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

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CY 2013 Parts C & D Benefits Review

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Agenda

• Overview• Part C Requirements• Part D Requirements• Quality Bid Submissions

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Important Dates (1 of 2)

April 6 PBP & BPT software available in HPMS

April 16 Formulary submission/Transition attestations deadline (11:59 p.m. EDT)

May 11 HPMS available to accept bids

June 4 Bid submission and Formulary-to-Plan crosswalk deadline (11:59 p.m. PDT)

June 8 deadline Part D supplemental file submission deadline

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Important Dates (2 of 2)

June/July Part C and Part D Bid review activities

July/August Rebate reallocation

Aug/Sep Attestations/contracts

October 1 Deadline to submit plan correction requests; marketing begins

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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

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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 [email protected]

• Medicare Managed Care Manual (MMCM)-Chapter 4-Benefits & Beneficiary Protections

• User Group Calls• Part C & D User Group Calls• OACT User Group Calls

mailto:[email protected]

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Bid Prep Resources (2 of 2)

• Prescription Drug Benefit Manual• (http://www.cms.gov/PrescriptionDrugCovContra/

12_PartDManuals.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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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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• 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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• 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

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 Enrollment Yes Yes No No

Meaningful Difference

Yes No No No

Total Beneficiary Cost

Yes No No No

Maximum Out-of –Pocket (MOOP) Limits

Yes Yes No Yes

PMPM Actuarial Equivalent Cost Sharing

Yes Yes Yes Yes

Service Category Cost Sharing

Yes Yes Yes1 Yes

In-network $0 Cost Share Preventive Services

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).

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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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• 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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• 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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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

• 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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• 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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• 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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• 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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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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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%

Non-Preferred Brand Tier $95 69%

Injectable Tier $95 ----

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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 DatesRegular 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, 201211:59 pm PDT

June 4, 201211:59 pm PDT

• Associate formulary to a single parent organization• Formulary tier models selected in formulary

submission module

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Agenda


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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

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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

• [email protected]• Part D policy related questions

• [email protected]• Questions regarding OOPC model

• [email protected]• Questions regarding bid instructions or completing the BPT

• [email protected] • Questions regarding the Capitated Financial Alignment Demonstration

https://mabenefitsmailbox.lmi.org/





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Contact Information

• For Part D benefit policy, PBP and benefit review questions contact: • [email protected]• Rosalind Abankwah, 410 786-2012• [email protected]• Kady Flannery, 410 786-6722• [email protected]• Frank Tetkoski, 410 786-5233• [email protected]


mailto:%[email protected]



Documents

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