<DOC>
Ways and Means Committee Print WMCP:106-14]
[2000 Green Book]
[From the U.S. Government Printing Office Online via GPO Access]


                    END-STAGE RENAL DISEASE SERVICES

                                Coverage

    Medicare's End-Stage Renal Disease (ESRD) Program 
established in the Social Security Amendments of 1972, covers 
individuals who suffer from ESRD if they are: (1) fully insured 
for Old-Age and Survivors Insurance benefits; (2) entitled to 
monthly Social Security benefits; or (3) spouses or dependents 
of individuals described in (1) or (2). Such persons must be 
medically determined to be suffering from ESRD and must file an 
application for benefits.
    Benefits for qualified ESRD beneficiaries include all part 
A and part B medical items and services. ESRD beneficiaries are 
automatically enrolled in the part B portion of Medicare and 
must pay the monthly premium for such protection. 
Medicare+Choice (M+C) plans may provide ESRD benefits to the 
Medicare beneficiary who has been enrolled in an M+C 
organization and subsequently develops ESRD. However, 
beneficiaries with ESRD cannot enroll in an M+C plan.
    Table 2-25 shows expenditures, number of beneficiaries, and 
the average expenditure per person for all persons with ESRD 
(including the aged and disabled) from 1974 through 2005. Total 
projected program expenditures for the Medicare ESRD Program 
for fiscal year 2000 are estimated at $10.7 billion. In fiscal 
year 2000, there are an estimated 320,005 beneficiaries, 
including successful transplant patients and persons entitled 
to Medicare on the basis of disability who also have ESRD.

 TABLE 2-25.--END-STAGE RENAL DISEASE MEDICARE BENEFICIARIES AND PROGRAM
                         EXPENDITURES, 1974-2005
------------------------------------------------------------------------
                                Expenditures
                                 (HI & SMI)         HI        Per person
          Fiscal year            in millions  beneficiaries      cost
                                 of dollars
------------------------------------------------------------------------
1974..........................          $229        15,993       $14,319
1975..........................           361        22,674        15,921
1976..........................           512        28,941        17,691
1977..........................           641        35,889        17,861
1978..........................           800        43,482        18,398
1979..........................         1,009        52,636        19,169
1980..........................         1,245        54,725        22,750
1981..........................         1,464        61,487        23,810
1982..........................         1,640        69,267        23,676
1983..........................         1,984        78,361        25,319
1984..........................         2,325        87,609        26,538
1985..........................         2,835        96,965        29,237
1986..........................         3,165       106,568        29,699
1987..........................         3,490       117,020        29,824
1988..........................         3,998       128,075        31,216
1989..........................         4,653       140,324        33,159
1990..........................         5,251       154,575        33,971
1991..........................         5,634       170,718        33,003
1992..........................         6,115       182,826        33,445
1993..........................         7,059       201,168        35,091
1994..........................         7,902       220,972        35,758
1995..........................         8,751       239,056        36,608
1996..........................         9,634       256,096        37,620
1997..........................         9,841       271,880        36,198
1998..........................         9,943       287,589        34,573
1999..........................         9,880       303,476        32,557
2000..........................        10,748       320,005        33,585
2001..........................        11,580       337,351        34,327
2002..........................        12,316       355,488        34,645
2003..........................        13,257       374,769        35,374
2004..........................        14,242       395,953        35,969
2005..........................        15,351       415,597        36,938
------------------------------------------------------------------------
Note.--Estimates for 1982-2005 are subject to revision by the Office of
  the Actuary, Office of Medicare and Medicaid Cost Estimates;
  projections for 1998-2005 are under the fiscal year 1996 budget
  assumptions.

Source: Health Care Financing Administration, Office of the Actuary.


    When the ESRD Program was created, it was assumed that 
program enrollment would level out at about 90,000 enrollees by 
1995. That mark was passed several years ago, and no indication 
exists that enrollment will stabilize soon.
    Table 2-26 shows that new enrollment for all Medicare 
beneficiaries receiving ESRD services grew at an average annual 
rate of 4.6 percent from 1992 to 1998. Most of the growth in 
program participation is attributable to growth in the numbers 
of elderly people receiving services and growth in the numbers 
of more seriously ill people entering treatment. Table 2-26 
shows the greatest


                    TABLE 2-26.--MEDICARE END-STAGE RENAL DISEASE PROGRAM INCIDENCE BY AGE, SEX, RACE, AND PRIMARY DIAGNOSIS, 1992-98
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                            Number of new enrollees                                             Average
                                             ------------------------------------------------------------------------------------   Percent     annual
    Age, sex, race, and primary diagnosis                                                                                           change      percent
                                                 1992        1993        1994        1995        1996        1997        1998       1997-98     change
                                                                                                                                                1992-98
--------------------------------------------------------------------------------------------------------------------------------------------------------
Age:
  Under 15 years............................         410         428         444         465         428         373         342        -8.3        -3.0
  15-24 years...............................       1,359       1,301       1,298       1,351       1,288       1,099       1,093        -0.6        -3.6
  25-34 years...............................       3,545       3,562       3,638       3,497       3,342       3,120       3,030        -2.9        -2.6
  35-44 years...............................       5,892       5,738       6,068       6,438       6,342       5,951       5,891        -1.0         0.0
  45-54 years...............................       7,575       7,856       8,968       9,327       9,448       9,589       9,880         3.0         4.5
  55-64 years...............................      11,429      11,561      12,843      13,266      13,220      13,753      14,140         2.8         3.6
  65-74 years...............................      16,530      17,147      18,832      18,640      19,550      21,472      21,712         1.1         4.6
  75 years or older.........................      10,443      11,065      12,571      13,072      14,605      17,405      18,694         7.4        10.2

Sex:
  Male......................................      30,401      31,430      34,434      35,221      36,878      39,021      40,100         2.8         4.7
  Female....................................      26,782      27,228      30,228      30,835      31,345      33,741      34,682         2.8         4.4

Race:
  Asian.....................................       1,317       1,441       1,684       1,509       1,570       1,415       1,531         8.2         2.5
  African-American..........................      16,621      17,115      18,675      19,162      19,790      20,451      21,145         3.4         4.1
  White.....................................      37,606      38,080      41,597      41,251      42,359      46,611      47,806         2.6         4.1
  Native American...........................         774         660         749       1,001       1,109         771       1,133        47.0         6.6
  Other/unknown.............................         865       1,362       1,957       3,133       3,395       3,514       3,167        -9.9         4.1

Ethnicity:
  Non-Hispanic..............................       1,302       1,400       1,980      45,103      59,796      64,188      66,085         3.0        92.4
  Hispanic..................................         133         142         186       5,379       7,281       7,327       7,816         6.7        97.2
  Unknown...................................      55,748      57,116      62,496      15,574       1,146       1,247         881       -29.4       -49.9

Primary diagnosis:
  Diabetes..................................      21,292      21,751      25,289      27,679      29,486      31,962      33,359         4.4         7.8
  Glomerulonephritis........................       6,535       6,565       7,161       7,267       7,361       7,078       6,933        -2.1         1.0
  Hypertension..............................      17,685      17,447      19,755      17,677      17,947      19,601      20,297         3.6         2.3
  Cystic/hereditary disease.................       2,247       2,236       2,359       2,479       2,313       2,256       2,242        -0.6         0.0
  Interstitial nephritis....................       2,532       2,314       2,646       2,918       2,870       2,784       2,925         5.1         2.4
  Other.....................................       3,388       3,551       3,876       4,802       5,072       5,488       5,501         0.2         8.4
  Unknown...................................       2,623       2,393       2,459       2,446       2,645       2,787       2,991         7.3         2.2
  Not reported..............................         881       2,401       1,117         788         529         806         534       -33.8        -8.0
                                             -----------------------------------------------------------------------------------------------------------
    Total number of new enrollees...........      57,183      58,658      64,662      66,056      68,223      72,762      74,782         2.8         4.6
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: Health Care Financing Administration, Office of Clinical Standards and Quality.

rate of growth in program participation is in people over age 
75, at 10.2 percent, followed by people of ages 65-74 with a 
growth rate of 4.6 percent. The largest rate of growth in 
primary causes of people entering ESRD treatment was diabetes. 
People with diabetes frequently have multiple health problems, 
making treatment for renal failure more difficult.
    The rates of growth in older and sicker patients entering 
treatment for ESRD indicate a shift in physician practice 
patterns. In the past, most of these people would not have 
entered dialysis treatment because their age and severity of 
illness made successful treatment for renal failure less 
likely. Although the reasons that physicians have begun 
treating older and sicker patients are not precisely known, it 
is clear that these practice patterns have resulted, and will 
continue to result, in steady growth in the number of patients 
enrolling in Medicare's ESRD Program.
    ESRD is invariably fatal without treatment. Treatment for 
the disease takes two forms: transplantation and dialysis. 
Although the capability to perform transplants had existed 
since the 1950s, problems with rejection of transplanted organs 
limited its application as a treatment for renal failure. The 
1983 introduction of a powerful and effective immunosuppressive 
drug, cyclosporin, resulted in a dramatic increase in the 
number of transplants being performed and the success rate of 
transplantation.
    Table 2-27 indicates that a total of 13,272 kidney 
transplants were performed in Medicare-certified U.S. hospitals 
in 1998. Despite the significant increases in the number and 
success of kidney transplants, transplantation is not the 
treatment of choice for all ESRD patients. A chronic, severe 
shortage of kidneys available for transplantation now limits 
the number of patients who can receive transplants. Even absent 
a shortage of organs, some patients are not suitable candidates 
for transplants because of their age, severity of illness, or 
other complicating conditions. Finally, some ESRD patients do 
not want an organ transplant.
    For all of these reasons, dialysis is likely to remain the 
primary treatment for ESRD. Dialysis is an artificial method of 
performing the kidney's function of filtering blood to remove 
waste products. There are two types of dialysis: hemodialysis 
and peritoneal dialysis. In hemodialysis, still the most common 
form of dialysis, blood is removed from the body, filtered and 
cleansed through a dialyzer, sometimes called an artificial 
kidney machine, before being returned to the body. There are 
three types of peritoneal dialysis. Intermittent peritoneal 
dialysis and continuous cycling peritoneal dialysis (CCPD) 
requires the use of a machine while continuous ambulatory 
peritoneal dialysis does not require the use of a machine. 
Under peritoneal dialysis, filtering takes place inside the 
body by inserting dialysate fluid through a permanent surgical 
opening in the peritoneum (abdominal cavity). Toxins filter 
into the dialysate fluid and are then drained from the body 
through the surgical opening. Hemodialysis is usually performed 
three times a week, Intermittent peritoneal dialysis is 
performed once or twice a week, while continuous ambulatory 
peritoneal dialysis and CCPD require daily exchanges of 
dialysate fluid.


          TABLE 2-27.--TOTAL KIDNEY TRANSPLANTS PERFORMED IN MEDICARE-CERTIFIED U.S. HOSPITALS, 1979-98
----------------------------------------------------------------------------------------------------------------
                                                                          Living donor         Cadaveric donor
                     Calendar year                          Total    -------------------------------------------
                                                         transplants    Number    Percent     Number    Percent
----------------------------------------------------------------------------------------------------------------
1979...................................................        4,189      1,186         28      3,003         72
1980...................................................        4,697      1,275         27      3,422         73
1981...................................................        4,883      1,458         30      3,425         70
1982...................................................        5,358      1,677         31      3,681         69
1983...................................................        6,112      1,784         29      4,328         71
1984...................................................        6,968      1,704         24      5,364         76
1985...................................................        7,695      1,876         24      5,819         76
1986...................................................        8,976      1,887         21      7,089         79
1987...................................................        8,967      1,907         21      7,060         79
1988...................................................        8,932      1,816         20      7,116         80
1989...................................................        8,899      1,893         21      7,006         78
1990...................................................        9,796      2,091         21      7,705         79
1991...................................................       10,026      2,382         24      7,644         76
1992...................................................       10,115      2,536         25      7,579         75
1993...................................................       10,934      2,828         26      8,106         74
1994...................................................       11,312      3,000         26      8,312         73
1995...................................................       11,902      3,416         29      8,426         71
1996...................................................       12,198      3,084         25      8,495         70
1997...................................................       12,427      3,210         26      8,512         68
1998...................................................       13,272      3,453         26      8,752         70
----------------------------------------------------------------------------------------------------------------
Source: Health Care Financing Administration, Office of Clinical Standards and Quality.


                             Reimbursement

    Medicare reimbursement for facility-based dialysis services 
provided by hospital-based and independent facilities are paid 
at prospectively determined rates for each dialysis treatment 
session. The rate, referred to as a composite rate, is derived 
from area wage differences and audited cost data adjusted for 
the national proportion of patients dialyzing at home versus in 
a facility. Adjustments are made to the composite rate for 
hospital-based dialysis facilities to reflect higher overhead 
costs.
    Beneficiaries electing home dialysis may choose either to 
receive dialysis equipment, supplies, and support services 
directly from the facility with which the beneficiary is 
associated (method I) or to make independent arrangements for 
equipment, supplies, and support services (method II). Under 
method I, the equipment, supplies, and support services are 
included in the facility's composite rate. Under method II, 
payments are made on the basis of reasonable charges and 
limited to 100 percent of the median hospital composite rate, 
except for patients on CCPD, in which case the limit is 130 
percent of the median hospital composite rate.
    Typically, neither the composite rate nor the reasonable 
charge payment for method II is routinely updated. To the 
extent that kidney transplantation services are inpatient 
hospital services, they are subject to the Medicare PPS. There 
is no specific update policy for reasonable costs of kidney 
acquisition, and 100 percent of reasonable costs is reimbursed. 
However, the composite rate for renal dialysis was updated in 
the Medicare Balanced Budget Refinement Act (BBRA) of 1999 
(Public Law 106-113). The act increased the composite rate by 
1.2 percent above the revised composite rate that was in effect 
in 1999. In fiscal year 2000, the composite rate is $132 for 
hospitals and $128 for freestanding facilities, following an 
additional increase of 1.2 percent in the rates in effect in 
1999.

                            MEDICARE+CHOICE

    Medicare has a longstanding history of offering its 
beneficiaries an alternative to the traditional fee-for-service 
program, beginning with private health plans contracts in the 
1970s and the Medicare Risk Contract Program in the 1980s. 
Then, in 1997, Congress passed BBA 1997 (Public Law 105-33), 
replacing the Risk Contract Program with the new 
Medicare+Choice (M+C) Program. The M+C Program established new 
rules for beneficiary and plan participation, along with a new 
payment methodology. In addition to controlling costs, the M+C 
Program was also designed to expand health plans to markets 
where access to managed care plans was limited or nonexistent 
and to offer new types of health plans. Most recently, Congress 
enacted legislation in order to address some of the issues 
arising from the BBA changes. BBRA 1999 (Public Law 106-33) 
changed the M+C Program in an effort to make it easier for 
Medicare beneficiaries and plans to participate in the program.
    By March 2000, M+C plans were available to about 72 percent 
of the 39 million Medicare beneficiaries, and about 16 percent 
of them chose to enroll in one of over 260 available M+C plans. 
The rapid growth rate of Medicare managed care enrollment in 
the 1990s has leveled off since the implementation of the M+C 
Program, and there was even a small decline in enrollment in 
2000. Despite this recent trend, the Congressional Budget 
Office (CBO) projects that M+C enrollment will almost double by 
2010, covering 31 percent of the Medicare population.
    In order to increase enrollment in Medicare managed care 
and to allow beneficiaries to better meet their health care 
needs, the M+C Program offers a diverse assortment of managed 
care plans. However achieving the goals of the M+C Program has 
been difficult, in part because the goal to control Medicare 
spending may have dampened interest by managed care entities in 
developing new markets, adding plan options, and in maintaining 
their current markets (see appendix E for further information 
about the M+C Program).

                            SELECTED ISSUES

       Utilization and Quality Control Peer Review Organizations

    The Medicare Utilization and Quality Control Peer Review 
Organization (PRO) Program was established by Congress under 
the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA, 
Public Law 97-35). Building on the former Professional 
Standards Review Organizations, the new PROs were charged by 
the 1982 law with reviewing services furnished to Medicare 
beneficiaries to determine if the services met professionally 
recognized standards of care, were medically necessary, and 
delivered in the most appropriate setting. Major changes were 
made to the PRO Program by the Social Security Act Amendments 
of 1983 (Public Law 98-21) and subsequent budget reconciliation 
acts. Most PRO review is focused on inpatient hospital care. 
However, there is limited PRO review of ambulatory surgery, 
postacute care, and services received from Medicare health 
maintenance organizations (HMOs).
    There are currently 53 PRO areas, incorporating the 50 
States and the territories. Organizations eligible to become 
PROs include physician-sponsored and physician-access 
organizations. In limited circumstances, Medicare fiscal 
intermediaries may also be eligible. Physician-sponsored 
organizations are composed of a substantial number of licensed 
physicians practicing in the PRO review area (for example, a 
medical society); physician access organizations are those 
which have available to them sufficient numbers of licensed 
physicians so that adequate review of medical services can be 
assured. Such organizations obtain PRO contracts from the 
Secretary of the U.S. Department of Health and Human Services 
(DHHS) through a competitive proposal process. Each 
organization's proposal is evaluated by HCFA for technical 
merit using specific criteria that are quantitatively valued. 
Priority is given to physician-sponsored organizations in the 
evaluation process. Effective October 1, 1999, all 53 PROs are 
operating under the sixth round of contracts (also referred to 
as the ``sixth scope of work'').
    In general, each PRO has a medical director and a staff of 
nurse reviewers (usually registered nurses), data technicians, 
and other support staff. In addition, each PRO has a board of 
directors, comprised of physicians and, generally, 
representatives from the State medical society, hospital 
association, and State medical specialty societies. The Omnibus 
Budget Reconciliation Act of 1986 (Public Law 99-509) requires 
each board to have a consumer representative. Because the board 
is usually consulted before a case is referred by the PRO to 
the DHHS inspector general for sanction, it assumes a major 
role in the PRO review process. Each PRO also has physician 
advisors who are consulted on cases in which there is a 
question regarding the nurse reviewer's referral. Only 
physician advisors can make initial determinations about 
services furnished or proposed to be furnished by another 
physician.
    PROs are paid by Medicare on a cost basis for their work. 
Outlays for PROs in fiscal year 1998 and in fiscal year 1999 
totaled $221.6 million and $213.4 million, respectively, with 
fiscal year 2000 outlays projected to be $484.9 million. 
Spending varies considerably from year to year depending on 
where the PROs are in their contract cycles. HCFA has indicated 
that actual outlays for fiscal year 2000 may be considerably 
lower than their current projection. Currently HCFA uses an 
allocation of 80 percent from the Medicare Hospital Insurance 
(HI) Trust Fund and 20 percent from the Supplementary Medical 
Insurance (SMI) Trust Fund to finance PRO activity.
    The PRO review process combines both utilization and 
quality review. In conducting utilization review, the PRO 
determines whether the services provided to a Medicare patient 
were necessary, reasonable, and appropriate to the setting in 
which they were provided. Although some utilization review is 
done on a prospective basis, the bulk of the reviews are done 
retrospectively. When a PRO determines that the services 
provided were unnecessary or inappropriate (or both), it issues 
a payment denial notice. The providers, the physicians, and the 
patient are given an opportunity to request reconsideration of 
the determination.
    The PRO checks for indications of poor quality of care as 
it is conducting utilization review. If a PRO reviewer detects 
a possible problem, further inquiry is made into the case. If 
it is determined that the care was of poor quality, the PRO 
must take steps to correct the problem. Specific sanctions are 
required if the PRO determines that the care was grossly 
substandard or if the PRO has found that the provider or the 
physician has a pattern of substandard care. In addition, under 
section 9403 of COBRA (Public Law 99-272), as amended by Public 
Law 101-239, authority exists for the PROs to deny payments for 
substandard quality care. This provision, however, has never 
been used.
    Each of the contracts between DHHS and the PROs must 
contain certain similar elements outlined in a document known 
as the Scope of Work. Under the third and previous scopes of 
work, PRO review was centered on case-by-case examinations of 
individual medical records, selected primarily on a sample 
basis. This approach to medical review was criticized by the 
Institute of Medicine and others as being costly, 
confrontational, and ineffective. The fourth scope of work 
incorporated a new review strategy called the Health Care 
Quality Improvement Initiative. PROs were required to use 
explicit, more nationally uniform criteria to examine patterns 
of care and outcomes using detailed clinical information on 
providers and patients. Instead of focusing on unusual 
deficiencies in care, the PROs were instructed to focus on 
persistent differences between actual indications of care and 
outcomes from those patterns of care and outcomes considered 
achievable. HCFA believed that this approach would encourage a 
continual improvement of medical practice in a way that would 
be viewed by physicians and providers as educational and not 
adversarial.
    The fifth scope of work similarly emphasized continuous 
quality improvement. Sample case reviews, other than those 
mandated by law (such as those relating to hospital notices of 
noncoverage and to beneficiary complaints) are no longer 
required. Instead, each PRO is required to conduct 4-18 quality 
improvement projects each year, depending on the size of their 
beneficiary populations.
    The sixth scope of work includes national and local quality 
improvement projects which address clinical priorities that are 
designed to improve the health status of Medicare 
beneficiaries. The intent is to increase the PRO's experience 
in collaborating with providers, practitioners, plans, 
purchasers, and beneficiaries to improve quality of care, test 
quality indicators and intervention strategies. One more 
controversial task has also been included in this most recent 
scope of work. PROs will implement a Payment Error Prevention 
Program to identify incorrect payments that result from billing 
errors. This is a cooperative program and does not include 
punitive actions. In the first year of the contract, PROs will 
implement review activities to identify unnecessary admissions 
and miscoded diagnosis-related group (DRG) assignments.

                            Secondary Payer

    Generally, Medicare is the ``primary payer,'' that is, it 
pays health claims first, with an individual's private or other 
public health insurance filling in some or all of Medicare's 
coverage gaps. However, in certain cases, the individual's 
other coverage pays first, while Medicare is the secondary 
payer. This phenomenon is referred to as the Medicare Secondary 
Payer Program.
    An employer (with 20 or more employees) is required to 
offer workers age 65 and older (and workers' spouses age 65 and 
older) the same group health insurance coverage as is made 
available to other employees. Workers have the option of 
accepting or rejecting the employer's coverage. If the worker 
accepts the coverage, the employer's plan is primary for the 
worker and/or spouse who is over age 65; Medicare becomes the 
secondary payer. Employers may not offer a plan that 
circumvents this provision.
    Similarly, a group health plan, offered by a large employer 
with 100 or more employees, is the primary payer for employees 
or their dependents who are on the Medicare Disability Program. 
The provision applies only to persons covered under the group 
health plan because the employee (generally the spouse of the 
disabled person) is in ``current employment status'' (i.e., is 
an employee or is treated as an employee by the employer).
    Secondary payer provisions also apply to ESRD individuals 
with employer group health plans (regardless of employer size). 
Prior to enactment of BBA 1997, the group health plan was the 
primary payer for 18 months for persons who became eligible for 
Medicare ESRD benefits. The employer's role as primary payer 
was limited to a maximum of 21 months (18 months plus the usual 
3-month waiting period for Medicare ESRD coverage). The BBA 
extended the application of the secondary payer provisions for 
the ESRD population from 18 to 30 months. This applies to items 
and services furnished on or after August 5, 1997 for periods 
beginning on or after February 5, 1997.
    Medicare is also the secondary payer when payment has been 
made, or can reasonably be expected to be made, under workers' 
compensation, automobile medical liability, all forms of no-
fault insurance, and all forms of liability insurance.
    The law authorizes a data match program which is intended 
to identify potential secondary payer situations. Medicare 
beneficiaries are matched against data contained in Social 
Security Administration and Internal Revenue Service files to 
identify cases in which a working beneficiary (or working 
spouse) may have employer-based health insurance coverage. 
Cases of previous incorrect Medicare payments are identified 
and recoveries are attempted. The BBA clarifies that recoveries 
can be initiated up to 3 years after the date the service was 
furnished. Further, recoveries may be made from third-party 
administrators except where such administrators cannot recover 
amounts from the employer or group health plan.
    Table 2-28 shows savings attributable to these Medicare 
secondary payer provisions. In fiscal year 1998, combined 
Medicare part A and B savings are estimated at $3.4 billion.

TABLE 2-28.--MEDICARE SAVINGS ATTRIBUTABLE TO SECONDARY PAYER PROVISIONS BY TYPE OF PROVISION, FISCAL YEARS 1988-
                                                       98
                                            [In millions of dollars]
----------------------------------------------------------------------------------------------------------------
                                                                    End-stage
          Year and Medicare part             Workers'     Working     renal    Automobile  Disability    Total
                                           compensation     aged     disease
----------------------------------------------------------------------------------------------------------------
1988:
  Part A.................................       $110.1      $786.7      $88.4      $149.6      $275.5   $1,410.3
  Part B.................................         18.1       313.8       20.2        22.3        93.5      467.9
                                          ----------------------------------------------------------------------
    Total................................        128.2     1,100.5      108.6       171.9       369.0    1,878.2
                                          ======================================================================
1989:
  Part A.................................         99.4       867.7       75.0       179.6       399.3    1,621.0
  Part B.................................         27.5       337.1       25.1        28.2       137.0      554.9
                                          ----------------------------------------------------------------------
    Total................................        126.9     1,204.8      100.1       207.8       536.3    2,175.9
                                          ======================================================================
1990:
  Part A.................................        120.9       981.6      144.1       220.1       498.4    1,965.1
  Part B.................................         21.6       325.8       21.5        26.4       123.2      518.5
                                          ----------------------------------------------------------------------
    Total................................        142.5     1,307.4      165.6       246.5       621.6    2,483.6
                                          ======================================================================
1991:
  Part A.................................        107.4       932.7      144.9       235.6       526.6    1,947.2
  Part B.................................         21.2       417.5       40.2        26.6       186.2      691.7
                                          ----------------------------------------------------------------------
    Total................................        128.6     1,350.2      185.1       262.2       712.8    2,638.9
                                          ======================================================================
1992:
  Part A.................................        118.9     1,044.9      140.8       233.9       600.9    2,139.4
  Part B.................................         17.3       398.3       37.4        34.5       182.9      670.4
                                          ----------------------------------------------------------------------
    Total................................        136.2     1,443.2      178.2       268.4       783.8    2,809.8
                                          ======================================================================
1993:
  Part A.................................        100.4     1,073.1      133.6       239.6       657.8    2,204.5
  Part B.................................         11.3       392.2       32.8        28.9       192.3      657.5
                                          ----------------------------------------------------------------------
    Total................................        111.7     1,465.3      166.4       268.5       850.1    2,862.0
                                          ======================================================================
1994:
  Part A.................................         96.5     1,101.1      130.2       265.9       682.3    2,276.0
  Part B.................................         13.0       398.1       31.8        32.7       211.8      687.4
                                          ----------------------------------------------------------------------
    Total................................        109.5     1,499.2      162.0       298.6       894.1    2,963.4
                                          ======================================================================
1995:
  Part A.................................        107.0     1,068.0      142.0       295.5       728.9    2,341.4
  Part B.................................         10.5       360.3       39.0        40.2       215.5      665.5
                                          ----------------------------------------------------------------------
    Total................................        117.5     1,428.3      181.0       335.7       944.4    3,006.9
                                          ======================================================================
1996:
  Part A.................................         93.6     1,062.5      133.4       335.0       728.5    2,353.0
  Part B.................................         11.1       295.1       34.3        50.1       196.4      586.9
                                          ----------------------------------------------------------------------
    Total................................        104.7     1,357.6      167.6       385.0       924.9    2,939.9
                                          ======================================================================
1997:
  Part A.................................         99.7     1,046.5      114.3       366.8       697.5    2,324.9
  Part B.................................         11.8       276.4       32.4        63.7       178.9      563.2
                                          ----------------------------------------------------------------------
    Total................................        111.5     1,322.9      146.7       430.6       876.3    2,888.0
                                          ======================================================================
1998:
  Part A.................................         96.7     1,303.0      108.1       219.2       810.8    2,683.9
  Part B.................................         11.6       364.3       35.0        28.0       238.4      707.7
                                          ----------------------------------------------------------------------
    Total................................        108.3     1,667.3      143.1       247.1     1,049.3    3,391.6
                                          ======================================================================
----------------------------------------------------------------------------------------------------------------
Note.--Totals may not add due to rounding.

Source: Health Care Financing Administration, Bureau of Program Operations.


                    Supplementing Medicare Coverage

    Most beneficiaries depend on some form of private or public 
coverage to supplement their Medicare coverage. In 1996, only 
about 11.3 percent of beneficiaries relied solely on the 
traditional fee-for-service Medicare Program for protection 
against the costs of care; an additional 8.0 percent were 
enrolled in managed care organizations.
    The majority of the Medicare population (62.5 percent in 
1996) have private supplemental coverage. This private 
insurance protection may be obtained through a current or 
former employer (29.9 percent had such coverage in 1996). It 
may also be obtained through an individually-purchased policy, 
commonly referred to as a ``Medigap'' policy (28.4 percent had 
these plans in 1996). Some persons have both (4.2 percent in 
1996). In addition, a smaller percentage (about 16.5 percent in 
1996) have Medicaid coverage; a small group (1.7 percent in 
1996) have supplemental coverage from one of a variety of other 
public sources (such as the military) (table 2-29).

TABLE 2-29.--SUPPLEMENTARY HEALTH INSURANCE FOR THE MEDICARE POPULATION,
                                  1996
------------------------------------------------------------------------
                                                      Number     Persons
                  Type of coverage                      of        (in
                                                     Persons    percent)
------------------------------------------------------------------------
Medicare only.....................................    7,609.0       19.3
     Fee-for-service population...................    4,462.3       11.3
     Managed care population......................    3,146.7        8.0
 Medigap..........................................   11,180.4       28.4
 Employer-sponsored coverage......................   11,768.3       29.9
 Both private types...............................    1,667.9        4.2
 Medicaid, total..................................    6,494.1       16.5
    Full coverage.................................    3,268.6        8.3
    Qualified Medicare beneficiaries..............    2,925.7        7.4
    Specified low-income Medicare beneficiaries...      299.9        0.8
Other.............................................      665.4        1.7
                                                   ---------------------
       Total......................................   39,385.1     100.0
------------------------------------------------------------------------
Source: Eppig, et al., 1997.

 Medigap
     Medigap policies offer coverage for Medicare's deductibles 
and coinsurance and for some services not covered by Medicare. 
Premiums vary widely by type of coverage, geographic location 
and whether premiums are community-rated or based on a 
beneficiary age. The Omnibus Budget Reconciliation Act of 1990 
provided for a standardization of Medigap policies; the 
intention was to enable consumers to better understand policy 
choices and to prevent marketing abuses. Implementing 
regulations generally limit the number of different types of 
Medigap plans that can be sold in a State to no more than 10 
standard benefit plans, known as ``plan A'' to ``plan J.'' The 
standardized plan A covers a core benefits package. Each of the 
other nine includes the core package plus a different 
combination of additional benefits. Only plan H, plan I, and 
plan J offer some drug coverage. Beneficiaries who purchased 
policies prior to the standardization requirement may renew 
these policies; however, policies issued after July 1992 must 
be one of the 10 standard plans.
    The law contains certain requirements which guarantee the 
ability of beneficiaries to enroll in Medigap plans under 
certain specified conditions. These guaranteed issue 
provisions, which are outlined below, were significantly 
expanded by the Balanced Budget Act of 1997.
    Six-month open enrollment.--Federal law establishes an open 
enrollment period for the aged. All insurers offering Medigap 
policies are required to offer open enrollment for 6 months 
from the date a person first enrolls in part B (generally when 
the enrollee turns 65). During this time an insurer cannot deny 
the issuance, or discriminate in the pricing of a policy 
because of an individual's medical history, health status, or 
claims experience This requirement is known as guaranteed open 
enrollment.
    There is no guaranteed open enrollment period for the 
nonaged disabled population. However, when a disabled person 
turns 65, that individual has the same open enrollment 
guarantee as other aged persons.
    Guaranteed issue.--The law guarantees issuance of specified 
Medigap policies (without an exclusion based on a preexisting 
condition) for certain persons whose previous supplementary 
coverage was terminated. Guaranteed issue also applies to 
certain persons who elect to try out an M+C plan but 
subsequently disenroll from such plan. In these cases, the 
insurer is prohibited from discriminating in the pricing of the 
Medigap policy on the basis of the individual's health status, 
claims experience, receipt of health care or medical condition. 
In general, this right must be exercised within 63 days of 
termination of other enrollment. In the case of terminating M+C 
plans, beneficiaries may elect to obtain the Medigap policy 
within 63 days of the notice of termination (rather than within 
63 days of the actual termination date).
    Certain requirements enable persons whose previous 
supplementary coverage was terminated to obtain Medigap 
coverage. These provisions may be particularly important to 
persons whose HMO terminates its participation in the M+C 
Program.
    The following groups of persons whose coverage is 
involuntarily terminated are guaranteed issue of any Medigap 
plan A, B, C, or F that is sold to new enrollees by Medigap 
issuers in the State:
 1. An individual enrolled under an employee benefits plan that 
        provides benefits supplementing Medicare and the plan 
        terminates or ceases to provide such benefits;
 2. A person enrolled with an M+C organization whose enrollment 
        is discontinued because the plan's certification is 
        terminated or the organization no longer provides the 
        plan in the individual's service area; the individual 
        moves outside of the entity's service area; or the 
        individual elects termination due to cause; and
 3. An individual enrolled under a Medigap policy if enrollment 
        ceases because: (i) of the bankruptcy or insolvency of 
        issuer and there is no provision under State law for 
        continuation of such coverage; (ii) the issuer violates 
        a material provision; or (iii) the issuer materially 
        misrepresented the policy's provisions.
    Guaranteed issue protections also extend to certain persons 
who elect to try out one of the options available under the M+C 
Program. An individual is guaranteed issuance of the Medigap 
policy in which he or she was previously enrolled if the 
individual terminated enrollment in a Medigap policy, enrolled 
in an M+C organization or similar entity, and terminated such 
enrollment within 12 months. (If the same policy is no longer 
sold by the insurer, the individual is guaranteed issuance of 
Medigap plans A, B, C, or F.) The guarantee only applies if the 
individual was never previously enrolled in an M+C or similar 
plan.
    One group of persons are guaranteed issuance of any Medigap 
policy sold in the State. These are persons who, when they 
first become entitled to Medicare at age 65, enroll in an M+C 
plan and disenroll from such plan within 12 months.
    Preexisting condition exclusions.--At the time insurers 
sell a Medigap policy, they are generally permitted to limit or 
exclude coverage for services related to a preexisting health 
condition; such preexisting condition exclusions cannot be 
imposed for more than 6 months. However, preexisting 
limitations may not be imposed in the following cases:
 1. During the first 6-month open enrollment period, if on the 
        date of application, the individual had health 
        insurance coverage meeting the definition of 
        ``creditable coverage'' under the Health Insurance 
        Portability and Accountability Act.
 2. An individual who has met the preexisting condition 
        limitation in one Medigap policy. The individual does 
        not have to meet the requirement under a new policy for 
        previously covered benefits; however, an insurer could 
        impose exclusions for newly covered benefits (for 
        example, for prescription drugs if not covered under 
        the previous policy).
 3. Any individual who falls into one of the qualifying events 
        categories discussed above under ``Guaranteed Issue.'' 
        These include persons whose previous coverage was 
        involuntarily terminated or persons who elect to try 
        out Medicare+Choice.
    The prohibition applies to persons who had coverage under a 
prior policy for at least 6 months. If the individual has less 
than 6 months prior coverage, the policy must reduce the 
preexisting exclusion by the amount of the prior coverage.
     The Balanced Budget Act (BBA) provides for high deductible 
Medigap plans. Specifically, it added 2 plan types to the list 
of 10 standard Medigap plans. These offer the benefit package 
of either plan F or plan J, except for the high deductible 
feature. The high deductible was set at $1,500 in 1998 and 
1999. In subsequent years, it is increased by the Consumer 
Price Index (CPI). The beneficiary would be responsible for 
expenses up to this amount. The 2000 deductible is $1,530.
 Employer-based policies
     In 1996, employer-based policies covered 34 percent of 
Medicare beneficiaries. Employer-based plans are typically more 
comprehensive than Medigap plans. Generally they are defined 
benefit plans which may overlap significantly with Medicare 
benefits. As a result, employers use a variety of approaches to 
coordinate their plans with Medicare (which is the primary 
payer for retirees). The costs of coverage are generally shared 
by the employer and retiree.
     In recent years, the percentage of employers offering 
retiree health coverage for their Medicare retirees has 
dropped. Between 1993 and 1999, the number of large firms (with 
500 or more employees) offering such coverage dropped from 40 
percent to 28 percent (Foster Higgins, 1999).
     In addition, many other employers are pursuing strategies 
to lower their liabilities for retiree health costs. Some 
employers are moving toward a defined contribution model for 
retiree health benefits. Others are using Medicare risk plans 
and other managed care organizations to deliver services to 
their retirees.
Impact of supplemental insurance on Medicare spending
    Medicare cost-sharing requirements are intended, in part, 
to encourage cost-conscious utilization. Insurance that 
supplements Medicare by covering deductibles and coinsurance 
removes these incentives. Many analyses have addressed how 
supplemental insurance affects beneficiaries' use of Medicare-
covered services and the cost of those services to Medicare. 
Typically, these studies have estimated that Medicare spending 
for beneficiaries with supplemental coverage are one-quarter to 
one-third higher, on average, than expenditures for 
beneficiaries without such coverage.
    A Physician Payment Review Commission analysis (Physician 
Payment Review Commission, 1997) of the Medicare Current 
Beneficiary Survey found a similar effect: Medicare 
expenditures for beneficiaries covered by supplemental 
insurance were about 30-percent higher than they were for those 
without such coverage. Subsequent analysis showed that the 
effect of secondary coverage on Medicare expenditures differs, 
depending on the source of coverage. Expenditures for 
beneficiaries having Medicare only are less than 75 percent of 
those for beneficiaries with Medigap. Spending for 
beneficiaries with employer-provided benefits average only 
about 10 percent less (chart 2-1).


  CHART 2-1. COMPARISON OF PROJECTED PER CAPITA SPENDING FOR AVERAGE 
       BENEFICIARIES, BY TYPE OF SUPPLEMENTAL INSURANCE AND YEAR 
<GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT>

    Note._These spending levels represent the expected 
differences in outlays after other factors have been taken into 
account.

    Source: Physician Payment Review Commission analysis of 
data from the 1993 and 1995 Medicare Current Beneficiary 
Survey. The sample size for 1993 was 11,285 and the sample size 
for 1995 was 13,261.


    Higher utilization among beneficiaries with supplemental 
insurance translates into increased Medicare costs because 
Medicare is the primary payer for those services. The Medicare 
Current Beneficiary Survey analysis found that per capita 
expenditures for Medicare beneficiaries with Medigap insurance 
were from $1,000 to $1,400 higher than those for beneficiaries 
with Medicare only. Per capita spending for beneficiaries with 
employer-provided supplements were from $700 to $900 higher 
than those for beneficiaries with no supplemental coverage.
    These results reflect the difference in spending by source 
of insurance, once other factors have been considered. High 
service use among beneficiaries with secondary insurance 
appears to be a consequence of having such insurance, 
presumably reflecting the reduced financial burden associated 
with using additional services.
Medicaid
    Some low-income aged and disabled Medicare beneficiaries 
are also eligible for full or partial coverage under Medicaid. 
Persons entitled to full Medicaid protection generally have all 
of their health care expenses met by a combination of Medicare 
and Medicaid. For these ``dual eligibles'' Medicare pays first 
for services both programs cover. Medicaid picks up Medicare 
cost-sharing charges and provides protection against the costs 
of services generally not covered by Medicare. Of particular 
importance for this population is coverage for prescription 
drugs and long-term care services.
    Several population groups are entitled to more limited 
Medicaid protection. These include qualified Medicare 
beneficiaries (QMBs), specified low-income Medicare 
beneficiaries (SLMBs), and certain qualified individuals. 
Persons meeting the qualifications for coverage under one of 
these categories, but not otherwise eligible for Medicaid, are 
not entitled to the regular Medicaid benefits package. Instead, 
they are entitled to have Medicaid make specified payments in 
their behalf.
    Qualified Medicare beneficiaries.--State Medicaid Programs 
are required to make Medicare cost-sharing assistance available 
to QMBs. A QMB is an aged or disabled Medicare beneficiary who 
has: (1) income at or below the Federal poverty line ($8,592 
for a single, $11,496 for a couple in 2000, including the $20 
per month disregard); and (2) resources below 200 percent of 
the resources limit set for the Supplemental Security Income 
(SSI) Program (the QMB resource limits are $4,000 for an 
individual and $6,000 for a couple). Certain items, such as an 
individual's home and household goods, are excluded from the 
calculation.
    Persons meeting the QMB definition are entitled to Medicare 
part A. Included is the relatively small group of aged persons 
who are not automatically entitled to part A coverage, but who 
have bought part A protection by paying a monthly premium. Not 
included are working disabled persons who have exhausted 
Medicare part A entitlement but who have extended their 
coverage by payment of a monthly premium.
    Medicaid is required to pay Medicare premiums and cost-
sharing charges for the QMB population as follows: (1) part B 
monthly premiums; (2) part A monthly premiums paid by the 
limited number of persons not automatically entitled to part A 
protection; (3) coinsurance and deductibles under part A and 
part B including the Medicare hospital deductible, the part B 
deductible, and the parts A and B coinsurance; and (4) 
coinsurance and deductibles that M+C plans charge their 
enrollees.
Payment of QMB benefits
    States are required to pay part A and part B premiums in 
full for the QMB population. They are also required to pay the 
requisite deductibles and coinsurance, though the actual amount 
of the payment may vary. State Medicaid Programs frequently 
have lower payment rates for services than those applicable 
under Medicare. Federal law permits States to either: (1) pay 
the full Medicare deductible and coinsurance amounts; or (2) 
only pay those amounts to the extent that the Medicare provider 
or supplier has not received the full Medicaid rate for the 
service.
    All States have buy-in agreements with the Secretary that 
allow them to enroll their QMB population in part B. Some 
States have also elected to include payment of part A premiums 
under their buy-in agreements. Payment of premiums under a buy-
in agreement is advantageous to the State because premiums paid 
through this method are not subject to delayed enrollment 
penalties which might otherwise be applicable in the case of 
delayed enrollment or reenrollment.
    The buy-in agreements for the QMB population are in 
addition to the traditional buy-in agreements that States have 
for other population groups. Under these traditional buy-in 
agreements, States enroll in Medicare part B persons who are 
eligible for both Medicare and Medicaid. As a minimum, States 
may limit buy-in coverage to persons receiving cash assistance; 
alternatively, they may add some or all categories of other 
persons who are eligible for both programs.
    Specified low-income Medicare beneficiaries.--States are 
also required to pay Medicare part B premiums for SLMBs. These 
are persons meeting the QMB criteria except that their income 
is slightly over the QMB limit. The SLMB income limit is 120 
percent of the Federal poverty line. In 2000 this is $10,260 
for a single and $13,740 for a couple (including the $20 per 
month disregard). Medicaid protection is limited to payment of 
the Medicare part B premiums, unless the beneficiary is 
otherwise eligible for Medicaid.
    Qualifying individuals.--BBA 1997 required State Medicaid 
Programs, effective January 1, 1998 through December 31, 2002, 
to pay part B premiums for beneficiaries with incomes up to 135 
percent of poverty. These persons are referred to as QI-1s. For 
Medicare beneficiaries with incomes between 135 and 175 percent 
of poverty, State Medicaid Programs are required to cover that 
portion of the Medicare part B premium attributable to the 
transfer of home health visits from part A to part B. These 
persons are referred to as QI-2s.
     The Federal Government will pay 100 percent of the costs 
associated with expanding Medicare part B premium assistance 
from 120 to 135 percent of poverty, as well as the extra 
premium cost attributable to the home health transfer for 
persons with incomes between 135 and 175 percent of poverty. To 
cover these costs, the Secretary is required to provide for 
allocations to States based on the sum of: (1) a State's number 
of Medicare beneficiaries with incomes between 135 and 175 
percent of poverty, and (2) twice the number of Medicare 
beneficiaries with incomes between 120 and 135 percent of 
poverty, relative to the sum for all eligible States. Total 
amounts available for allocations are $200 million for fiscal 
year 1998, $250 million for fiscal year 1999, $300 million for 
fiscal year 2000, $350 million for fiscal year 2001, and $400 
million for fiscal year 2002. The Federal matching rate for 
each participating State will be 100 percent up to the State's 
allocation. If a State exceeds its allocation, the matching 
rate on the excess is zero. Payments are to be made from 
Medicare part B for the costs of this program.
    Qualified disabled and working individuals (QDWIs).--
Medicaid is authorized to provide partial protection against 
Medicare part A premiums for QDWIs. QDWIs are persons who were 
previously entitled to Medicare on the basis of a disability, 
who lost their entitlement based on earnings from work, but who 
continue to have the disabling condition. Medicaid is required 
to pay the Medicare part A premium for such persons if their 
incomes are below 200 percent of the Federal poverty line, 
their resources are below 200 percent of the SSI limit, and 
they are not otherwise eligible for Medicaid. States are 
permitted to impose a premium, based on a sliding scale, for 
individuals between 150 and 200 percent of poverty.
Data
    As of July 1998, Medicare reported that there were 331,924 
Medicare part A beneficiaries for whom QMB payments for part A 
premiums were being made. As of the same date, States reported 
a total of 5,109,228 part B buy-ins of which 2,421,298 were 
separately identified as QMBs and 272,565 were separately 
identified as SLMBs (table 2-30). However, these numbers are 
low due to reporting problems. The QMB and SLMB numbers include 
persons who were eligible for the full Medicaid benefit 
package. No QMB-only or SLMB-only number is available. 
Nationwide there were 18 QDWIs in May 1997; this information is 
not broken down by State.

 TABLE 2-30.--NUMBER OF QUALIFIED MEDICARE BENEFICIARIES, SPECIFIED LOW-INCOME MEDICARE BENFICIARIES, AND STATE
                                          BUY-INS BY JURISDICTION, 1998
----------------------------------------------------------------------------------------------------------------
                                                                           Part B buy-                  Part B
                            State                             Part A QMBs      ins      Part B QMBs     SLMBs
----------------------------------------------------------------------------------------------------------------
Alabama.....................................................        3,315      121,990       30,575        8,649
Alaska......................................................          584        7,093            0           16
Arizona.....................................................          451       51,141       32,763        1,944
Arkansas....................................................        3,708       78,514       20,966        4,792
California..................................................       94,202      776,832      377,822       10,774
Colorado....................................................          512       52,175       11,930            0
Connecticut.................................................        2,465       51,335       40,737        3,961
Delaware....................................................          462        8,900        1,938          514
District of Columbia........................................        1,152       14,582          390        1,599
Florida.....................................................       41,860      313,744      199,721       16,584
Georgia.....................................................        6,181      171,047       47,531       10,631
Hawaii......................................................        4,783       19,226        4,434          147
Idaho.......................................................          250       14,909        8,473          864
Illinois....................................................        3,401      145,976      111,933       13,928
Indiana.....................................................        1,739       81,184       52,626       11,585
Iowa........................................................        1,176       49,844       34,802        7,033
Kansas......................................................          635       39,008       15,064        1,675
Kentucky....................................................        3,242      106,537       29,826        8,029
Louisiana...................................................        5,132      115,031       26,461        4,519
Maine.......................................................           14       33,006       14,128        2,715
Maryland....................................................        6,387       61,669       43,784        2,154
Massachusetts...............................................       14,885      138,796      116,511       11,465
Michigan....................................................        6,387      135,769       40,969       15,115
Minnesota...................................................        3,766       57,559       14,871        3,354
Mississippi.................................................        6,814      106,336       68,307        5,169
Missouri....................................................          666       81,841       60,047        7,615
Montana.....................................................          426       11,882        9,188        1,472
Nebraska....................................................            1       18,029        7,727          785
Nevada......................................................        1,047       17,191       12,590        1,839
New Hampshire...............................................           25        6,295        1,411            0
New Jersey..................................................        7,420      137,598       88,668       15,065
New Mexico..................................................          496       34,411        7,914        2,427
New York....................................................          253      363,331      169,511        1,187
North Carolina..............................................       11,254      210,388       45,553       10,195
North Dakota................................................            6        5,612        1,394          388
Ohio........................................................        6,389      180,172       72,377        7,333
Oklahoma....................................................        4,373       63,142       55,936        6,858
Oregon......................................................           40       51,392       27,329        3,697
Pennsylvania................................................       15,903      179,295      113,357       10,595
Rhode Island................................................          744       17,729        1,540            8
South Carolina..............................................        1,793      104,111       85,020        5,729
South Dakota................................................          759       12,791        4,508        1,388
Tennessee...................................................        7,642      171,653       73,825        2,219
Texas.......................................................       42,979      339,648       96,543       18,763
Utah........................................................          140       14,900       10,147        1,474
Vermont.....................................................          218       13,197        3,330        1,829
Virginia....................................................        2,939      108,427       42,957        6,450
Washington..................................................        5,144       89,419       26,461        6,478
West Virginia...............................................        3,560       43,019       38,503        3,911
Wisconsin...................................................        4,021       74,429       16,880        6,896
Wyoming.....................................................          196        5,963        2,020          747
Outlying areas..............................................            0        1,160            1            0
                                                             ---------------------------------------------------
      Total.................................................      331,924    5,109,228    2,421,298     272,565
----------------------------------------------------------------------------------------------------------------
Note.--Total part B buy-ins include part B QMBs, part B SLMBs, and QI-1s (not separately broken out).

 Source: Health Care Financing Administration, Office of Information Services.