Group25 Filings and Certs for Medicare Grp Covs

Question 1

Employer Options for Providing Retiree Benefits

MA Plans: Employer group waivers

Answer 1

1. ER Group Waivers give group MA more flexibility than individual MA products
2. MA organization may build a benefit plan tailored to each ER, as long as:
3. 1 The benefit plan is at least as rich as traditional Medicare benefits
4. 2 Demonstrate how they spent additional benefit cost to benefit eligible retirees
5. MA organizations may expand their group service areas to include all Medicare-eligible retiree in the designated state(s)

Question 2

Employer Options for providing Retiree Benefits

MA Plans: Employer group bids

Answer 2

1. Part A/B ER Group Bids for MA Organizations
   
   1. 1 Steps
      
      1. 1.1 Estimate risk-adjusted benchmark CMS procedures
      2. 1.2 Develop medical and admin cost estimate
      3. 1.3 add a target profit load
      4. 1.4 Subtract from benchmark to project savings
   2. 2 rebates
   3. 3 considerations: base period experience, other data sources, trends, population characteristics, admin costs, profit loads
   4. 4 CMS issues electronic bid forms, instructions, suggested actuarial certification language, and filing direction
   5. 5 CMS performs audits on bids, which are in-depth reviews

Question 3

Employer Options for providing Retiree Benefits

MA plans: special needs plans

Answer 3

1. Special Needs Plans (SNPs) for ER groups
   1.1 SNPs respect enrollment to members with particular characteristics
   (E.g. Dual eligible a, institutionalized members. And disease specific SNPs)
   1.2 Disease-specific SNPs must create care management programs
   1.3 All SNPs must include prescription drug coverage

Question 4

Employer Options for Providing Retiree Benefits

Board list

Answer 4

1. Provide coverage that wraps around Medicare A/B, or replace Part A/B benefits through a Medicare Advantage (MA) plan
2. Can provide prescription drug benefits by:
   
   2. 1 Wrapping coverage around retiree-purchased Medicare Part D plan
   3. 2 Providing primary coverage without federal retiree drug subsidy (RDS)
   4. 3 Providing primary coverage with a federal RDS
   5. 4 Purchasing coverage on behalf of the retiree through a part D plan

Question 5

Employer Options for providing retiree benefits

Medicare Supplement plans

Answer 5

1. Policy must be filed with state insurance department
2. Rate filing require actuarial memorandums or statements
3. Actuaries consider: same as MA bids, plus loss ratio requirements
4. If group experience not fully credible
   
   4. 1 rates sometimes based on individual Med Supp experience
   5. 2 or rate filings available for other carriers
5. Other products not technically Medicare supplement policies (e.g. Medicare Wrap or Retiree Health plans) are not subject to rate approval

Question 6

Prescription drug plans under part D, and the ER group waivers

Answer 6

1. PDP or MA-PD organization submits Part D bids for each benefit plan sold to individuals
2. For group plans, PDP and MA-PD do not submit part D bids
3. PDP or MA-PD organizations may build a benefit plan tailored to each ER as long as plan meets equivalence requirements
   
   3. 1 benefits at least as rich as standard part d
   4. 2 deductible less or equal to the standard Part D deductible
   5. 3 Catastrophic coverage at least as rich as standard Part D catastrophic

Question 7

Plan Sponsor Credible Coverage Notice

Answer 7

1. Plans send credible coverage notices to Medicare-eligible covered individuals
2. Individual without credible coverage, if they do not initially elect Part D but do later, will be charged a late enrollment penalty

Question 8

Retiree Drug Subsidy (RDS) for Plan Sponsors Under Part D

Answer 8

1. To receive the subsidy, coverage must be actuarially equivalent to Part D
2. Actuarial attestation: plan meets the gross and net tests
3. Gross test: is coverage at least as rich as standard Part D?
   
   3. 1 Test separately for each benefit option
   4. 2 The gross test includes all Part D covered drugs
   5. 3 Tested against the Part D benefits with no coverage between the ICL and out of pocket maximum
4. Net test: is subsidy by the plan greater or equal CMS Part D subsidy?
5. When performing tests, consider: base period experience, other data sources, trends, population characteristics, rebates, formularies, cost of drugs not covered by Part D
6. Adjustments to experience include:
   
   6. 1 Benefit design and premium changes, costs trends, utilization trends, drug rebates, expiration of high cost drug patents, shifts from generic to new brand drugs, release of new drugs, formulary changes, drug utilization review modifications, medication therapy management modifications