FOLLOW-UP QUESTIONS FROM THE PART D CASH FLOWS WEBINAR PRESENTED JULY 7 TH, 2015
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1 FOLLOW-UP QUESTIONS FROM THE PART D CASH FLOWS WEBINAR PRESENTED JULY 7 TH, So the goal for 2020 is to continue the Drug Manufacturer responsibility in the GAP at 50% and split the rest between the member and plan - 25% and 25%? The ultimate goal of the Affordable Care Act is to achieve 25% beneficiary coinsurance for both brand and generic drugs by For generic drugs, beneficiary coinsurance in the gap (aka donut hole) will gradually decrease each year until it reaches 25% in The MA-PD or PDP plan is responsible for the balance (e.g. 75% in 2020). For brand drugs, the Drug Manufacturer discount remains flat at 50%, but the beneficiary coinsurance decreases each year, similar to generic drugs. By 2020, liabilities for brand drugs in the gap will be roughly 25% beneficiary, 25% MA-PD/PDP plan, and 50% drug manufacturer. 2. Were these slides ed out? Copies of the July 7 th presentation are available for download on the website. If you would like slides directly from Wakely, please Tim Courtney at [email protected]. 3. Please talk about Dual beneficiary and how Part D is paid to plans. Exclusively examining a Medicare Part D plan, the loss ratio will be generally unaffected by a low income member s status (assuming equivalent consumption patterns for a low income and a non-low income member); only the payment mechanics will differ for a dual or non-dual member. For a dual member, the only difference on the premium side is that a dual member s premium is fully or partially subsidized by the federal government, and the plan will receive the funds for this Low Income Premium Subsidy Amount (LIPSA) in the standard MMR payment, whereas a non-dual member must transmit premium payment to the plan on a monthly basis. For claim payments, dual members point-of-sale (POS) copays are subsidized and discounted by the federal government. For these Low Income Cost Sharing (LICS) subsidies, the plan covers the dual member s subsidy at POS. The plan is paid a prospective expected LICS PMPM amount each month, and a settlement occurs after the plan year ends where actual LICS payments are reconciled against the prospective payments during the year. The prospective LICS subsidy payment is based on the calculated cost of the LICS subsidy from the Bid Pricing Tool (BPT). Page 1
2 4. Can you explain these medical (MA) rebates? At a high level, MA Rebates are determined by comparing the difference between the risk scoreadjusted Part C benchmark and the bid submitted by an MA-PD plan. The bid represents the plan s estimate of the costs to cover the standard Medicare benefit for the expected population upon which the bid is based. The formula for rebates is: Max{(Risk Adjusted Part C Benchmark Bid) x Rebate %, 0}, where rebate % varies according to the MA-PD plan s star rating. The rebate % is 50% for plans with a rating of 3 stars or lower, 65% for plans with a 3.5 or 4.0 star rating, and 70% for plans with a 4.5 or 5.0 star rating. The MA rebate can be used to buy-down Part D basic and/or supplemental premiums. 5. What is the definition of the non-covered plan payment? Non-covered plan payment will be equal to the Total Covered Drug Cost minus Patient Pay Amount (including LICS, PLRO, and Other TrOOP) minus Covered Plan Payment (CPP). For claims below the catastrophic threshold, CPP is defined as the plan liability amount for DS/AE/BA plans, and the plan liability under a defined standard benefit for EA plans. For claims in the catastrophic phase of the benefit, CPP will also include any plan payments made at point-of-sale for catastrophic amounts ultimately covered by federal reinsurance (i.e. the 80% coinsurance covered by the federal reinsurance after the Cat TrOOP threshold has been crossed is included in CPP). Note, NPP will only be populated with non-zero values for Enhanced Alternative plans. Defined Standard, Actuarially Equivalent, and Basic Alternative plan claims will have $0 values in the PDE NPP field. The full CMS description and demonstration of the calculation of NPP under several different scenarios can be found at: Coverage/DrugCoverageClaimsData/downloads/partdpymntdemo.pdf Page 2
3 6. Can you confirm that PLRO would also be a plan liability for EGWPs? As a secondary payer, PLRO would typically be plan liability for the EGWP, although it is possible there may be other amounts bucketed into PLRO if there is other non-primary health insurance. For those interested, the CMS definition of PLRO can be found on pages (#35) at: Coverage/DrugCoverageClaimsData/downloads/PDEGuidance.pdf 7. We are dual but I only see $ payment in 3 fields; direct subsidy, reinsurance and LI subsidy cost sharing. Is the latter LICS LIPSA? Where would I see CGDP? In the MMR, the Part D Direct Subsidy Monthly Payment Amount field is indeed the direct subsidy, reinsurance is the Reinsurance Subsidy Amount, and the Low-Income Subsidy Cost- Sharing Amount field is the LICS payments representing the point-of-sale copay cost subsidies the government grants to low-income members. The LIPSA, or portion of the basic premium payment below the regional low-income benchmark that the federal government pays for lowincome members, is the LIS Premium Subsidy field. The CGDP is in the Part D Coverage Gap Discount Amount field. Note, low-income members are ineligible to receive CGDP, so for these members this field should be zero. 8. Does the direct subsidy timing chart work the same for PDP as it does for MA plans? If not, how does PDP work since we don't have "sweeps"? The timing of the PDP mid-year and final payments should mirror the timing of the payments for MA plans. As for MA plans, the PDP mid-year subsidy adjustment represents the 6-month shift forward of the medical claim data used to calculate risk scores (for the 2015 plan year, this would shift the baseline from a July 13-June 14 range to a CY2014 range), and the final payment is generated by the additional claim run-out and any RAPS submissions for the CY2014 plan year. The mechanics of the payment operate the same for PDP and MA plans. The difference is that PDP plans have no visibility or influence over the medical data that is used as the basis for calculating Part D risk scores. Page 3
4 9. What is the best way to estimate the final settlement amount for federal reinsurance, especially when projections vary wildly monthly? The most appropriate tool to use to forecast federal reinsurance would be a robust Part D Forecast Tool that can, with relative accuracy, project total allowed costs and adjudicate the Part D benefit through every phase of coverage. Generally, this tool should take into consideration member-level drug experience and projected trends for all drug types, particularly specialty drugs which are common amongst the subset of the population that reaches the catastrophic TrOOP threshold. The model should also account for any potentially expensive new market drugs that could drive more members with specific conditions into the catastrophic phase of the benefit. 10. Can you unpack the term "target amount" and how that is established? The target amount for purposes of calculating the risk corridor is the projected plan liability for the drug cost (not including any supplemental coverage) as estimated in the bid. The target amount is the product of the 1.0 Bid, the actual RAF, and the estimated loss ratio as originally projected in the BPT. Supplemental premium is not considered when calculating the target amount for risk corridor purposes. Stated differently, the target amount is calculated by summing actual direct-subsidy cash flows from CMS and actual basic member premiums, while subtracting administrative costs and profit margins assumed in the bids. (Note: this definition can be found on page 9, A7 of the April 2008 AAA Medicare Part D Accounting Practice Note referenced on slide 19 of the July 7 th Webinar). 11. Is risk corridor only for the plan pay pink areas/ costs from your chart? Is the plan pay 15% in the reinsurance section part of risk corridor? Q1: Correct. The risk corridor calculation compares the actual plan liability to the projected defined standard plan liability in the bid, represented as the drug cost component of the premium. In the chart represented on slide #3 of the presentation, the pink area represents plan pay, so yes, the risk corridor calculation only considers the plan pay/pink area costs from the Side #3 chart. For Defined Standard (DS), Actuarially Equivalent (AE), and Basic Alternative (BA) plans, the risk corridor simply compares actual plan pay amounts to the plan pay amounts projected from the bid. However, for Enhanced Alternative plans, the risk corridor calculation is more complicated. Risk corridor protection only applies to the basic (i.e. Defined Standard) portion of the benefit. Page 4
5 Therefore, only the risk-adjusted direct subsidy and basic premium (adjusted for the bid loss ratio) are counted towards the projected claim amounts. Similarly on the claims side, only the basic portion of the benefit is counted towards claim expense. For this calculation, the Covered Plan Payment (CPP) field is used, as that field represents the defined standard benefit coverage for a claim. Q2: The plan pay will approach, but be less than, 15%. This is due to the mechanics that determine true member copay for claims occurring in catastrophic phase of the benefit. For a claim occurring in the catastrophic phase of the benefit, the member will pay the greater of 5% of the cost of the drug or a copay of $2.65/$6.60 ($2.95/$7.40 in 2016) for a generic or brand drug, respectively. For example, if a generic drug costs $20 at point-of-sale, the member will pay the copay of $2.65, as the copay of $2.65 is greater than 5% of the cost of the drug ($1 in the example). The federal government covers exactly 80% of allowed costs for every prescription filled in the catastrophic phase of the benefit, so for the example given the reinsurance reimbursement due to the plan for the claim is $16. The plan s actual liability is ($20 - $ $16) = $1.35, which is 6.75% of the total cost of the drug. Due to these member copays for claims like those in the above example, plan liability will be less than 15% (but usually within 0.5% to 1.0% of 15%). 12. What is "Wakely" and "SOA" in seasonality chart? The Wakely line in the seasonality represents a quarterly loss ratio study performed internally by Wakely. The SOA line in the seasonality chart represents the results of a comparable study performed by the SOA. 13. SOA- some other analysis on slide 16? Slide 16 shows the results for 3 distinct studies examining Part D plan loss ratios, performed by CMS, the SOA, and Wakely. Note, the SOA and Wakely studies only examine basic (non-ea) plans, which is why the loss ratio seasonality varies between the SOA/Wakely studies and the CMS study (Enhanced plans almost always reduce the deductible, typically down to $0, driving the Q1 loss ratio higher than it would be for basic plans). Page 5
6 14. Should the Low Income Premium Subsidy paid to Plans by CMS be treated on the FS as Member Premium? Yes. The Low Income Premium Subsidy is the portion of the member s basic premium below the regional low-income benchmark (LIB). Assuming a plan s basic premium is below the regional LIB, the only difference between a Low Income Premium Subsidy and a basic premium payment from a member is the source of the payment (if the basic premium is higher than the regional LIB, then the LIPS will only cover the amount up to the regional LIB). 15. The Accounting practice note shows as not found under your path. Can you send it to the group? The link should still be active; however, Wakely can distribute pdf files of the Accounting Practice note to audience members who request it. Please contact Tim Courtney at [email protected]. Thanks to all who participated in this call. We look forward to speaking with you again. Wakely will be participating in the September 15, 2015 MAC Meeting in Portland, OR, and will be presenting at another webinar on October 27, The topic for the October webinar is New vs Existing Markets. We hope you can join us at one or both events. Wakely has many resources available to you at no charge such as professional summaries of CMS announcements and instructions, and industry White Papers. To access these, or to receive more information about Wakely, call me anytime at or visit - Tim Courtney, FSA, MAAA Page 6
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