Medicare: Humana s Strategic Actuarial Positioning John M. Bertko, F.S.A., M.A.A.A.

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1 Medicare: Humana s Strategic Actuarial Positioning John M. Bertko, F.S.A., M.A.A.A. Vice President and Chief Actuary Humana Inc. 1

2 Cautionary Statement This presentation is intended for instructional purposes only. Humana s business may be impacted by certain risks and uncertainties described in Humana s annual and quarterly filings with the Securities and Exchange Commission (SEC). Users of this presentation are advised to also read Humana s disclosures in its Form 10-K (annual) and Form 10-Q (quarterly) filings with the SEC. Those documents are available via the Investor Relations page of the company s web site (www.humana.com). 2

3 Today s Discussion Medicare program basics Humana s Medicare strategy Prescription Drug Plan (PDP) Bidding process Actuarial considerations & plan comparisons Medicare Advantage (MA) Bidding process Actuarial considerations & plan comparisons Humana s competitive edge 3

4 The Medicare Program Administered by the Centers for Medicare and Medicaid Services (CMS), under the Department for Health and Human Services Restructured significantly via the Medicare Modernization Act of 2003 Now Includes four major components: Part A helps pay for inpatient hospital services, skilled nursing facility services, certain home health services, and hospice care Part B helps pay for doctor services, outpatient hospital services, certain home health services, medical equipment and supplies, and other health services and supplies Part C offers Medicare beneficiaries an array of private health plan options (HMOs, PPOs, and Private Fee-for-Service plans) as an alternative to traditional Medicare; includes Part D benefits effective January 1, 2006 Part D coverage for prescription drugs available beginning January 1,

5 Overview of the PDP Provides Medicare beneficiaries with standard prescription drug benefits under Part D of the program May be offered through MA plans or on a stand-alone basis; offered exclusively through private entities Involves an annual competitive bidding process Beneficiaries who have dual-eligibility for Medicare and Medicaid will be auto-assigned into a PDP if not already in an MA plan (dual-eligibles maintain the right to switch between plans) Employers who currently sponsor qualified retiree plans with a drug benefit equivalent to the PDP will be provided a tax-free subsidy Private entities accept most of the related insurance risk but some is offset by risk-sharing corridors and reinsurance subsidies from CMS 5

6 PDP Risk Sharing Corridors (2006 & 2007) Pharmacy costs higher than expected: 2.5% - 5.0%: CMS reimburses plan for 75% of excess > 5.0%: CMS reimburses plan for 80% of excess Pharmacy costs lower than expected: 2.5% - 5.0%: plan reimburses CMS for 75% of savings > 5.0%: plan reimburses CMS for 80% of savings Pharmacy costs associated with benefits in excess of the defined standard plan design may not be included for determining risk sharing Administrative expense overruns or savings are not subject to the risk corridor provisions 6

7 Overview of MA Provides Medicare beneficiaries with private health plan options (local HMOs, local PPOs, regional PPOs and Private Fee-for- Service plans) as alternatives to traditional Medicare under Part C of the program MA participants receive benefits in excess of those available under traditional Medicare such as supplemental prescription drug benefits, reduced monthly premiums, and/or reduced cost sharing Effective January 1, 2006, includes regional PPO offerings and MA plans with a Part D benefit (MA-PD) Involves an annual competitive bidding process Companies must revise MA bids to reallocate savings below the PDP benchmark once that benchmark is determined 7

8 Regional PPO Risk Sharing Corridors Offered to regional PPO plans in 2006 and 2007 in connection with their Part A/B bids If medical expenses > 3% above the plan s bid amount, CMS will reimburse the plan 50% of the overage until expenses reach 8% above the bid amount, overages in excess of 8% are reimbursed to the plan by CMS at 80% If medical expenses >3% below the plan s bid amount, the plan must reimburse CMS 50% of the savings up to 8% below the bid amount, savings in excess of 8% are reimbursed to CMS by the plan at 80% Medical costs associated with ancillary benefits offered by the plans may not be included for determining risk sharing Administrative expense overruns or savings are not subject to the risk corridor provisions 8

9 Humana s Medicare Strategy Leverage Medicare opportunities in both PDP and MA Establish relations with Medicare eligibles early (first-mover advantages for MA products in many locations) Offer broad portfolio of products from which Medicare eligibles may choose Position each opportunity for profitability on a stand-alone basis Longer-term strategy of migration to higher-revenue MA products 9

10 PDP Annual Bidding Process Spring and early summer Company actuarial teams evaluate data and benefit plan designs to determine bids Early June Companies submit bids for all PDP plans to be offered the following year (each company must submit one bid for the defined standard plan design or its actuarial equivalent) June and July CMS reviews bids for adequacy and appropriateness of plan designs August Mean average of PDP bids for the standard plan determines the national benchmark Regional benchmarks are determined by both PDP bids and MA-PD plans Part D bids in each region September CMS signs final contracts for upcoming year Auto-assignment of dual eligibles for plans below the regional benchmark (effective January 1) 10

11 Defined Standard PDP Benefit Design Annual drug costs CMS* Plan Member First $ % Next $2,000-75% 25% Next $2,850 (coverage gap) % Remainder of costs 80% 15% 5% * Through reinsurance subsidies 11

12 Analysis of Projected Medical Costs Review of historical pharmacy claims data: Survey data from CMS covering all categories of eligibles (all plans) Medicare HMO claims (some plans) TRICARE Senior Pharmacy claims (some plans) Medicare Supplement claims (some plans) Geographic factors from CMS (all plans) Project using historical data and negotiated discounts: Risk scores by region (based on Parts A & B diagnosis codes) Geographic adjusters for differences in pharmacy utilization patterns Company-specific discounts and rebates on pharmacy unit costs Project total pharmacy costs based on benefit design, expected risk scores and geographic adjusters 12

13 Sources of PDP Revenue Average income member Low income member Standard premium CMS pays CMS pays (including risk adjuster) Member premium Member pays CMS pays Low income cost subsidy N/A CMS pays Reinsurance subsidy CMS pays CMS pays or capitation 13

14 Impact of Risk Scoring on Member Premium Plan A Plan B Projected PDP revenue excluding reinsurance subsidy $80.00 $80.00 Divided by projected risk score used in projected PDP revenue Revenue adjusted to standard risk score of 1.00* Less national bid average (92.30) (92.30) Plus national base member premium Member premium included in PDP bid $16.09 $12.63 *Revenue received will be adjusted to reflect member s actual risk score 14

15 Bid Member Premium Comparison Factors Unit price competitiveness of the plan Benefit design Deductibles, copays Coverage gap fill-ins Formulary design, including tiers Utilization management initiatives Expansiveness of data used in projecting pharmacy costs Experience of the actuarial team analyzing the data Differences in projected risk scores and geographic adjusters will skew comparisons Humana PDP offerings priced for profitability in all markets Not enough public data available for valid margin comparisons 15

16 Observations about 2006 PDP Offerings Many more competitors than CMS expected More competitors probably drove up the national benchmark Some are small or new players in the Rx area for beneficiaries All bids are equally weighted for 2006 in calculation of the benchmark Different bidders may appeal to different populations, such as: Legacy employers/retirees Medigap subscribers Dual eligibles Other non-low income beneficiaries 16

17 MA Annual Bidding Process Spring and early summer CMS publishes Medicare rate book for the following year Company actuarial teams evaluate data and benefit plan designs to determine bids Early June Companies submit bids for all MA plans to be offered the following year (separate bids for (1) Parts A & B and (2) integrated Part D) June and July CMS reviews bids for adequacy and appropriateness of plan designs August Regional PPO benchmarks are determined by CMS based on both the bids and the Medicare rate book Plans bidding below the PDP benchmark adjust bids to re-allocate savings to lower premiums or increase benefits September CMS signs final contracts for upcoming year 17

18 MA-PD Choices for Seniors in 2006 Traditional Medicare with drug benefit Medigap with drug benefit Private Fee-for- Service PPOs HMOs Approximate monthly premium $0 $150 - $225 $0 - $100 $30 - $130 $0 - $50 Out-of-pocket cash very high low moderate low - moderate very low Part B premium $80 $80 $80 $80 $0 - $80 Level of benefits compared to traditional Medicare with drug benefit Medical Drugs same same moderately higher same marginally to moderately higher marginally higher moderately to significantly higher moderately higher significantly higher significantly higher Choice of providers expansive expansive expansive moderately expansive limited 18

19 Humana s Competitive Edge Expansiveness of data for evaluation and experience of the team First mover in many locations with MA products Benefit design One formulary across all plans maximizes leverage and discounts Incorporation of Maximize Your Benefits program into monthly statements Efficient and effective use of tiering, pre-authorization, and other utilization management techniques Positioning PDP membership for potential future migration to higher-revenue MA-PD products in a profitable environment 19

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