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CY 2012 Medicare Advantage Benefits Review

Agenda. Overview of CY 2012 bid review processBenefit design and cost-sharing requirementsQuality bid submissions. 2. Important Dates. April 8PBP

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CY 2012 Medicare Advantage Benefits Review

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    1. CY 2012 Medicare Advantage Benefits Review

    2. Agenda Overview of CY 2012 bid review process Benefit design and cost-sharing requirements Quality bid submissions 2

    3. Important Dates April 8 PBP & BPT software available in HPMS May 13 HPMS available to accept bids June 6 Bid submission deadline (11:59 p.m. PDT) June/July Bid review Activities July/August Rebate Reallocation Aug/Sep Attestations/contracts October 1 Deadline to submit Plan correction requests; marketing begins 3

    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 the third week of 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 4

    5. Use Available Tools Prior to Submitting Bids Final Regulation CMS-4144-F (April 2011) Final CY 2012 Call Letter (April 2011) HPMS Memo regarding MA operational guidance (April 2011) Medicare Managed Care Manual (MMCM)-Chapter 4-Benefits & Beneficiary Protections Out-of-Pocket Cost (OOPC) Model Resources (April 2011) Go to https://MABenefitsMailbox.lmi.org to submit benefit policy and PBP questions Participate in User Group Calls 5

    6. MA Benefits Review Goals Conduct low enrollment Plan reviews Ensure that bids for an organizations’ 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 6

    7. Summary of Bid Review Requirements 7

    8. Low Enrollment Approach (1 of 2) Review Plans for insufficient enrollment after a specified length of time Evaluation based on Plans operating for at least three years (i.e., ‘09, ‘10, ‘11 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 8

    9. 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) OR submit a business case to CMS for an exception (e.g., serving a unique population) Organizations may consolidate / eliminate Plans in accordance with CMS renewal/non-renewal guidance 9

    10. Meaningful Difference Approach (1 of 2) Ensure that bids for an organizations’ Plans in a service area are meaningfully different from one another Acceptable difference between Plans is $20 pmpm, based on Out-of-Pocket Cost data (OOPC) for both Part C and Part D benefits combined Premiums are excluded for purposes of evaluating meaningful differences Providers are not considered a meaningful difference Organizations may consolidate/eliminate Plans in accordance with CMS renewal/nonrenewal guidance 10

    11. Meaningful Difference Approach (2 of 2) Non-SNP criteria: Plan Type (i.e., HMO, HMO-POS, Local PPO, Regional PPO, and PFFS) Presence of Part D benefit (i.e., MA-Only or MA-PD) Parts C & D combined OOPC difference > $20 SNP criteria: Plan Type SNP type (e.g., a C-SNP and an I-SNP are meaningfully different) Unique Population Served (e.g., a C-SNP serving heart failure enrollees is meaningfully different from a C-SNP serving diabetes enrollees) Parts C & D combined OOPC difference > $20 11

    12. Total Beneficiary Cost (1 of 3) 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) Represents the combined financial impact of premiums and benefit design changes A change in TBC from one year to the next is indicative of changes in cost sharing and/or benefits 12

    13. Total Beneficiary Cost (2 of 3) From CY 2011 to CY 2012, the TBC change amount is set at approximately $36 pmpm (about a 10% increase) Each Plan’s TBC change amount is adjusted based upon the net impact of benchmark and/or bonus payment changes Some adjustments will increase the Plan’s TBC change amount, while others will decrease the Plan’s TBC change amount 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 13

    14. Total Beneficiary Cost (3 of 3) CMS will provide guidance and Plan-specific amounts to organizations via HPMS (April): CY 2011 TBC amount Adjustment factor that reflects impact of benchmark and/or bonus payment changes Evaluating potential adjustment factor that reflects impact of changes in OOPC model between CY 2011 and CY 2012 Organizations can calculate each Plan’s CY 2012 TBC by using OOPC model tools to calculate OOPC value for CY 2012 CY 2012 BPT to determine premium (net of rebates) For Plans that consolidate multiple CY 2011 Plans into a single CY 2012 plan, CMS will use the enrollment-weighted-average of the CY 2011 plan values for TBC 14

    15. CY 2012 Maximum Out-of-Pocket (MOOP) Amounts by Plan Type 15

    16. PMPM Actuarial Equivalent Cost Sharing Maximums 16 Total MA cost sharing for Parts A and B services must not exceed cost sharing for Original Medicare on an actuarially equivalent basis This requirement is also applied separately to the following service categories: Inpatient Facility Skilled Nursing Facility (SNF) Home Health Durable Medical Equipment (DME) Part B Drugs

    17. CY 2012 MA Service Category Cost Sharing Standards (1 of 4) To be considered a benefit, 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 for example) Co-payment amount may not be greater than CMS coinsurance requirement for the lower limit of the strata The number of co-payment strata may not exceed four 17

    18. CY 2012 MA Service Category Cost Sharing Standards (2 of 4) 18

    19. CY 2012 MA Service Category Cost Sharing Standards (3 of 4)

    20. CY 2012 MA Service Category Cost Sharing Standards (4 of 4) 20

    21. Discriminatory Pattern Analysis Conform with requirements and standards Additional analyses will be conducted to identify cost sharing designs that may discriminate against sicker beneficiaries on the basis of: Patient health status Certain disease states or conditions MS will ensure that CY 2012 bid submissions 21

    22. Preventive Services and ER Visits 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) CY 2012 PBP software has been changed to accommodate a single entry to attest to coverage of preventive services Recent regulatory change allows CMS to annually establish dollar limit for each ER visit For CY 2012, the limit will increase from $50 to $65 22

    23. Quality Bid Submissions (1 of 2) Do not use PBP notes to limit or diminish Medicare covered benefits in the PBP Notes must only be used to clarify a benefit when standard data entry screen cannot accommodate information Out-of-network cost sharing HMO Plans do not cover out-of-network benefits HMO-POS Plans must offer 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 23

    24. Quality Bid Submissions (2 of 2) 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 24

    25. Plan Correction Requests Last day to submit Plan correction requests is October 1, 2011 – 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 2012 Organizations with a history of submitting plan corrections may receive a Corrective Action Plan (CAP) 25

    26. Final Thoughts Deadline for bid submissions is June 6, 2011 – No late submissions will be accepted Submit complete and accurate bids before the deadline If you experience difficulty uploading your bid, contact HPMS at 1-800-220-2028 or hpms@cms.hhs.gov before the deadline Go to https://MABenefitsMailbox.lmi.org to submit benefit policy or PBP questions prior to submitting bids 26

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