Revolution or Evolution: What s Happening Next for MedAdv and Prescription Drug Plans
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1 Revolution or Evolution: What s Happening Next for MedAdv and Prescription Drug Plans Issues & Trends in Medicare Supplement Insurance 2012 Conference Presented by: T. Scott Bentley, FSA, MAAA Consulting Actuary May 17, 2012
2 Medicare Supplement vs. Medicare Advantage Comparison Medicare Supplement Plan F Benefits Covers all Part A and Part B deductible / coinsurance PDP premium separate Premiums vary by age $1,800 / yr at age 65 $3,600 / yr at age 80 No out-of-pocket Medicare Advantage Benefits IP admit or per day copays and physician copays Includes Part D Premiums don t vary by age $500 / yr, ranges from $0 - $1,800 / yr $3,400 max out-of-pocket 2 May 17, 2012
3 Medicare Advantage vs. Medicare Supplement Enrollment (000 s) Plan Type Dec 2007 Dec 2008 Enrollment Dec 2009 Dec 2010 Dec 2011 Annual change Annual change Medicare Supplement* 9,576 9,492 9,452 9,704 9, % 2.0% Medicare Advantage** 8,949 10,224 11,266 11,864 12, % 5.5% PDP** 17,180 17,439 17,559 17,890 18, % 4.9% Total Medicare Population 44,368 45,500 46,575 47,492 48, % 3.0% *Source: National Association of Insurance Commissioners **Source: CMS 3 May 17, 2012
4 Discussion Overview Medicare Advantage Background Review Definitions / Acronyms Illustrate Business Models Risk Adjustment Model Discuss Products Medicare Advantage Market Overview Medicare Advantage Reform 2013 Observations and Expectations Medicare Supplement / Medicare Advantage Opportunities and Threats Questions 4 May 17, 2012
5 Medicare Advantage Background Medicare Advantage populations Medicare Advantage (general, DSNP, CSNP, ISNP) Cost Contracts Dual Demos PDPs STAR Rating creating pressure to improve for revenue gain Continued payment reform and regulatory changes are occurring that may create Medicare Supplement opportunities 5 May 17, 2012
6 Definitions / Acronyms CMS Centers for Medicare & Medicaid Services Administers the Medicare Advantage and Part D Programs MA Plan Medicare Advantage Medicare Health Insurance Plan that Replaces Part A & Part B of Medicare Part C Choice of Medicare Advantage Plans Provided Through Independent Contractors STAR Rating CMS Quality Measures 6 May 17, 2012
7 Definitions / Acronyms (continued) Part D Choice of Medicare s Prescription Drug benefit provided through independent contractors known as Medicare Advantage Prescription Drug Plans (MA-PDs) or Prescription Drug Plans (PDPs) Bid Actuarial filing to justify benefits and member premiums considering CMS revenue Federal Pre-Emption For MA & Part D, Federal law pre-empts State law 7 May 17, 2012
8 Medicare Advantage Business Model Costs Admin & Profit Revenue Member Premium? Additional Benefits Traditional Medicare Medical Costs Risk-Adjusted Payment From CMS 8 May 17, 2012
9 Part D Business Model Cost Estimated Rx Benefits Revenue Member Premium (or low income subsidy) CMS Subsidies Administration Profit 9 May 17, 2012
10 Risk Adjustment Previous Year Enrollees (i.e., Enrollees with Disease Data) Member Info Age / Gender Diagnoses Institutional? Medicaid? Originally Disabled? A/B Risk Adjuster Part D Risk Adjuster Member- Specific A/B Score Member- Specific Part D Risk Score 10 May 17, 2012
11 MEDICARE ADVANTAGE MARKET OVERVIEW 11 May 17, 2012
12 Top Medicare Advantage Organizations by Enrollment Organization Name Total MA Enrollment as of February 2011 Market Share as % of Total MA Enrollees UnitedHealth Group, Inc. 2,201, % Humana Inc. 1,901, % Kaiser Foundation Health Plan, Inc. 1,015, % WellPoint, Inc. 552, % Aetna Inc. 396, % HealthSpring, Inc. 328, % Highmark Inc. 326, % Blue Cross Blue Shield of Michigan 238, % Coventry Health Care, Inc. 218, % Health Net, Inc. 212, % Aveta, LLC 188, % Universal American Corp. 175, % EmblemHealth, Inc. 168, % SCAN Health Plan, Inc. 129, % SOURCE: Calculated by AIS from CMS data. Excerpted from AIS Managed Medicare and Medicaid Factbook: May 17, 2012
13 13 May 17, 2012
14 14 May 17, 2012
15 MA Plan Payments Relative to Traditional FFS Source: MedPAC March 2011 Report 15 May 17, 2012
16 2010 Rebate Dollars Nationwide Average 10% 2% Nationwide 13% 54% 21% Reduce Part A B Cost-Sharing Reduce Part D Supplemental Premium Reduce Part B Premium Provide non-medicare Covered Benefits Reduce Part D Basic Premium Source: BNA Health Plan & Provider Report 1/3/ May 17, 2012
17 Medicare Advantage Payments Payment Reductions Health Care Reform is reducing MA payment rates Potential to thin the market considerably Marginal players will not be able to survive Requires significant operational improvement as market is already competing on small margins Will significantly reduce arbitrage (i.e., low FFS cost / high benchmark) opportunities 17 May 17, 2012
18 Other Medicare Advantage Observations Market segmentation trend was curtailed by OOPC requirements Risk score improvement continues to be critical to success STAR ranking is a new critical success factor HMO-POS bidding rule changes Administration costs and profit margins getting a lot of attention MLR limits coming in 2014 Member out-of-pocket costs increasing overall, but variations seen by plan type and enrollee health status 18 May 17, 2012
19 Other Medicare Advantage Observations More age-ins to general enrollment MA products Consolidation occurring Provider Contracting Arrangements Risk contracts re-emerging in some markets Way to mitigate benchmark revenue hits Narrow network products 19 May 17, 2012
20 MEDICARE ADVANTAGE REFORM 20 May 17, 2012
21 Medicare Advantage Payment Reform New Concepts Payments Based on Fee-For-Service (FFS) Costs Bonus Payments Revised Rebates Minimum Loss Ratios Transition from Old Methods to New Methods Began in May 17, 2012
22 Benchmark Payments Based on FFS Costs Counties Stratified Based on FFS Costs Divided into Quartiles Highest-cost quartile 95% of FFS Costs Second-highest cost quartile 100% of FFS Costs Third-highest cost quartile 107.5% of FFS Costs Lowest-cost quartile 115% of FFS Costs Can Not Exceed Benchmark Under Current Methodology - Including bonus payments Re-ranked Annually Counties that change quartiles are transitioned for 1 year Straight average of previous year multiplier and current year multiplier 22 May 17, 2012
23 MA Membership by FFS Cost Quartile Counties Ranked by FFS Costs MA Enrollees in Each Quartile 25% 25% 25% 25% Lowest Cost Quartile 2nd Highest Cost Quartile 3rd Highest Cost Quartile Highest Cost Quartile 45% 19% 22% 14% Lowest Cost Quartile 3rd Highest Cost Quartile 2nd Highest Cost Quartile Highest Cost Quartile 23 May 17, 2012
24 Transition Period Depends on Difference Defined by Formula Current rate less ½ x current rate + ½ x (FFS % x 2010 FFS x (1+bonus %)) where FFS % is 95%, 100%, 107.5%, or 115%; 2010 FFS is reduced for the phase-out of IME; and Bonus % is 1.5% for most counties but 3% for additional bonus counties described shortly 24 May 17, 2012
25 Benchmark Payment Transition Varies Depending on 2010 Differences (Current Method vs. New Method) Benchmark Payment Transition: Current vs. New < $30 PMPM in % Current, 50% New 100% New Benchmark Payment Transition: Current vs. New > $30 PMPM and < $50 PMPM in % Current, 25% New 50% Current, 50% New 25% Current, 75% New 100% New Benchmark Payment Transition: Current vs. New > $50 PMPM % Current, 16.7% New 66.7% Current, 33.3% New 50% Current, 50% New 33.3% Current, 66.7% New 16.7% Current, 83.3% New 100% New 25 May 17, 2012
26 Medicare Advantage STAR (Quality) Ratings Five rating categories: Staying healthy preventative care (13) Managing chronic conditions (10) Plan responsiveness and care (6) Member complaints, appeals, disenrollment (4) Plan telephone customer service (3) 26 May 17, 2012
27 Bonus Payments 2 Types of Bonus Payments Starting in 2012 STAR Bonus Payments Dependent on Quality Measure of Plan Must be 4.0+ STAR Rated Plan Additional Bonus Payments Dependent on Quality Measure of Plan Must be 4.0+ STAR Rated Plan 3 Additional Criteria Specific to County MA Penetration > 25% as of December 2009 When 2004 Rates Established, Affiliated with MSA with > 250,000 Population FFS Costs < National Average FFS Costs 27 May 17, 2012
28 Overall Star Rating 2012 STAR Ratings MA and MA-PD 2011 Membership % of 2011 Membership 5 STARS 1,084, % 4.5 STARS 1,256, % 4 STARS 1,137, % 3.5 STARS 3,883, % 3 STARS 3,258, % 2.5 STARS 1,031, % 2 STARS 29, % Did Not Report 523, % Total 12,206, % SOURCE: Alan Roberts, OptumInsight, October 12, 2011, based on data released by CMS 28 May 17, 2012
29 Counties Qualifying for Additional Bonus 6% Eligible for Additional Bonus 94% Not Eligible for Additional Bonus Approximately 200 Counties Qualify for Additional Bonus 29 May 17, 2012
30 Benchmark Rates 2012 New (Post STAR Demonstration ) vs. Current Nationwide Impact Without Physician Payment Fix (reflects annual decrement of 1.0% for growing physician fix issue) 100.0% 95.0% 90.0% 85.0% 80.0% 75.0% Current Rate Below 3.0 STAR 3 to 3.5 STAR 4 to 4.5 STAR 5 STAR 30 May 17, 2012
31 Benchmark Rates New vs. Current Nationwide Impact Without Physician Payment Fix (reflects annual decrement of 1.0% for growing physician fix issue) 100.0% 95.0% 90.0% 85.0% 80.0% 75.0% Current Rate Below 3.0 STAR 3 to 3.5 STAR 4 to 4.5 STAR 5 STAR 31 May 17, 2012
32 Benchmark Rates 2012 New vs. Current Nationwide Impact Without Physician Payment Fix 100.0% 99.0% 98.0% 97.0% 96.0% 95.0% 94.0% Current Rate Without Bonuses With STAR Bonus With STAR and Additional Bonus 32 May 17, 2012
33 Benchmark Rates New vs. Current Nationwide Impact Without Physician Payment Fix 100.0% 98.0% 96.0% 94.0% 92.0% 90.0% 88.0% 86.0% 84.0% 82.0% 80.0% Current Rate Without Bonuses With STAR Bonus With STAR and Additional Bonus 33 May 17, 2012
34 Minimum Medical Loss Ratios (MLRs) Minimum MLR of 85% in 2014 and Beyond Must Pay Back to Government Revenue * (85% - Plan MLR) If MLR < 85% for 3 Consecutive Years No New Enrollees in Plan During Second Succeeding Contract Year If MLR < 85% for 5 Consecutive Years Termination of Plan 34 May 17, 2012
35 Part D Reform Highlights Reform closes coverage gap: 1. Pharmaceutical Companies to cover 50% of usual brand cost by paying that amount to reduce member cost share through coverage gap starting in Generic coinsurance will decrease by 7% annually until 2019 and then is 25% in Brand coinsurance decreases according to a schedule but always reduced by Pharma s 50% 4. Brand discounts will not change Part D True Out-of-Pocket (TrOOP) accrual 5. TrOOP will reduce gradually starting in 2014 (phased in until 2019) 35 May 17, 2012
36 Part D Reform Highlights (continued) Year Member Generic Coinsurance Nominal Brand Coinsurance Pharma Coinsurance Contribution Net Member Brand Coinsurance % 100% 50% 50% % 100% 50% 50% % 97.5% 50% 47.5% % 97.5% 50% 47.5% % 95% 50% 45% % 95% 50% 45% % 90% 50% 40% % 85% 50% 35% % 80% 50% 30% % 75% 50% 25% 36 May 17, 2012
37 2013 OBSERVATIONS AND EXPECTATIONS 37 May 17, 2012
38 Medicare Advantage Observations Few new entrants and expansions Some market departures Plans find upcoming boomers (2011+), who will likely be more accepting of MA products given similarity to employment-based products, hard to ignore 38 May 17, 2012
39 2013 and Beyond - Changes and Expectations Cost and revenue management increasingly important Regulatory burden continues to increase Quality requirements will grow in coming years Audits (bids, financial, risk adjustment) getting more detailed and demanding CMS data submissions are now going to include Part A/B (i.e., encounter data) and will be onerous These data submissions will be the key to risk adjustment Increasing cost of compliance 39 May 17, 2012
40 2013 and Beyond - Predictions MA organizations will leave some markets Consolidation will continue as big players have cash on hand and program changes require more infrastructure investment The competitive advantage that remaining MA products generally have over Medicare Supplement products will decline Some areas, enough to really matter Other areas, a significant amount but probably not enough to really matter Creates Medicare Supplement opportunity for those organizations that can determine where the best opportunities will be 40 May 17, 2012
41 Looking to 2013 MA Plan Challenges Benchmark Revenue was flat from 2012 levels as part of MA payment reform CMS limited Total Beneficiary Cost (TBC) changes through negotiation (i.e., large premium increases and / or benefit reductions were negotiated to more modest changes reform granted explicit authority for CMS to reject bids) 41 May 17, 2012
42 42 May 17, 2012
43 Medicare Advantage Opportunities Annual benefit election Flexibility Risk adjusted Managed Care Threats Payment reform MLR requirement Filing and oversight 43 May 17, 2012
44 Medicare Supplement Opportunities Cost pressures on MA will improve the relative attractiveness of Medicare Supplement and Medicare Select products No provider network restrictions freedom of choice More flexibility with respect to filing requirements Threats Unmanaged care (lacks medical management controls) Rx coverage must be provided by a separate PDP Plan Carrier is not provided any risk-adjusted revenue Outlaw of full coverage possible Possible MLR requirements 44 May 17, 2012
45 Medicare Supplement - Pricing Methodology and Practical Considerations Medicare Supplement Market is very price sensitive Product standardization makes it difficult to differentiate other than price Easy for others to compare you to competitors Review of Competition is an important part of pricing process Industry loss ratios have increased over the years due to competitive pressures Keys to profitability Balance of competitive yet adequate rate levels Expense efficiencies Business retention Rate increases and accurate analysis of emerging experience key to reaching lifetime profit targets 45 May 17, 2012
46 DISCUSSION / QUESTIONS? 46 May 17, 2012
47 Thank You! T. Scott Bentley, FSA, MAAA Consulting Actuary Milliman, Inc May 17, 2012
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