CY 2013 Parts C & D
Benefits Review
1
Agenda
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•
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Overview
Part C Requirements
Part D Requirements
Quality Bid Submissions
2
Important Dates (1 of 2)
April 6
April 16
May 11
June 4
June 8 deadline
PBP & BPT software available in
HPMS
Formulary submission/Transition
attestations deadline (11:59 p.m. EDT)
HPMS available to accept bids
Bid submission and Formulary-to-Plan
crosswalk deadline (11:59 p.m. PDT)
Part D supplemental file submission
deadline
3
Important Dates (2 of 2)
June/July
July/August
Part C and Part D Bid review activities
Rebate reallocation
Aug/Sep
October 1
Attestations/contracts
Deadline to submit plan correction
requests; marketing begins
4
Bid Review Activities (June/July)
• CMS will conduct bid reviews and anticipates
communicating issues with plans late June
• Bid review should be completed by mid/late July
• CMS bid review points of contact for Plan Benefit Package
(PBP) and Bid Pricing Tool (BPT):
• Office of the Actuary (OACT) and contractors
• Medicare Drug Benefit and C&D Data Group (MDBG)
• Medicare Drug & Health Plan Contract Administration Group
(MCAG)
• MCAG contractors for notes review
5
Bid Prep Resources (1 of 2)
• Final Regulation CMS-4157-FC (April 2012)
• Final CY 2013 Call Letter
• HPMS Memos
• Out-of-Pocket Cost (OOPC) Model Resources
OOPC@cms.hhs.gov
• Medicare Managed Care Manual (MMCM)-Chapter 4Benefits & Beneficiary Protections
• User Group Calls
• Part C & D User Group Calls
• OACT User Group Calls
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Bid Prep Resources (2 of 2)
• Prescription Drug Benefit Manual
• (http://www.cms.gov/PrescriptionDrugCovContra/12_PartD
Manuals.asp#TopOfPage)
• Chapter 5 (Benefits and Beneficiary Protections)
• Chapter 6 (Part D Drug and Formulary Requirements)
• Chapter 7 (Medication Therapy Management and Quality
Improvement Program
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Agenda
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•
•
•
Overview
Part C Requirements
Part D Requirements
Quality Bid Submissions
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CY 2013 Part C PBP Changes (1 of 3)
• Out-of-network cost sharing
• HMO plans do not cover out-of-network benefits outside of the
HMO-POS benefit
• HMO-POS plans must cover at least one out-of-network
benefit
• Ensure that out-of-network cost sharing is defined completely
and accurately for HMO-POS and PPO plans
• RPPO and LPPO deductibles align with final regulation
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CY 2013 Part C PBP Changes (2 of 3)
• Note Fields
• PBP Notes must only be used to clarify a benefit when a
standard data entry screen cannot accommodate information
• Restricted to 3,000 characters
• No longer contain duplicate language for purpose of marketing
material review
• Rewards & Incentives: CMS does not expect to see rewards
and incentives in the PBPs (refer to Marketing Guidelines)
• “Other” Category in PBP
• Increased from 2 to 3 categories
• Highly Integrated D-SNPs will have a 4th “other” category to
place benefits that are provided through additional flexibility
discussed in the Call Letter
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CY 2013 Part C PBP Changes (3 of 3)
• PBP software has been changed to accommodate a single
entry to attest to appropriate coverage of preventive
services
• MA plans are required to provide zero cost sharing for
preventive services that are covered by Original Medicare at
zero cost sharing
• Requires same service frequency (e.g., colonoscopy once
every 24 months if patient is high risk for colorectal cancer)
• Plans may offer certain supplemental preventive benefits
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MA Benefits Review Goals
• Evaluate low enrollment plans
• Ensure that bids for an organization’s plans in a service
area are meaningfully different from one another
• Evaluate significant increases in cost sharing or decreases
in benefits (Total Beneficiary Cost)
• Ensure cost sharing amounts and benefit designs do not
discriminate against or steer beneficiaries on the basis of
health status
• Ensure supplemental benefits are in compliance with CMS
guidance
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Summary of Bid Review Requirements
Bid Review
Criteria
Low Enrollment
Meaningful
Difference
Total Beneficiary
Cost
Maximum Out-of –
Pocket (MOOP)
Limits
PMPM Actuarial
Equivalent Cost
Sharing
Service Category
Cost Sharing
In-network $0 Cost
Share Preventive
Services
Applies to NonEmployer Plans
(Excluding Dual
Eligible SNPs)
Applies to NonEmployer Dual
Eligible SNPs
Applies to Cost
Contractors
Applies to
Employer Plans
Yes
Yes
No
No
Yes
No
No
No
Yes
No
No
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes1
Yes
Yes
Yes
Yes2
Yes
1 Section
3202 of the ACA established that MA plans and cost contracting plans may not charge enrollees higher cost sharing than is charged under original Medicare
for chemotherapy administration, skilled nursing care and renal dialysis services (42 CFR §§417.454(e) and 422.100(j)).
2 Requirement that all MA plans and 1876 cost contractors cover, without cost sharing, all in-network preventive services covered under original Medicare without
cost sharing is codified at 42 CFR §§417.454(d) and 422.100(k).
13
Low Enrollment Approach (1 of 2)
• Evaluation based on plans operating for at least three years
(i.e., ‘10, ‘11, ‘12 or longer)
• CMS will contact parent organizations to potentially
consolidate or eliminate plans (April/May)
• Non-SNPs with fewer than 500 enrollees
• SNPs with fewer than 100 enrollees
• Flexibility may be extended to plans, based on population
served and/or access to other plans
• CMS may not allow plans with sustained very low
enrollment (fewer than 25) to renew
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Low Enrollment Approach (2 of 2)
• Instructions will be provided to impacted organizations
through a CMS communication
• Organizations should agree to either
• Consolidate
• Eliminate identified plan(s)
• Submit a justification for CMS consideration (e.g., serving a
unique population)
• Organizations choosing to consolidate/eliminate plans must
be in accordance with CMS renewal/non-renewal guidance
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Meaningful Difference Approach
• Acceptable difference between plans is $20 pmpm, based
on Out-of-Pocket Cost (OOPC) data for both Part C and
Part D benefits combined
• Premiums are excluded for purpose of evaluating
meaningful differences
• Does not apply to D-SNP or employer group plans
• Providers are not considered a meaningful difference
• Organizations must consolidate/eliminate plans in
accordance with CMS renewal/nonrenewal guidance
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Total Beneficiary Cost (1 of 2)
• Evaluate bids for significant increases in beneficiary costs or
decreases in benefits from one year to the next
• Total Beneficiary Cost (TBC)
• Sum of plan-specific premium, Part B premium factor, and
beneficiary out-of-pocket costs (OOPC)
• A change in TBC from one year to the next is indicative of
changes in cost sharing and/or benefits
• From CY 2012 to CY 2013, the TBC change limit is set at
$36 pmpm
• Organizations can calculate each plan’s TBC by using
• OOPC model tools provided by CMS
• CY 2013 BPT to determine premium (net of rebates)
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Total Beneficiary Cost (2 of 2)
• CMS will provide guidance and plan-specific amounts to
organizations via HPMS (April):
• CY 2012 TBC amount
• Adjustment factors that reflects impact of benchmark and/or
bonus payment changes and Part B premium
• Adjustment factor that reflects impact of changes in OOPC
model between CY 2012 and CY 2013
• For plans that consolidate multiple CY 2012 plans into a
single CY 2013 plan, CMS will use the enrollment-weighted
average of the CY 2012 plan values for TBC
• CMS reserves the right to further examine and to request
additional changes to a plan bid, even if its TBC change is
within the plan-specific TBC change amount
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CY 2013 MA Cost Sharing Standards
• See CY 2013 Call Letter and HPMS memo for details
related to other important cost sharing requirements:
• Maximum out-of-pocket limits (MOOP)
• PMPM actuarial equivalence
• Service category cost sharing
• A benefit’s cost sharing may not exceed 50% for an Original
Medicare in or out-of-network service (MMCM: Chapter 4)
• CMS may specify cost sharing requirements lower than 50%
for certain in-network services
• Beneficiaries generally find co-payment amounts more
predictable and less confusing than coinsurance
• Plans may use stratified co-payments for DME and/or Part B
drugs (See MMCM: Chapter 4)
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Supplemental Benefits (1 of 3)
• All MA plans, including SNPs are required through their
Chronic Care Improvement Program (CCIP) to provide care
coordination services that enhance the effectiveness and
efficiency of the health care delivered by the plan
• In addition, SNPs are required to provide a higher level of
coordinated care and disease management services
through their Model of Care (MOC)
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Supplemental Benefits (2 of 3)
• Non-SNP plans can include the following to be considered a
supplemental benefit for enhanced disease management
above and beyond the CCIP
• Targeted members assigned to qualified case managers with
specialized knowledge
• Educational activities provided by licensed professionals
• In-home measures of monitoring symptoms
• General Nutrition/Dietary Education: Provided by a certified
health educator or qualified health professional
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Supplemental Benefits (3 of 3)
• In-Home Safety Assessment
• Performed by occupational therapist or qualified health
professional
• Focus on risk for falls and identify how falls are prevented
• Subject to enrollee approval, include bathroom safety devices
that are appropriate
• Can include identification and minor home modification of
some hazards outside the bathroom
• Health Education
• Includes topics such as diabetes, fitness, preventive services
• CMS does not consider the following stand-alone items as a
supplemental benefit: Brochures, Non-interactive web content
and newsletters
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Additional Supplemental $0 Preventive Services
• Smoking and Tobacco Cessation must include one of the
following:
• Face-to-face sessions
• Interactive web
• Telephonic coaching
• Medical Nutrition Therapy: Provided by registered dieticians
or nutritionists
• Pap smear and pelvic exams may be offered annually
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Agenda
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Overview
Part C Requirements
Part D Requirements
Quality Bid Submissions
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Standard Benefit 2013
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Benefit Types
• Basic Prescription Drug Coverage
• Defined Standard (DS) Coverage
• Actuarially Equivalent (AE) Coverage
• Basic Alternative (BA) Coverage
• Enhanced Alternative (EA) Coverage
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BENEFIT REVIEW HIGHLIGHTS:
Bid Design and Submission
Requirements
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CY 2013 Part D PBP Changes
• Allowable tier models are programmed into the PBP tool
• Meaningful benefit offerings for plans with 5 or 6 tiers
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Excluded-drug-only tier
Injectable tier
Select Care Drugs
Select Diabetic Drugs
Specialty tier
Vaccines
• Optional daily copay
• Average expected cost-sharing for coinsurance tiers
• LTC brand other days supply
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Benefit Review/Approval Timeframe
• Continue to have shorter timeframe due to annual
enrollment period start date of October 15, 2012
• Initial bids should be complete and consistent with all CMS
policy/guidance
• OOPC model can be used to improve bid submissions
• Revised resubmissions are not guaranteed for bids that fail to
meet benefit review requirements
• Sponsors risk bid denial for incomplete or non-compliant
submissions
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Low Enrollment (Stand-alone PDPs)
• A sufficient number of enrollees is needed for a plan to
establish themselves as a viable option
• CMS urges sponsors to consider withdrawing or
consolidating any stand-alone plan with less than 1,000
enrollees
• Prior to bid submission CMS will notify Part D sponsors with
less than 1,000 enrollees of available consolidation/withdrawal
options (April 2012)
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Meaningful Differences (1 of 3)
• Plan offerings within a service area must be meaningfully
different with respect to benefit packages and cost
structures
• Stand-alone prescription drug plans (PDPs) may offer no
more than 3 plans in a region
• 1 basic plan offering (required)
• Maximum of 2 enhanced plan offerings
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Meaningful Differences (2 of 3)
• Cost-sharing out-of-pocket cost (OOPC) differential analysis
for PDPs
• Used to establish meaningful differences among basic and
enhanced plan offerings
• Measure of additional benefits available to the average consumer
• Not intended to take plan-specific enrollee utilization into
account
• Exclusive of premiums
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Meaningful Differences (3 of 3)
• Minimum monthly cost-sharing OOPC differential for PDPs
• Between basic and lowest EA plan in the same region: $23
• Between 2 EA plans in the same region: $12
• 2nd EA plan also expected to offer additional gap coverage for 10-65%
of formulary brand entities
• Plans should use the OOPC model to ensure meaningful
differences between plan offerings
• Organizations may consolidate/eliminate plans in
accordance with CMS renewal/nonrenewal guidance
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Part D Cost-Sharing (1 of 4)
• Cost-sharing for tiered benefit designs may not exceed
levels annually determined to be discriminatory
• Preliminary 2013 cost-sharing thresholds were established
based on 2012 PDP and MA-PD benefit package data
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Part D Cost-Sharing (2 of 4)
• In-network pharmacy and in-network non-preferred
pharmacy cost-sharing thresholds are the same Pre-ICL and
in the Coverage Gap
• Coinsurance tier evaluation
• Injectable tier coinsurance should be less than or equal to the
specialty tier coinsurance for the same formulary
• Average expected cost-sharing for drugs evaluated for
coinsurance cost-sharing >25%
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Part D Cost-Sharing (3 of 4)
Maximum Pre-ICL Copay and Coinsurance
(INPh & INNPPh) - 3 or more tiers
Tier Label
Copay
Coinsurance
Preferred
Generic/Generic Tier
$10
25%
Non-Preferred Generic
Tier
$33
25%
Preferred Brand/Brand
Tier
$45
25%
Non-Preferred Brand
Tier
$95
50%
Injectable Tier
$95
33%
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Part D Cost-Sharing (4 of 4)
Maximum Additional Gap Coverage Copay and Coinsurance
(INPh & INNPPh) - 3 or more tiers
Tier Label
Copay
Coinsurance
Preferred
Generic/Generic Tier
$10
59%
Non-Preferred Generic
Tier
$33
59%
Preferred Brand/Brand
Tier
$45
69%
$95
69%
$95
----
Non-Preferred Brand Tier
Injectable Tier
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Part D Supplemental
and
Formulary File Submissions
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CY 2013 Part D Supplemental File Submissions
• Submission process is the same as CY 2012
• New validations to ensure files are appropriate and
consistent with the approved bid and/or formulary
• For example: after bid approval, home infusion (HI) drugs that
will be bundled under Part C need to be added to both the
formulary and HI file during the same formulary upload window
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CY 2013 Formulary File Submissions
CY 2013 Formulary Submission Dates
Regular
Demo
Submission deadline
April 16, 2012
11:59 pm EDT
April 30, 2012
11:59 pm EDT
Contract to formulary
crosswalk
April 16, 2012
11:59 pm EDT
May 14, 2012
11:59 pm EDT
Plan to formulary
crosswalk
June 4, 2012
11:59 pm PDT
June 4, 2012
11:59 pm PDT
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•
Associate formulary to a single parent organization
Formulary tier models selected in formulary
submission module
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Agenda
•
•
•
•
Overview
Part C Requirements
Part D Requirements
Quality Bid Submissions
41
Parts C & D Quality Bid Submissions
• PBP submissions must be accurate and complete for bid
review and marketing materials
• Compare PBP to BPT—cost sharing amounts must match
• Review PBP notes for completeness and accuracy
• Generate a Summary of Benefits to ensure marketing
materials will be correct
• Actuarial certification is required
• Communicate and coordinate within your organization
42
Plan Correction Requests
• Last day to submit plan correction requests is October 1,
2012 – No exceptions to deadline
• Request for plan correction indicates inaccuracies and/or
incompleteness of bid and organization’s inability to submit
a correct bid
• In general, CMS will issue compliance letters to
organizations requesting plan corrections for CY 2013
• Organizations with a history of submitting plan corrections
may be subject to significant compliance actions
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Resource Guide
• Policy Mailboxes
• Https://MABenefitsMailbox.lmi.org
• Part C bid guidance for CY 2013
• Part C policy related questions and FAQs
• Partdbenefits@cms.hhs.gov
• Part D policy related questions
• OOPC@cms.hhs.gov
• Questions regarding OOPC model
• Actuarial-bids@cms.hhs.gov
• Questions regarding bid instructions or completing the BPT
• MMCOcapsmodel@cms.hhs.gov
• Questions regarding the Capitated Financial Alignment Demonstration
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Contact Information
• For Part D benefit policy, PBP and benefit review questions
contact:
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PartDBenefits@cms.hhs.gov
Rosalind Abankwah, 410 786-2012
rosalind.abankwah@cms.hhs.gov
Kady Flannery, 410 786-6722
kathleen.flannery@cms.hhs.gov
Frank Tetkoski, 410 786-5233
frank.tetkoski@cms.hhs.gov
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