TRACKING MEDICARE HEALTH AND PRESCRIPTION DRUG PLANS Mnthly Reprt fr July 2006 Prepared by Stephanie Petersn and Marsha Gld, Mathematica Plicy Research Inc. as part f wrk cmmissined by the Kaiser Family Fundatin PROGRAM STATUS: PRIVATE PLAN OFFERINGS, ENROLLMENT, AND CHANGE Enrllment and Penetratin, by Plan Type Current Mnth: July 2006 Change Frm Previus Mnth* Same Mnth Last Year July 2005 Change Frm July 2005-2006 Enrllment Ttal Stand-Alne 16,213,157-222,693 Nt Applicable Nt Applicable Prescriptin Drug Plans (PDPs):** Duals Aut Enrlled in PDPs Nt available *** Nt Applicable Nt Applicable All thers Enrlled in PDP Nt available Ttal Medicare Advantage (MA)** 7,274,299 **** 5,793,667 Medicare Advantage-Prescriptin Drug (MA-PD) Medicare Advantage (MA) nly 6,278,020 996,279 +238,377 Nt Applicable 5,793,667 Medicare Advantage (MA) by Type**** MA Lcal Crdinated Care Plans Health Maintenance Organizatins (HMOs) Prvider Spnsred Organizatins (PSOs) Preferred Prvider Organizatins (PPOs) 5,813,218 5,416,562 87,789 308,858 4,943,668 +869,550 Reginal Preferred Prvider Organizatins (PPO) 83,294 Nt Applicable Nt Applicable Private Fee Fr Service (PFFS) Cst Other**** General vs Special Needs Plans Special Needs Plan Enrllees Other Medicare Advantage Plan Enrllees Penetratin (as percent beneficiaries)***** 763,559 313,510 307,718 119,723 322,341 284,517 +643,836-8,831-70,678 Prescriptin Drug Plans (PDPs) 37.3% 0% Nt Applicable Nt Applicable Medicare Advantage Plans (MA) 16.3% 13.4% +2.9% Medicare Advantage-Prescriptin Drug Plans (MA- PDs) Lcal Health Maintenance Organizatins (HMOs), Preferred Prvider Organizatins (PPOs) r Prvider Spnsred Organizatins (PSO) 14.2% +0.5% 12.3% 0.7% 0.2% Nt Applicable Nt Applicable Private Fee Fr Service (PFFS) 1.3% 0% 0.3% +1.0% July data is frm the 7.26.06 data release by CMS n its website at: (http://www.cms.hhs.gv/prescriptindrugcvgenin/02_enrllmentdata.asp) * The June 2006 PDP and MA-PD data is based n data frm CMS with a cited date f June 11, 2006. (CMS 6/14/06 press release). 1
**The ttal PDP and MA enrllment includes emplyer grups because CMS has histrically included emplyer grup enrllees in the Mnthly Managed Care Cntract Reprt pre-2006. (The ttal PDP withut emplyer grups is 15,515,433 and the ttal MA withut emplyer grups is 6,293,676). ***CMS reprted in April 2006 that f the 16,435,850 enrlled in stand-alne prescriptin drug plans (PDPs), 6,066,938 were duals aut enrlled (CMS 4/20/06 press release). **** MA nly and MA by type data were nt reprted by CMS in June 2006. Tabular infrmatin frm CMS with a cited date f April 2006 reprted 910,475 MA nly enrllees. The infrmatin als included MA enrllment by type: Ttal MA Lcal CCPs: 5,679,600; HMOs: 5,335,225; PSOs: 76,946; PPOs: 267,429; rppos: 54,378; PFFS: 579,041; Cst: 313,312; Other 205,295. *****Other includes Dem cntracts, HCPP, and PACE cntracts. ******Penetratin rates fr July and June 2006 are calculated using the number f eligible beneficiaries reprted in the December 2005 State/Cunty File. Penetratin rates fr June 2005 are calculated using the number f eligible beneficiaries reprted in the December 2004 State/Cunty File. DEFINITIONS: Crdinated Care Plans, r CCPs, include health maintenance rganizatins (HMOs), prvider-spnsred rganizatins (PSOs) and preferred prvider rganizatins (PPOs). The 2005 data include the PPO demnstratin. The Medicare preferred prvider rganizatin demnstratin began in January 2003. PFFS refers t private fee-fr-service plans. Cst plans are HMOs that are reimbursed n a cst basis, rather than a capitated amunt like ther private health plans. Other Dem refers t all ther demnstratin plans that have been a part f the Medicare+Chice / Medicare Advantage prgram. Special Needs Plans refers t Medicare Advantage crdinated care plans fcused n individuals with special needs. Special needs individuals were defined by Cngress as: 1) institutinalized; 2) dually eligible; and/r 3) individuals with severe r disabling chrnic cnditins. Summary f MA cntracts (excluding SNPs) in July: Plan Participatin, by type MA Cntracts (excluding SNPs)** CURRENT MONTH: JULY 2006* SAME MONTH LAST YEAR JULY 2005 CHANGE FROM JULY 2005 2006 Ttal 512 292 +220 Lcal Crdinated Care Plan 367 149 +218 Health Maintenance Organizatins (HMOs) Preferred Prvider Organizatins (PPOs) (Includes Physician Spnsred Organizatins (PSOs)) Reginal Preferred Prvider Organizatins (rppos) 11 Nt Applicable Nt Applicable Private Fee Fr Service (PFFS) 25 5 +20 Cst 28 29-1 Other** 81 74 +7 *Cntract cunts fr July 2006 are based n the 7.26.06 data release by CMS n its website at: (http://www.cms.hhs.gv/prescriptindrugcvgenin/02_enrllmentdata.asp) ** Cntracts that nly include SNPs maybe included in the ttal. *** Other includes Dem cntracts, Health Care Prepayment Plans (HCPP) and Prgram fr all-inclusive care f Elderly (PACE) cntracts Pending Applicatins Nne Available Summary f new MA cntracts annunced in June: Nne 2
NEW ON THE WEB FROM CMS Relevant t Bth Medicare Advantage and Prescriptin Drug Plans On July 26, 2006, CMS psted a new reprt: Medicare Advantage, Cst, PACE, Dem and Prescriptin Drug Organizatins Annual Reprt by Plan, July 2006. The 506-page Excel spreadsheet is rganized by cntract number within plan type (Lcal Medicare Advantage, Cst, PACE and Dem Plans; Reginal MA plans; and PDPs). The spread sheet shws fr each cntract/plan cmbinatin the: rganizatin and plan type, whether the plan includes Part D, the rganizatin name (including als marketing name and plan name and parent rganizatin), the cntract effective data, and the enrllment as f July 1, 2006. Enrllment is nt reprted when the cunt is less than 10 (in ttal, this excludes nly abut 1,200 peple accrding t CMS.) While this is the mst detailed data CMS has reprted t date, it nly supprts natinal estimates because it excludes infrmatin n the cunties served and enrllment in each cunty (This infrmatin histrically has been prvided mnthly at the cntract level fr MA). The data is available t dwnlad n CMS s website at: http://www.cms.hhs.gv/prescriptindrugcvgenin/02_enrllmentdata.asp This mnth CMS released its 2007 marketing guidelines fr Medicare Advantage (MA) plans; Medicare Advantage Prescriptin Drug plans (MA-PDs); stand-alne prescriptin drug plans (PDPs) as well as 1876 cst plans. The guidelines revise the riginal August 15, 2005 published guidelines as first revised n Nvember 1, 2005. The dcument is available n CMS s website at: http://www.cms.hhs.gv/prescriptindrugcvcntra/07_rxcntracting_marketing.asp#tp OfPage Amng ther items, the revisins included: C-brand relatinships. While rganizatins are allwed t cntinue this practice, rganizatins must nt display the name r lg f the cbranded entity n the card and firms must let beneficiaries knw that ther pharmacies/physicians/prviders are available in the netwrk. (Exceptins apply t allw specificatins f specific prviders the member has selected and SPAPs.) Marketing Materials. Materials marketed after Octber 10, 2006, if they reference 2006 benefits, must nte that they may r will change in the upcming cntract year. PPOs that advertise ptential savings acknwledge that added cst f ut f netwrk services. PDPs must state that if an enrllee is in an MA-PD they cannt enrll in a PDP withut disenrlling frm the MA-PD. Lw Incme Subsidy. Organizatins enrlling such individuals must send a lw incme subsidy rider t the evidence f cverage any LIS member receives. Enrllees newly qualifying fr a rider during the year shuld receive the rider within 30 days. Riders must shw the premium and cst sharing amunts the member will pay and nte that the payments exclude the Part B premium. 3
Other Beneficiary Infrmatin. Web sites are required t prvide specific infrmatin n the plan s grievance, cverage determinatin (including exceptins) and appeals prcesses including instructins fr filing grievances, links t varius frms, cntact infrmatin etc. Additinal detail n the cntent fr inbund telephne scripts must be prvided. The guidelines als have been expanded t include infrmatin n marketing and disclsure/disseminatin waivers fr emplyer/unin grups. Marketing requirements fr special needs plans (SNPs) als have been revised t cnvey better the fact that ut f pcket csts may vary because f state payments and address ther issues. They als have been expanded t prvide mre detail n call center requirements. The February 23, 2006 ntice requirements apply until Nvember 15, 2006. During pen enrllment and 60 days therefre (Nvember 15, 2006 thrugh March 1, 2006, the call center must be pen 7 days a week frm 9 AM t 8 PM; after that until the next perid alternative technlgies may be used n Saturdays, Sundays and Hlidays. Call centers are require t respnd t inquires n at least a specified set f tpics. They als must answer 80 percent f incming calls within 30 secnds and the abandnment rate must nt exceed 5 percent. Call centers fr physicians and ther business must perate during nrmal business hurs and never less than 8 AM t 6 PM. Vice can be used fr prviders if it includes specific messages (including a way fr immediate access in situatins where an enrllee s life r health is in serius jepardy). On July 10, 2006, CMS annunced a new Medicare Advantage (MA) Medical Savings Accunt (MSA) plan demnstratin prject. The demnstratin will allw rganizatins mre flexibility t ffer prducts similar t health savings accunts (HSAs). Specific features f the demnstratin include: 1) a design that includes a minimum deductible and a separate limit n an enrllee s ut-f-pcket expenditures; 2) Cverage f services after the deductible is met, prir t reaching the ut-f-pcket expenditure cap; 3) reduced cst sharing fr in-netwrk services; and 4) cverage fr preventive services. CMS des nt have the authrity t allw fr demnstratin participants t ffer Medicare Advantage prescriptin drug prducts nly stand-alne prducts. The 2007 MSA Demnstratin Applicatins were due July 21, 2006 and the rganizatin s bid and benefit submissin are due n August 10, 2006. CMS als stated that rganizatins interested in participating in 2008 are requested t submit a Ntice f Intent t Apply (NOI) as sn as pssible. The annuncement, guidelines, applicatin and ther infrmatin is available at: http://www.cms.hhs.gv/medicareadvantageapps/02_final5202007%20applicatins.asp This mnth, CMS released data n Medicare cmplaints abut bth Medicare Advantage drug plans and stand-alne prescriptin drug plans fr the mnth f June. The tables prvide each rganizatin s name and ttal cmplaints per 1,000 enrllees as well as infrmatin n the varius types f cmplaints (Benefit/access; enrllment/ disenrllment; pricing and c-insurance cmplaints and all ther cmplaints) fr bth Medicare Advantage drug plans and stand-alne drug plans. CMS cmpiles these data in a cmplaint tracking prcess t receive and reslve individual cmplaints abut specific plan service. The data cmes frm three surces: 1) cmplaints frm the 1-800-MEDICARE number; 2) cmplaints frm CMS reginal ffices; and 3) frm Medicare Integrity Cntractrs. The cmplaints are frm beneficiaries as well as family members, pharmacists r thers wh are assisting Medicare beneficiaries. 4
Average cmplaints per mnth acrss plans were 2.6 cmplaints per 1,000 Medicare beneficiaries enrlled in prescriptin drug plans and 1.4 fr thse in MA plans). The mst cmmn type f cmplaints related t enrllment/disenrllment. The press release as well as the tabular infrmatin is available n CMS s website at: http://www.cms.hhs.gv/apps/media/press/release.asp?cunter=1905. Relevant t Medicare Advantage Nne Relevant t Prescriptin Drug Plans On July 11, 2006, CMS released a fact sheet titled Medicare Part D Spending Prjectins Dwn Again, Part A and Part B Increases Highlight Need fr Further Refrms. The fact sheet states that Medicare Part D expenditures are nw prjected t be lwer ver the next 5 years (2006-2010) than prjectins made in bth the President s budget in February as well as the Mid- Sessin Review last year. (The new prjectins are $34 billin lwer than February s prjectin and $110 billin lwer than last year). CMS states there are several reasns why Part D spending prjectins are lwer than expected: 1) The drug plans participating have been able t establish mre savings due t aggressive price negtiatins; 2) Beneficiaries have verwhelmingly chsen drug plans with lw premiums; and 3) Fr the first time in ver a decade there has been lwer actual grwth in drug csts, with a single digit percentage increase expected this year partly because f mre generic drugs becming available as well as ther aggressive measures t keep drug csts dwn. The fact sheet als states that cntinued higher than expected expenditures fr Medicare Part A and Part B highlight the need fr refrm in these areas as well. The fact sheet is available at http://www.cms.hhs.gv/apps/media/press/release.asp?cunter=1895. Relevant t Special Needs Plans Specifically This mnth, CMS released a fact sheet n Special Needs Plans titled, Imprving Access t Integrated Care fr Beneficiaries wh are Dually Eligible fr Medicare and Medicaid, (http://www.cms.hhs.gv/apps/media/press/release.asp?cunter=1912). The fact sheet describes hw CMS is implementing an actin plan t facilitate better care fr dual eligibles thrugh SNPs. The actin plan is based n the lessns learned frm varius meetings ver the past several mnths, which discussed current barriers t successfully integrating care fr the dual eligibles thrugh SNPS. CMS held meetings with states, ther stakehlder grups as well as several utside grups such as the Center fr Health Care Strategies (CHCS). The actin plan includes several steps: CMS is in the prcess f releasing Hw T Guides t help states wrk with bth SNPs and Medicare with the gal f streamlining prcesses and reducing cnfusin fr SNPs and beneficiaries abut rules that apply. s. The Hw T Guides address marketing, enrllment and quality issues and are cnsidered living dcuments that CMS can update and expand as needed. See the CMS s website at: http://www.cms.hhs.gv/dualeligible/04_integratedmedicareandmedicaidmdels.a sp#tpofpage. CMS has implemented new plicy that allws SNPs that has a relatinship with a state t target subgrups f dual eligibles (versus all dual eligibles) when ding s allws SNPs t better take int accunt exclusins frm state managed care prgrams. The fact sheet 5
stated that mre details f this plicy will be psted n CMS s website sn (as f press time it was nt yet released). CMS is wrking with the Center fr Health Care Strategies (CHCS) t develp a guide with a mdel agreement that SNPs, states and CMS can use t clarify rles and respnsibilities f each party and facilitate care integratin. CMS is als currently wrking with the Natinal Cmmittee fr Quality Assurance (NCQA) t develp imprved quality measures specific fr SNP enrllees that will better reflect specific chrnic cnditins such as AIDS. These measures will be at the individual SNP plan level. CMS als will cnduct, additinal utreach effrts fr beneficiaries will be cnducted this fall and will include cllabratin with varius nn-english speaking grups including Asian American, Hispanic and African-American cmmunities. 6