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1 CY 2013 Parts C & D Benefits Review. 2 Agenda Overview Part C Requirements Part D Requirements Quality Bid Submissions.

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Presentation on theme: "1 CY 2013 Parts C & D Benefits Review. 2 Agenda Overview Part C Requirements Part D Requirements Quality Bid Submissions."— Presentation transcript:

1 1 CY 2013 Parts C & D Benefits Review

2 2 Agenda Overview Part C Requirements Part D Requirements Quality Bid Submissions

3 3 Important Dates (1 of 2) April 6PBP & BPT software available in HPMS April 16Formulary submission/Transition attestations deadline (11:59 p.m. EDT) May 11HPMS available to accept bids June 4Bid submission and Formulary-to-Plan crosswalk deadline (11:59 p.m. PDT) June 8 deadlinePart D supplemental file submission deadline

4 4 Important Dates (2 of 2) June/JulyPart C and Part D Bid review activities July/AugustRebate reallocation Aug/SepAttestations/contracts October 1Deadline to submit plan correction requests; marketing begins

5 5 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

6 6 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 OOPC@cms.hhs.gov Medicare Managed Care Manual (MMCM)-Chapter 4- Benefits & Beneficiary Protections User Group Calls Part C & D User Group Calls OACT User Group Calls

7 7 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

8 8 Agenda Overview Part C Requirements Part D Requirements Quality Bid Submissions

9 9 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

10 10 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

11 11 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

12 12 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

13 13 Summary of Bid Review Requirements Bid Review Criteria Applies to Non- Employer Plans (Excluding Dual Eligible SNPs) Applies to Non- Employer Dual Eligible SNPs Applies to Cost Contractors Applies to Employer Plans Low EnrollmentYes No Meaningful Difference Yes No Total Beneficiary Cost Yes No Maximum Out-of – Pocket (MOOP) Limits Yes No Yes PMPM Actuarial Equivalent Cost Sharing Yes Service Category Cost Sharing Yes Yes 1 Yes In-network $0 Cost Share Preventive Services Yes Yes 2 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).

14 14 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

15 15 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

16 16 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

17 17 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)

18 18 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

19 19 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)

20 20 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)

21 21 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

22 22 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

23 23 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

24 24 Agenda Overview Part C Requirements Part D Requirements Quality Bid Submissions

25 25 Standard Benefit 2013

26 26 Benefit Types Basic Prescription Drug Coverage Defined Standard (DS) Coverage Actuarially Equivalent (AE) Coverage Basic Alternative (BA) Coverage Enhanced Alternative (EA) Coverage

27 27 BENEFIT REVIEW HIGHLIGHTS: Bid Design and Submission Requirements

28 28 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 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

29 29 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

30 30 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)

31 31 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

32 32 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

33 33 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

34 34 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

35 35 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%

36 36 Part D Cost-Sharing (3 of 4) Maximum Pre-ICL Copay and Coinsurance (INPh & INNPPh) - 3 or more tiers Tier LabelCopayCoinsurance Preferred Generic/Generic Tier $1025% Non-Preferred Generic Tier $3325% Preferred Brand/Brand Tier $4525% Non-Preferred Brand Tier $9550% Injectable Tier$9533%

37 37 Part D Cost-Sharing (4 of 4) Maximum Additional Gap Coverage Copay and Coinsurance (INPh & INNPPh) - 3 or more tiers Tier LabelCopayCoinsurance Preferred Generic/Generic Tier $1059% Non-Preferred Generic Tier $3359% Preferred Brand/Brand Tier $4569% Non-Preferred Brand Tier $9569% Injectable Tier$95----

38 38 Part D Supplemental and Formulary File Submissions

39 39 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

40 40 CY 2013 Formulary File Submissions CY 2013 Formulary Submission Dates RegularDemo Submission deadlineApril 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 Associate formulary to a single parent organization Formulary tier models selected in formulary submission module

41 41 Agenda Overview Part C Requirements Part D Requirements Quality Bid Submissions

42 42 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

43 43 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

44 44 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

45 45 Contact Information For Part D benefit policy, PBP and benefit review questions contact: 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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