Article Summary
Medicare Advantage plans significantly increased cost-sharing for advanced diagnostic imaging services between 2018 and 2026, with median copayments rising from $195 to $260 and more plans requiring both coinsurance and copayments, potentially affecting patient access to clinically necessary imaging.
- The percentage of Medicare Advantage plans requiring cost-sharing for advanced imaging grew from 98.3% in 2018 to 98.9% in 2026
- Plans requiring both coinsurance and copayment increased from 40.1% to 49.1% over the eight-year period
- Median copayments rose significantly from $195 to $260, while maximum copayments also increased.
- PPO plans charged higher median copayments compared to HMO plans.
Patient cost-sharing for outpatient advanced diagnostic imaging vary across Medicare Advantage plans, suggest findings published July 1 in the American Journal of Roentgenology.
Researchers led by Jessica Billig, MD, from the University of Texas Southwestern Medical Center in Dallas found that Medicare Advantage plans “overwhelmingly” involved patient cost-sharing for these imaging services. And throughout the study period, plans most commonly required both coinsurance and a copayment.
“The findings are relevant to CMS [Centers for Medicare and Medicaid Services] oversight of Medicare Advantage benefit design and beneficiary protections,” Billig and colleagues wrote.
Patients in traditional Medicare who undergo outpatient advanced diagnostic imaging are responsible for 20% of the exam’s Medicare-approved amount. In some cases, patients may also face an added facility fee for hospital-based imaging.
Medicare Advantage plans cover all medically necessary services covered by traditional Medicare but have greater flexibility in the design of plan benefits including patient cost-sharing policies.
Billig et al highlighted that this may affect patient access to clinically indicated imaging because of variation across plans in patient cost-sharing for covered services. The researchers studied trends in patient cost-sharing for advanced diagnostic imaging in Medicare Advantage plans.
The team used benefits data from two CMS Plan Benefit Package datasets, which provide information about approved benefits for active Medicare Advantage plans nationally. These included the 2018 quarter-one dataset, representing the earliest available benefits dataset, and the single 2026 benefits dataset available at the time of analysis.
The study included three categories of outpatient radiologic services: radiography, advanced diagnostic imaging (including CT, MRI, and other modalities), and therapeutic services the researchers noted were generally related to radiation oncology. It also included only health maintenance (HMO) and preferred provider organization (PPO) plans in the datasets.
Final analysis included 4,046 plans from 2018 and 6,909 from 2026. No plan in either year reported a deductible for radiology services, the researchers reported.
The team reported the following findings:
The percentage of plans requiring cost-sharing for advanced imaging grew from 98.3% in 2018 to 98.9% in 2026.
The share of plans requiring both coinsurance and a copayment grew from 40.1% in 2018 to 49.1% in 2026.
Plans requiring only a copayment declined from 20.9% to 14.9%, while those requiring only coinsurance dipped slightly from 37.3% to 34.9%.
The 20% coinsurance rate remained dominant, used by 97.9% of coinsurance plans in 2018 and 96.2% in 2026.
Between the two time periods, the maximum coinsurance rate doubled from 25% to 50%. And in 2026, 2.2% of plans had coinsurance rates between 41% and 50%.
The median copayment also rose from $195 to $260, and the maximum copayment increased from $600 to $780. And in 2026, 2.0% of plans required copayments in the $401 to $500 range.
Finally, PPO plans had higher median copayments in both time periods (2018, $245; 2026, $300) than HMO plans (2018, $175; 2026, $250).
The study authors highlighted that outlier high patient costs should be further studied.
Read the full study here.
