Financial burden of care greatest among rural beneficiaries in Medicare advantage.

Objective: To examine differences in access to care and financial burden between Traditional Medicare (TM) and Medicare Advantage (MA) beneficiaries in rural and urban areas and then explore whether there were potential differences in MA benefits between urban and rural areas.

Study setting and design: We conducted a cross-sectional study within the Medicare setting in the United States.

Data sources and analytical sample: Data from three distinct sources for 2017-2021: the Medicare Current Beneficiary Survey, the MA landscape data, and the Plan Benefit Package data. Our sample comprised 43,343 Medicare beneficiary-years, including TM and MA beneficiaries in urban and rural areas.

Principal findings: Our adjusted analysis showed that rural MA beneficiaries experienced higher rates of delayed care due to costs (10.0% [95% confidence interval (CI): 8.8-11.1]) compared with rural TM (9.5% [8.8-10.2]), urban MA (7.9% [7.4-8.4]), and urban TM (7.9% [7.5-8.2]) beneficiaries. Similarly, rural MA beneficiaries (11.4% [95% CI: 10.3-12.5]) reported more difficulty paying medical bills compared with rural TM (9.4% [8.7-10.1]), urban MA (8.1% [7.7-8.6]), and urban TM (7.8% [7.5-8.2]) beneficiaries. This disparity was associated with less generous financial structures in rural MA plans. Compared to urban MA plans, rural MA plans offered lower out-of-pocket maximums for in-network care ($5918 vs. $5439), but required higher copayments ($1686 vs. $1724 for a 5-day hospitalization, $37 vs. $41 for a specialist visit, and $35 vs. $38 for a mental health visit). However, differences in quality of care and provision of supplemental benefits were small.

Conclusion: Rural Medicare beneficiaries reported a greater financial burden of care than urban Medicare beneficiaries, but the most significant burden was observed among MA beneficiaries in rural areas. One possible mechanism could be the less generous financial structures offered by rural MA plans. These findings suggest the need for policies addressing the affordability of care for rural MA beneficiaries.