
  • MA plans must follow Medicare’s rules.
  • Most of these plans include prescription drug coverage.
  • A monthly premium is paid for this plan. In many instances, the premium is $0, but there are plans that offer more benefits and have a higher premium. 49% of the MA plans sold come with no premium bill for the enrollee.
  • For 2020, the average MA plan premium is $35 per month, according to Boomer Benefits. Kaiser Family Foundation reports slightly different numbers. They state the average premium for 2020 was $23.
  • Around of 80% of those that receive Medicare have access to at least one $0 premium, depending on where they live.
  • On average, they have access to 28 different plans to choose from.
  • Around 33% of beneficiaries choose to enroll in MA.
  • 22.4 million beneficiaries are expected to enroll in MA in 2020.

enrolling in MA plans

Types of Medicare Advantage Plans

  • Health Maintenance Organization– HMO- With this plan you must use doctors that are in a certain network. A primary care doctor must be chosen.
  • Medical Savings Account– MSA- MSA plans do not have a network of doctors, nor do they cover prescriptions. This plan deposits money into a savings account which can be used to pay health care costs before the deductible is met. These plans do not charge a premium, but you must continue to pay your Part B premium.
  • Preferred Provider Organization– PPO- These plans have network doctors, but you can also use out of network providers. If preferred providers are used, the prices are normally lower.
  • Private Fee for Service– PFFS- The plan decides how much you will pay for services. This can change yearly. Usually, they contract with providers that will agree to always treat you.
  • Special Needs Plan– SNO- This plan provides benefits and services to people with certain diseases, needs, or limited incomes. They tailor their benefits, provider choices, and formularies to meet the needs of the group they serve.

Highest Rated Medicare Advantage Plans

  • JD Power’sconducts a yearly survey to obtain an overall satisfaction score among several Medicare Advantage Plans. The average overall score was 800 out of 1,000 points.
  • The highest rated plans were Highmark (830), Kaiser Foundation Health Plan (829), Humana (806), and United Healthcare (800).
  • Aetna (780), Cigna-Health Spring, Anthem (781), Blue Cross Blue Shield of Michigan (779), Centene (775), and WellCare (773), were below average.

MA Innovators

  • Anthem is testing several new services, including home delivered meals, transportation to doctor’s appointments, limited in home support from a health aide, and offering up to $500 for home safety devices.
  • Cigna will also be offering transportation benefits and home delivery of meals.

Medicare Advantage Pain Points

  • Many times people do not understand what they are doing and feel nickeled and dimed in the end. Traditional supplements have a higher premium up front with very little out-of-pocket cost on the back end. With an MA plan, you pay lower premiums, but have co pays and coinsurance. They have not carefully reviewed the summary of benefits and are surprised each time they get a bill.
  • Some think the plan will be free. They do not understand they will still have to pay for Part B and that the insurance company is reimbursed for this.
  • Many enroll in the plan not understanding they will have to stay in network to realize full benefits. Once they figure it out, their favorite doctor or hospital is not in the network and they are disappointed. Medicare Advantage questions account for 35% of helpline calls. 28% of these callers were calling about a denial in coverage.
  • Out-of-pocket costs can be more than the insured really thought they would be because they did not think it through. Some plans can have a $6,700 out-of-pocket cost each year. If on a fixed income, this is a significant part of their income. Others will start an expensive treatment in the last few months of the year, like chemotherapy, and meet their $6,700 quickly. Since the plan resets in January, when they continue treatment in the new year, they are again out $6,700. For those without money set aside, Medigap might have been a better alternative, as the spending is more predictable.
  • “The best candidate for Medicare Advantage is someone who’s healthy,” says Mary Ashkar, senior attorney for the Center for Medicare Advocacy. “We see trouble when someone gets sick.”

Enrollment Periods

  • If you are close to 65, but not getting Social Security or Railroad Retirement Board benefits, you will need to sign up by contacting Social Security.
  • If you are receiving Social Security, you will automatically be enrolled.
  • The initial enrollment period begins 3 months before you turn 65, and end 3 months after you turn 65 (7 months). This is the initial enrollment period.
  • If you already have health insurance through an employer, you do not have to sign up at age 65 and can wait and sign up after that insurance is terminated.
  • Each year there is an open enrollment period from October 15 – December 7 where someone can join, switch, or drop a plan.
  • From January 1 – March 31 of each year if you are enrolled in Medicare Advantage, you can switch to a different MA plan or switch back to Original Medicare.

The Enrollment Process- The Journey

Enrollment Facts

  • Every day for the next 2 decades, an average of 10,000 Americans will become eligible for Medicare.
  • Approximately 50% of the Baby Boomer generation starts to research Medicare around the age of 63. They can spend up to six months researching a plan, some will research up to a year. 71% of seniors use search engines to look for information about healthcare.
  • An individual will not necessarily get a notice from the government telling them to sign up. Only people who already receive Social Security get a Medicare reminder and are automatically enrolled. Everyone else must initiate this process with Social Security. They can call, visit in person, or apply online.
  • Enrollment questions account for 23% of all helpline calls to Medicare. Affordability questions accounted for 20%, meaning that 43% of their calls were about enrollment and affordability, and not about benefits or other insurance questions. This percentage indicates the enrollment process, as a whole, is a complex one with many areas to navigate.
  • 66% of people who purchased Medigap chose Plan F with the most comprehensive coverage that included paying the Part B deductible. This will no longer be they case for anyone that signs up after Jan 1, 2020. They are no longer allowed to cover the deductible. Congress suspended Plans C and F in order to trim Medicare expenses. This could possibly drive more people to MA plans.
  • Only 22% of users are familiar with the Medicare star rating system. Of those familiar, 51% used the grading system to help them choose a plan. That means only about 10% of all respondents used the system in choosing a plan. “I’ve never used [star ratings] because I presume that they are doing some weighting of these factors to get to those stars and my only factor that I care about is cost. It’s like those lists of best places to live. You don’t know what they are weighting.”
  • A Kaiser Foundation report stated that seniors felt that premiums and out-of-pocket costs, access to desired providers, familiarity with the name of the company offering the plan (such as AARP), favorable experience with a plan representative, and adequate coverage for their health care needs, were the most important factors when they picked their initial plan.

The Basic Process

  • It is recommended that people start familiarizing themselves with the process 6 months before they start turning 65 so they can be sure to have coverage when they do. They can go check their eligibility and get the exact window where they can apply. They must also have a My SSA account.
  • Once this account is created, the user will apply for Medicare benefits. They can also apply over the phone, but this can take over a month to finish. Finally, you can apply in person by going to the local Social Security Office.
  • According to Consumer Reports, the first stop should be the plan finder on Medicare’s website. While on the plan finder, it is very important to list all medications that one is currently taking, as this impacts the coverage needed. The website will take this into account and provide you with the exact yearly costs for prescriptions under each plan.
  • The user will first sign up for parts A and B. Then they will select their Part D provider. The site attempts to walk the user through this process. For the user to make the best choice for them, they will need to compare the costs of purchasing Medigap and Part D with the costs of purchasing Medicare Advantage. They will also need to take into account out-of-pocket expenses for each program. This ends up being a complex calculation and assistance is often needed to make the best choice.
  • Consumer Reports goes on to explain several confusing parts about the process. A box must be checked to see plans with prescription coverage. If the user does not check a box at the top of the list, they will only see 10 choices instead of all their choices.
  • Although many are not aware, the State Health Insurance Assistance Program (SHIP), provides non-biased Medicare advice.
  • Once a plan is selected, the user can enroll online or call 1-800-MEDICARE. They also have the option of going directly through the chosen insurance company, or through a broker.
  • In a study completed on the Jornaya network, the average consumer began shopping 72 days before they requested a quote. They initiated 3.4 shopping events before initiating a quote.

The Complete Insurance Journey

  • According to McKinsey, there are seven different journeys that a consumer will take when buying and using insurance.
  • Sign Up & Join– At this stage they are finding, evaluating, applying, and purchasing across multiple channels.
  • Select a Provider– At this stage they are selecting the type of care and plan that suits them best.
  • Receiving Care– During this stage they want to make sure they can get the care they need and that they meet all the requirements for reimbursement.
  • Taking Control of Their Health– At this stage, after figuring out all the above details, they are now looking for long-term health and wellness. They are managing chronic conditions in this stage as well.
  • Managing Finances– At this stage they are dealing with claims submissions, adjudication, statements, and making payments.
  • Questions & Problems– This stage deals with updating information, replacing cards, or resolving billing and claims issues.
  • Renew Coverage– During this stage the consumer either renews or migrates to a new plan.
  • McKinsey polled consumers as to their most important journeys: (The journeys marked in bold are considered the most important.)

Factors That Drive the Choice of One Plan Over Another

  • When asked why they chose one plan over another in a joint study between the Kaiser Foundation and PerryUndem, cost was at the top of the list. Other considerations were staying with their provider, familiar with the insurance company, keeping the same coverage as their spouse, and finally, the coverage.
  • Kaiser stated, “While some seem willing to give up their regular doctors to have a more affordable plan, others are not. It seems to depend (at least to some extent) on the strength of the relationship between the doctor and patient.”
  • One survey participant stated, “This was the first one that I’d ever had, you know, the first time I was on Medicare with the Part D and I was young and impressionable when I made the decision and it was purely based on the fact that 95 percent of my medications were zero co-pay.”
  • Other quotes:
  • ” A couple of scripts are like “Phew. It’s the meds or the car payment, what do I do?”
  • “I look at the cap and then I want to look at the hospitalization. What I care about is if I have a major issue and go in the hospital and my out of pocket [is] $2,500 dollars or $5,000 dollars.”
  • “I want the choice. I like the PPO because I have a choice. I might not like this doctor always and want to go someplace else.”
  • “When I chose my current one I chose it because of the credibility of AARP; they were bound to be my advocate.”
  • Kaiser stated, “Among those with Medicare Advantage plans, the ability to get vision and dental coverage is a major draw. The addition of other services like the Silver Sneakers (exercise and gym) program is also attractive to many. They like feeling like they are getting a lot of services out of the plan, even if they do not use them.”

Many Are Waiting to Enroll

  • There an increasing number of individuals that work past the age of 65. This delays Medicare enrollment if they have insurance from their employer. Also, many are trying to make it to 70 where they can get the maximum benefit amounts.
  • In 2016, Only 60% of Medicare eligible 65 year old were taking Social Security. In 2002 this number was 92%.
  • Of the 4 million age-ins each year, it is estimated that 19% or more are delaying their entry to Medicare. According to Daft research, 48% intend to wait until after their eligibility to enroll. While these numbers were found in the same research and do seem at odds with each other, they are indicative of a trend. People, due to their jobs and the economy, are waiting to enroll in Medicare now more than ever. The Accenture transcript contains some interesting philosophies on marketing to this group and can be read here.
  • “They tend to enroll in just Part A because it’s free and then delay Part B and Part D because they’d have to pay premiums,” said Danielle Roberts, co-founder of insurance firm Boomer Benefits in Fort Worth, Texas.

MA User Survey- Perception of Their Provider

  • 19% of beneficiaries stated their plan knew them very well. 43% stated their plan knew them somewhat well and 23% said “not very well”. 15% said their plan knows nothing about them.
  • Only 16% felt that their plan knew if their health was on the mend or in decline.
  • 46% state their plan never communicates with them about their chronic condition and another 19% state this only happens once per year.
  • 67% state their plan does not incentivize them to take actions to improve their health.
  • 47% prefer digital communication.

Pain Points

  • 56% of people aged 47-56 state they know little or almost nothing about Medicare. These users, when they start their Medicare journey will need education. They want to be informed in their decisions. According to GuideWell, “A health plan needs to be visible and provide answers to key questions the moment a member begins considering their potential options. If your health plan is not the brand they are interacting with in the early stage, they are interacting with your competition, building trust and brand loyalty with another and inching further from your reach.”
  • More than 70% of future retirees wished they had a better understanding of Medicare. In a 2018 survey, more than half of the individuals surveys did not know that Part B was not free. 30% believed that Medicare costs the same for everyone. More than a third thought that once you signed up for a plan you were stuck with it.
  • They find it frustrating and difficult to compare plans due to the volume of information they receive through the mail and media. Furthermore, most do not use the Medicare Compare tool because they find it confusing, lacking information, and poorly constructed for comparisons. “For this reason, many rely on insurance agents as trusted advisors or receive suggestions from friends, family, doctors’ offices and/or pharmacists to help them narrow down their options.”
  • “I can’t find anything that makes any sense. When I call about it and ask for information I get such strange ideas about how I should get information from different providers and then analyze it and compare it like I’m some kind of computer or something. I can’t do that.”- Medicare beneficiary quote.
  • “That’s what gets me, they wait until we retire to make it complicated. […] now all of the sudden I have all of these Advantage programs and I have to do a spreadsheet.” –Medicare Advantage Beneficiary.
  • Only 11% of members aged 60+ stated their received any communication from their health plan regarding moving from their current coverage to Medicare Advantage. Those that did receive communication had higher satisfaction scores.
  • The Plan Finder that Medicare provides can help people compare things like premiums and projected expenses, but the often miss the non-monetary comparisons which are also important. The Plan Finder tends to not clearly explain the non-medical or non-monetary benefits of plans.
  • Customers can find it difficult to understand the various plan options and determine the best one for them. They also can struggle to understand the technical health insurance language. One user stated, “Have you tried to use the Medicare plan finder tool? It is very complicated! To improve elderly decision-making, we need improved information, less complexity, greater transparency, better use of defaults & personal reminders.”
  • The lack of a universal written notice informing people they need to actively enroll in Medicare Part B is confusing and results in many having to pay a penalty.
  • If one is not automatically enrolled, things can get very confusing. For example, if a person is on COBRA when they turn 65, they must enroll in Medicare Part B. If not, they will face penalties. Mistakes like this are common. In 2019, 764,000 people with Medicare were paying a late enrollment penalty which amounted to a 28% increase in their premium. When we take into account that half of all beneficiaries are living on less than $26,000 annually, and 24% are living on less than $15,250, this can be financially crippling.
  • Effective Communication– Medicare Advantage plans continue to miss the mark when it comes to effective communication with their members. According to the J.D. Power 2020 U.S. Medicare Advantage Study. Information and communication is a weakness for member satisfaction, which is driving a general lack of engagement among consumers and increases the likelihood of health plan members switching plans.
  • Only 54% of plan members say they completely understand how their plan works once they get it. They desire more assistance to figure out providers and manage co pays.

Kaiser Foundation Study- Friction & Pain Points

  • In a Kaiser Foundation study that looked at health plans and customer interactions, engagement accounted for 28% of the overall friction, process for 43%, and technology for 16%.
  • When looking at engagement friction, users noted things like the type being too small, and that showing a lack of regard for their needs. Users are irritated by cluttered landing pages. This causes immediate frustration.
  • Process friction included being confused while using the site, wasting customer time, and requiring the customer to move back and forth between communication channels. Checking Medicare eligibility was one of the biggest issues. The companies that had the least amount of friction has clean, simplified sites with appropriate fonts. They also enabled the customer with easy to use feedback mechanisms.
  • Companies that focused on transparency scored high with their consumers. Kaiser stated, “Only 25% of companies we assessed provided information on Medicare Advantage versus supplemental plans. This prevented customers from reviewing all their options in one place and quickly making an informed decision. The Leaders tended to provide better customer research tools and information. “
  • Companies that had seamless integration and guided the consumer step by step through the process scored better than those who did not. “Evaluators noted high friction when customers — after searching for plan information — were forced to return to the home page to find a doctor. This was confusing and didn’t make a lot of sense. When customers had to do this, the search criteria didn’t carry over and they may have had to re-enter information.”
  • Consumers want to be assured over and over that they are dealing with the same company. Successful companies did a great job with their brand throughout the site, therefore reassuring customers.
  • Overall, companies that took control of the process from beginning to end provided a better customer experience. Those that forced the user to go to lost control of the customer experience.
  • Companies that used multimedia to share information had less friction than those that did not.
  • They looked at enrollment data for the number 1 rated company in their study, which was Blue Cross/Blue Shield. In 2017, they gained 25,898 new members. The four large plans that ranked that lowest in the study only gained 6,480 new members. Clearly, BCBS is doing something right.
  • Kaiser also noticed that the smaller companies were a bit more nimble and had less process friction as it was easier for them to make site changes.
  • Please note, this is a very large study with many more pain points and comparisons between successful and non-successful companies. It is recommended that this be reviewed in its entirety.

J.D. Power Study- Desires of Beneficiaries With Their MAs

  • J.D. Power completed a study that looked at what members really want from an MA plan. “Members are looking for their plan to be a trusted partner, and that begins at enrollment. They are expecting their plan to provide guidance, ranging from assistance in selecting a doctor to helping them understand costs for prescriptions.”
  • Plan members that strongly agree that their health plan is a trusted partner in their health and wellness were also more satisfied.
  • When a member completely understands how to find a doctor, satisfaction levels increase.
  • When they call their plan provider they expect outstanding customer service. They expect immediate attention or advice. When they feel their plan is not concerned about their issues, satisfaction scores take a deep dive. They do not want to make multiple calls to solve a problem. “Overall member satisfaction increases 209 points (on a 1,000- point scale) when plans meet three key performance indicators related to information and communication: making sure members fully understand their out-of-pocket costs; providing health education; and delivering useful reminders for preventive services.”
  • “Prior to the COVID-19 pandemic, just 5% of Medicare Advantage members had used telehealth. Based on additional J.D. Power research conducted since the beginning of the pandemic, 20% of Medicare plan members say they are interested in receiving information about telehealth.”
  • “JD Power also turned up a new key driver of satisfaction: coordination of care among doctors and other healthcare providers. Most members say their plan isn’t able to effectively help them with this; on average, just 34% of Medicare Advantage plan members indicate their plans met this criterion.”

Senior’s Recommendations to Improve the Process

  • They want the ability to sit down with someone and discuss the process.
  • “Seniors need […] support. They need help that’s not just a matter of getting phone numbers and how to work the computer. They need actual, personalized help, that doesn’t cost money.”
  • The benefits of changing plans need to be explained in a clearer way.
  • Online tools need to be user-friendly to assist in narrowing down the options. They would really like a tool that could give them a shortlist of potential plans that could work for them. “Beneficiaries complained that the current Medicare Compare plan finder uses complicated language and does not provide helpful plan comparisons. They suggested updating the site with more clear language and streamlined tools that allow apples-to-apples comparisons.”
  • Although the star rating system would not be the most important factor in choosing, many seniors think it would provide another piece of helpful information. The star ratings should be more visible.

Yearly Review of Plans

  • 60% of seniors say they will switch their MA plan in the future, but only 40% actually review their plan each year, indicating that it is easier said than done.
  • While many say they are going to switch their plans, the actual number is closer to 11%. This is due to plan stability in recent years. There is just not a good reason for them to go through the hassle of changing. They believe they did their homework in the beginning and it just is not worth it.
  • For the small number that does change, they cite that there has been a significant change in their health, their plan had a major change in coverage, or a drug became too costly under their old plan. One recipient stated, “They wanted me on a less expensive statin and I would not change. I would not change. I would not change. So they kept elevating the price until I finally left them.”
  • Others are scared to change their plans. They fear disruption of care, increased costs, or new rules to learn. They are skeptical that another plan will actually be better.
  • According to WellCare, seniors are more likely to shop for cable than Medicare. Only one-third of seniors comparison shop for their Medicare plan. They go on to state there is an “epidemic of apathy” when it comes to Medicare coverage.
  • 23% of seniors state that reviewing their plan is the most unpleasant or second most unpleasant task when presented with a list of task by pollsters that included getting a colonoscopy and going to the dentist. Open enrollment is viewed by many as a time to change plans only if they are unhappy.
  • There are days when I look at a plan, or look at my plan, and I think about possibly making a change, depending upon what’s out there for me … I’ve reached the age of 78 and I’m saying to myself, “I’m too goddamn tired to investigate this.” -PDP Beneficiary (Baltimore, MD)
  • I think the older you get, the more resistant you are to change in general. There’s that comfort level, as well. I wouldn’t want to keep going from one plan to another. There would have to be a big reason. –PDP Beneficiary (Seattle, WA)
  • At our age as we get older we learned that the grass is not really greener on the other side. We’re very cautious about changing to something else that is unfamiliar when we have that [which we] know in front of us. –PDP Beneficiary (Tampa, FL)
  • Many do not know that Medicare Advantage is even a separate entity from traditional Medicare. “Heard of [Medicare Advantage], but I know nothing about it.”- PDP Beneficiary.


Medicare Parts A&B Demographics

  • Participants are 54% female, and 46% male.
  • 75% are Caucasian, 9% African American, 10% Hispanic, and 6% other.
  • 84.9% of beneficiaries are sharing information, talking about politics, and engaging on Facebook.
  • 17% are under the age of 65. 46% are between 65-74. 25% are between 75-84. 13% are 85 and older.
  • 77% live in an urban setting. 23% are rural.
  • 26% live alone, 47% with a spouse, 21% state other, and 4% live in an institution.
  • 20% do not have a high school education. 27% have a high school diploma. 52% have some college or more.
  • 16% are living below the poverty line. 8% are in the 100-125% of poverty range. 20% are in the 125-200% range, 30% are in the 200-400% range, and 25% are over 400%.
  • Most beneficiaries are female and white. They are married and have some college education.

Medicare Advantage Demographics- Compared to Overall Medicare Demographics

  • 55% are women, 45% are men. This is consistent with overall Medicare demographics.
  • Advantage plans have a higher percentage of beneficiaries in the 65-84 age group. (77% compared to 71%).
  • 37% with Advantage plans have incomes of less than $20,000. 18% have incomes over $50,000. When compared to traditional Medicare, recipients tend to have lower incomes.
  • Advantage plans have a higher proportion of Hispanic (44% of all Hispanics pick these plans), and African Americans (30% of all African Americans pick these plans).
  • 13.6% of Advantage members are rural, and 86.4% are urban.
  • A detailed explanation of Medicare Advantage demographics may be viewed here.

Medicare Part D- Private Prescription Coverage

  • 43 out of the 60 million people enrolled in Medicare have a Part D plan for prescriptions. The average user has 2.8 fills per month.
  • Females account for 59.1% of all Part D enrollees.
  • 73% are white, 10.8% are Hispanic, and 10% are Black.
  • Those between the ages of 65-74 are the largest group of beneficiaries.
  • 58% have a stand a lone plan (PDP), and 42% are in an Advantage plan.
  • More than 12 million receive premium and cost sharing assistance through the Low-Income Subsidy (LIS) Program.
  • cost sharing
  • Medicare part d
  • enrollees by provider
  • premiums

Demographic Insights/Analysis

  • Many will enroll in a plan because it is the one their spouse has. One MA plan beneficiary stated, “Same plan, same doctor, same household, same everything.”
  • Married seniors state their significant other has the most influence on them (43%), followed by their physician (36%). For those that are not married, their physician has the most influence (49%).

 Additional Resources

  • Medicare Quote Tools- Q1 2020– An in depth analysis from Corporate Insight that looks at quote tools and provides best practices and company profiles.
  • A breakdown of Medicare and MA beneficiaries by state may be viewed here.
  • The CMS Enrollment Dashboard may be viewed here.
  • Forrester has a webinar entitled Medicare Advantage Buyer’s Journey And Market Growth. “In this webinar, Forrester presents our health insurance buyer’s journey told through the lens of Medicare Advantage respondents, uncovering how these consumers shop for and select health plans. Next, Forrester presents analysis of current CMS Medicare Advantage data to highlight which vendors, plans, and plan designs are ultimately leading in plan selection.” This may be purchased through Forrester for $300.
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