Understanding the Bidding Process
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1 Medicare Prescription Drug, Modernization and Improvement Act ( MMA ) Understanding the Bidding Process Presented by William E. Gramlich, Esquire One Logan Square Philadelphia, PA (tel) (fax) Gramlich@blankrome.com February 4, 2005
2 Goals To understand generally the mechanics of the bidding process for coordinated care type health plans Review the changes from the proposed rules Focus on important dates 2
3 Medicare Advantage (MA) Contracting Process Generally The final rules establish a bidding process for MA plans (Part 422) and MA prescription drug plans (MA PD) or stand alone prescription drug plans (PDP) (Part 423) The bidding concept for MA plans and prescription drug plans is similar; they vary in scope and deliverables 3
4 MA Contracting Process Generally (continued) The MMA establishes two types of coordinated care plans Regional and local MA plans we will discuss this today Specialized MA plans this change allows an MA plan to focus on targeted groups Special rules for end-stage renal disease ( ESRD ) beneficiaries we will not review these 4
5 MA Contracting Process Generally (continued) The MMA bidding process changes how private plans contract with CMS replaces the adjusted community rate (the ACR ) payment process starting in 2006 Compare the bidding process to the prior contracting process in which plans were paid a fixed ACR rate 5
6 Enrollment Process Generally Like the prior M&C program, individuals need to enroll in the MA program Non-discrimination rules apply (compare to specialized plans) MA organizations may be able to limit enrollment for capacity reasons Time period set for enrollment, longer in 2006 Generally, have to be residents of the plan service area regional or local areas 6
7 What is the Bidding Process? For 2006, bids are due on or before the first Monday in June for the upcoming year Essentially, the rate setting process is a bid-to-benchmark comparison This process also determines the plan participant s premium, if any 7
8 What is the Bidding Process? (Continued) Not a true bidding arrangement CMS engages in limited negotiation Similar to negotiations for federal employee health care plans Non-interference provisions of statute CMS cannot require the plan to contract with designated providers or set a particular rate structure CMS reviews MA plans to confirm actuarial values and that cost sharing does not exceed traditional benefit cost sharing CMS reviews compliance with requirements CMS analyzes profit or anticipated return 8
9 What is the Bidding Process? (continued) Detailed rules for a bid Different submission rules for health benefits (Part C) and drug benefits (Part D) although concept is similar We will discuss Part C bidding first For MA plans, the bid includes one amount for: 1. The statutory unadjusted non-drug monthly bid amount essentially this is the MA plan s estimated average monthly required revenue to provide traditional Part A and B benefits (the A/B Bid ) 2. The amount to provide basic prescription drug coverage, if any (MA plans are required to make a consolidated bid); and 3. The amount to provide supplemental coverage, if any Bid must give uniform benefits for service area Must take into consideration cost sharing Actuarial estimate 9
10 What is the Bidding Process? (continued) In submitting bids, the MA plan will need to provide, among other things The monthly aggregate bid amount Allocation of the bid amount among A/B bid; Prescription drug coverage; and Supplemental benefits (This is needed to do the comparison of bid to benchmark) Projected number of MA plan enrollees used to calculate the bid amount and the MA plan s enrollment capacity 10
11 What is the Bidding Process? (continued) Actuarial basis for determining the bid under the prescription drug bid process, need an actuary to certify estimates Description of MA plan s deductibles, co-pays, coinsurance and their actuarial value Description of drug coverage (if applicable) Special provisions for regional plan risk corridor information for MA regional plans (this is to help buffer the increased risk) and relative cost factors in multiple counties Rebate information (if applicable) we will discuss rebate later 11
12 What is the Bidding Process? (continued) Required revenue the MA plan s estimate of the revenue required to provide traditional coverage in the service area for enrollees with a national average risk profile The required revenue must take into consideration actuarial assumptions on cost sharing 12
13 What is the Bidding Process? (continued) CMS favors the proportional method to determine the actuarial equivalent of cost sharing This is a change from the proposed rules and current approach Cost sharing cannot exceed the actuarial value of the traditional benefit, similar to the prior M&C program, except do not count the premium, or for regional plans, the out-of-network cost sharing Not required to bid below the benchmark 13
14 What is the Bidding Process? (continued) Once the A/B Bid is accepted, the amount of the A/B Bid is compared against the Benchmark for nondrug costs, both as adjusted for risk factors The Benchmark calculation differs for local and regional plans and is an amount computed by CMS; both essentially consider capitation rates, differ for weights and geographic areas MA regional Benchmark is announced on or before November 15 th, but after CMS receives bids from MA plans 14
15 What is the Bidding Process? (continued) Any excess of the adjusted Benchmark over the adjusted A/B Bid is the savings, subject to rebate Measurement of risk factors is different for local and regional plans The purpose of comparing the A/B Bid to the Benchmark is to standardize the evaluation of bids, permit a more accurate cost comparison of basic Part A/B services and correctly determine the savings and the related rebate 15
16 Beneficiary Premium If the unadjusted A/B Bid is less than the unadjusted Benchmark, basic premium = 0 If the unadjusted A/B Bid is greater than the unadjusted Benchmark, basic premium = the excess Special rules for MSA plans Subject to exceptions, premium must be same for all enrollees in the plan Can apply for segmented area option Cannot offer incentives to enroll 16
17 Beneficiary Premium (continued) Premium must be consolidated and charged in a monthly lump sum Payment options Credit for savings 17
18 What is the Rebate? The MA plan is required to rebate 75% of savings to participants Remaining 25% is retained by Medicare Trust Fund To be credited to mandatory supplemental benefits (drug and non-drug) premiums Cannot be used to reduce the cost of optional supplemental benefits CMS stated concern is that these benefits could be subsidized to attract enrollees For MA-PD plans, must show how rebate is allocated between Part C and D benefits 18
19 What is the Rebate? (continued) Gives flexibility to MA plans to use the rebate to subsidize the cost of mandatory supplemental benefits 19
20 How is the MA Plan Paid? Starting in 2006, CMS makes advance monthly payments for the Parts A/B component based upon the A/B Bid to Benchmark comparison If the A/B Bid is less than Benchmark, the MA plan essentially receives its A/B Bid amount plus the rebate (75% of savings), subject to reduction If the A/B Bid is greater, it receives the Benchmark amount 20
21 How is the MA Plan Paid? (continued) There are risk adjustment factors applied to the Benchmark and the A/B Bid before making the calculation Rate difference for service areas Age, health, disability status MA-PD plan is also paid for prescription drug subsidies (direct and reinsurance subsidies) Not all of the MA s plans are required to offer prescription drug coverage 21
22 How is the MA Plan Paid? (continued) Other Payments Reimbursements for premium and cost sharing reductions for low income enrollees Special rules for ESRD enrollees Reconciliation for actual number of enrollees (reconcile advance payments) Catch up from later enrolling enrollees, if conditions met Risk corridor payments for MA regional plans in 2006 and
23 How is the MA Plan Paid? (continued) MA plans are required to provide data to make calculations Timelines for data Late data not accepted 23
24 Prescription Drug Bidding Process Prescription drug bidding process works in similar fashion For MA-PD plans, they submit a consolidated bid For PDP plans, submit a separate bid In each case, bidding process is analyzed under Part
25 Prescription Drug Bidding Process (continued) Same bid to benchmark type of comparison, although the mechanics are different. Like the MA-PD plans, the following apply: Bids are due on first Monday in June, for upcoming year Bids reflect revenue required to provide prescription drug coverage with national average risk profile CMS regulations set forth requirements for bid submission, including actuarial assumptions, certain administrative costs, allocation of bid, supplemental coverage and profit on return Additional risk factor adjustments Special rule for negative premium Either reduce supplemental premium (if any); or CMS requires an enhanced benefit equal to negative premium 25
26 Prescription Drug Bidding Process Mechanics: (continued) CMS uses the standardized bids submitted to determine national average monthly premium. No geographic adjustment until CMS develops method To calculate beneficiaries base premium, multiply national average premium by the defined beneficiary premium percentage (25.5%, adjusted for reinsurance and payments to MA plans) this becomes the Benchmark 26
27 Prescription Drug Bidding Process (continued) This amount is compared to the standardized bid and the premium adjusted by the difference There is a late enrollment penalty 27
28 Prescription Drug Bidding Process (continued) Payments by CMS to PDP s equal: Bid amount plus risk adjustments for health status less beneficiary premium Reinsurance subsidy payments Low income subsidy Risk sharing payments Retroactive adjustments for advance payment Payments conditioned upon plan s disclosure of information 28
29 Principal Changes from the Proposed Regulations Methodology essentially the same MA plans Selection of the proportional method in making the actuarial determinations 29
30 Principal Changes from the Proposed Regulations (continued) MA regional plans may request CMS to use plan specific variations in payment rates MA-PD or PDP plans Clarified scope of bid review authority, including review of projected profit Permits a negative premium, by adjusting premiums or benefits Expressed a need to continue to refine required data elements Methodologies for subsidies, low income, reinsurance and risk corridors are proposed, not yet resolved 30
31 Important Bid Process Dates On February 15, 2005 final date to submit application for 2005 coordinated care plan March 1, 2005 final date to submit MA service area expansion for 2005 Late March 2005 CMS bid training in Baltimore March 23, 2005 Part D applications are due June 6, 2005 final date for MA (drug and nondrug) plans to submit bids for
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