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HomeMy WebLinkAboutKevin Wolf & Associates, LLC - LEOFF Retiree Drug Subsidy Medicare Part D for Employer Plan SponsersKevin Wolf & Associates, LLC Retiree Drug Subsidy/Medicare Part D for Employer Plan Sponsors (Less than 50 retirees) — For employers not in a Prescription Drug Plan (PDP) Services Available from Kevin Wolf & Associates, LLC (KW&A) Actuarial Attestation for the Retiree Drug Subsidy (RDS) 1. Provided by qualified actuary, Member of the American Academy of Actuaries (MAAA); 2. Gross (Creditable Coverage) and Net (Actuarial Equivalence) testing — the Centers for Medicare & Medicaid Services (CMS), a federal agency, requires the Plan Sponsor to pass both these tests to get the subsidy; a. If the Plan passes the Gross Test, the Plan Sponsor should send Creditable Coverage notice to Medicare eligible retirees. KW&A will provide a sample Creditable Coverage notice (or Non -Creditable Coverage notice, if failing the Gross Test) to the Plan Sponsor. b. If the Plan passes both tests, then the Plan Sponsor is eligible for the 28% subsidy of Medicare eligible retiree's drug claims (including co -pays). CMS pays the subsidy. c. The Plan Sponsor must fill out the RDS application, available at the RDS website: http://rds.cros.hhs.gov. KW&A can help with the application process. 3. Plan Sponsor should provide KW&A the Needed Data (see page 5, below) prior to 90 days before the RDS application effective date (e.g. by about 9/30/2021 for January 2022 effective) or 60 days before (about 10/31/202 1), if a 30 day extension is requested by the Plan Sponsor in the application. 4. KW&A will provide a report showing the results of the Gross and Net Tests and providing "next steps' in the RDS application process and Creditable or Non -Creditable Coverage notice. 5. Service Fees — Actuarial Attestation a. Gross Test only — $1,000 ($1,750 first year) for up to 4 retiree prescription drug benefit plans b. Gross & Net Tests — $1,500 renewal ($1,750 first year) for up to 4 retiree drug benefit plans c. These fees apply to each RDS application that is filed by the Plan Sponsor with the RDS application effective for policies ending in 2022. 1 If the Plan Sponsor has more than 100 Medicare -eligible retirees, they should contact KW&A for fee schedule and available RDS services, agreement terms, needed data, and service fees for KW&A to provide the services. 3047 N Lincoln Avenue, Suite 400, Chicago, IL 60657 Phone: 773-575-2128 Fax: 773-404-5837 E -Mail: kevin.wolf.associates@gmail.com ;kcag5 Kevin Wolf & Associates, LLC Interim and/or Reconciliation Payment Reporting 1. The Plan Sponsor must submit summarized claim information in the format that CMS requires through the electronic application to receive the RDS for Interim or Reconciliation Payment Reporting. 2. KW&A, after receiving the necessary data from the Plan Sponsor, will give the Plan Sponsor the needed summary. KW&A will review the data for reasonableness (e.g., test the claim dates, try to prevent claim duplication). KW&A will not confirm that the claims are Part D eligible (we expect the claim processor to do that). KW&A will not confirm the Medicare D eligibility of the retirees whose drug claims are included in the data. We expect the Plan Sponsor to check retiree eligibility. 3. KW&A will prepare a report with the information that the designated Cost Reporter (typically, the Account Manager) should submit in the RDS application. 4. We will maintain the data used for the report for six years. This data will be held confidentially. We will return it to the Plan Sponsor at the Plan Sponsor's request. 5. Service Fees — Interim and/or Reconciliation Payment Report a. Interim Payment Report: $4,800 for 12 monthly reports, $3,000 for 4 quarterly reports, $1,500 for one annual report. b. $2,000 for percent of premium factor development. This is only available for fully insured employers and before the annual reconciliation report. The reconciliation report still requires the claim data to be provided to KW&A. c. Reconciliation Payment Report: $1,500. This report is due up to 15 months after the end of the application effective year. d. If desired, we can provide a designated cost reporter. The fee will be $300 for each report submitted by and KW&A designated Cost Reporter. e. We recommend that the Payment Requester should be a person working for the Plan Sponsor. The reconciliation Payment Requestor must be the Plan Sponsor's Authorized Representative. Services Not Included in Our Base Fees We are available by phone and email to answer questions. If the client desires a site visit, we will bill for that separately, based on the current rate of $300 per hour (minimum $500) plus travel/accommodation expenses. We can help the client with any audit by CMS related to an actuarial attestation, interim payment report, or reconciliation report that we develop. However, the fees provided above do not include the cost of our providing this audit support. To do this audit support, we will bill at our standard hourly in effect at the time of the audit. We will provide interim bills at the client's request. If the client wants a fixed fee in advance of our help with an audit, we will provide that proposal. Policy years ending in 2022 2 Kevin Wolf & Associates, LLC If the client has 500 or more retirees, we will provide a separate proposal with our fees for that client. We will also need more detailed non -pharmacy claim experience than that requested at the end of this document. Definitions of PDP & Retiree Drug Subsidy Application Roles Prescription Drug Plans (PDP) cover plan sponsor's retirees on an already discounted insured premium basis under the Medicare Modernization Act of 2003; they aren't eligible for RDS The Account Manager, Actuary and Authorized Representative must be assigned in the Retiree Drug Subsidy application process. These roles must be held by different people. Additional people (e.g. Cost Reporter or Payment Requester) can be designated as the need arises. These roles are defined below. Account Manager — Typically, a Plan Sponsor employee, who fills out the bulk of the RDS application and acts as a Cost Reporter (or Payment Requestor, but not both); can assign additional designees; and needs Plan Sponsor confidential information, like bank account, retiree listing, etc. Actuary — The Account Manager assigns the Actuary, who provides the actuarial attestation; must be a qualified Member of the American Academy of Actuaries (MAAA); and cannot be the Cost Reporter or Payment Requestor. Authorized Representative — Must be an employee of the Plan Sponsor and must be a Payment Requestor (especially for the Reconciliation Reporting). Cost Reporter — Submits Interim and/or Reconciliation Payment Report in the RDS electronic application. Payment Requester — Requests payment from CMS in the RDS electronic application. For More Information, where to send the signed agreement and the needed data, please contact or send the information to: Kevin S. Wolf, FSA, MAAA Consulting Actuary kevin.wolf.associatesggmail.com Kevin Wolf & Associates, LLC 3047 N Lincoln Avenue, Suite 400 Chicago, IL 60657 Voice: 773-575-2128 Fax: 773-404-5837 Policy years ending in 2022 3 Kevin Wolf & Associates LLC Retiree Drug Subsidy (Medicare Part D) for Employer Plan Sponsors not in a Prescription Drug Plan (PDP) & 100 retirees or less2 -Agreement for Services and Fees Name of Employer Plan Sponsor: City of Pasco Street Address, Suite/Floor: 525 N 3rd Ave City, State, Zip: Pasco,WA 99301 Contact's Name: Colleen C'hnnin Contact's Title: Human Resources Director Contact's Phone & Fax #: 509-545-3473 Fax* 509-543-5720 Contact's Email Address: chapinc@pasco-wa.gov Provide billing address if different from the employer group's address. Select desired services that KW&A will provide: ❑Actuarial Attestation — Gross Test (Creditable Coverage Test) Only. Up to 4 pharmacy benefit plans; provide item 1 of the data request at least 90 days before effective date; Fee: $1,000. Actuarial Attestation — Gross (Creditable Coverage) & Net (Actuarial Equivalence) Tests; needed to request x❑ the Retiree Drug Subsidy (RDS). Up to 4 pharmacy benefit options; provide items 1 — 7 of the data request at least 90 days before effective date; Fee: $1,500 renewal ($1,750 first year). Interim Payment Reports for each Plan Sponsor (reduce fees by 40% for Pharmacy Benefit Managers requesting reports for 4 or more Plan Sponsors); Select one, if desired: ❑ 12 Monthly Reports; Fee $4,800 ($400 billable monthly); Provide 1 & 8 of the data request 4 Quarterly Reports; Fee $3,000 ($750 billable qtrly); Provide 1 & 8 of the data request F11 Annual Report; Fee $1,500; Provide 1 I & 8 of the data request ❑ Percent of Premium Factor; Need fully insured benefit; Fee $2,000; Provide 1 & 7 of data request Annual Reconciliation Report for each Plan Sponsor; Select, if desired: ❑ Fee $1,500 Acceptance of above requested services and fees Name and Title of Accepting Party 3: Dave Zabel] Employer of Accepting Party: City of Pasgo 16 Signature of Accepting Party: (741 Date: The actuarial attestations and payment reporting are based in material part upon information and assumptions furnished by the Employer Plan Sponsor. Accordingly, KW&A shall have no liability for the inaccuracy of these projections to the extent that any such inaccuracy is based in whole or in part upon the information and assumptions furnished by the Employer Plan Sponsor to KW&A. For all projects, KW&A's liability is limited to the fees charged. 2 If the Plan Sponsor has more than 100 Medicare -eligible retirees, they should contact LWCA for fee schedule and to discuss available RDS services, agreement terms, needed data, and service fees for LWCA to provide the services. 3 If the Accepting Party is not an employee of the Employer Group, then provide authorization on the Employer Plan Sponsor's letterhead that the Accepting Party can approve the work requested. Policy years ending in 2022 4 Kevin Wolf & Associates, LLC Medicare D RDS - Needed Data For Actuarial Attestation Gross and Net (Actuarial Equivalence) Tests, Needed for getting the Retiree Drug Subsidy; Provide the information requested in items 1 through 7. For Actuarial Attestation Gross (Creditable Coverage) Test only; Provide the information in items 1 and 2. Interim Payment Reporting using claims: Provide the information requested in items 1 and 9. Interim Payment Reporting using Percent of Premium: Provide the information requested in items 1 and 8. Reconciliation Payment Reporting: Provide the information requested in items 1, 9 and 10. Attach current and proposed pharmacy and non -pharmacy (latter includes hospital and physician services) benefit deScriptionS for Medicare eligible retirees. Also, fill in the benefit names and answer the question in (a) through (d) below: City of Pasco a. Option 1 Name: LEOFF 1 Retirees ; is this HMO, PPO, POS, open access or indemnity coverage? b. Option 2 Name: ; is this HMO, PPO, POS, open access or indemnity coverage? c. Option 3 Name: ; is this HMO, PPO, POS, open access or indemnity coverage? d. Option 4 Name: ; is this HMO, PPO, POS, open access or indemnity coverage? 2. For Pharmacy Benefit Managers providing information for several Plan Sponsors, please provide the name and location of each Plan Sponsor. 3. Insurance plan year definition for each distinct benefit plan or employee contribution sub- group (for example: 7/1 through 6/30) All eligible active employees and LEOFF 1 Retirees. 06/01/2021 - 05/31/2022 Policy years ending in 2022 Kevin Wolf & Associates, LLC Fill out the following grids for current and proposed contribution rates for each benefit option (show proposed on an additional page, if needed): Retiree and Employer Contribution Monthly Rates for Medicare Eligible Retirees Benefit Option 1: Effective 01 /Q1/21 (a different contribution level is a different benefit option) Pharmacy Only (if available) by Non -Pharmacy Medical Only (if available) by Total (if not separated) by Re- Em- Re- Em- Re- I Em - Category tiree ployer Total tiree ployer Total tiree Toyer Total Retirees 1459.00 1459.00 Retiree + Spouse Retirees Retiree + Children Retirees Retiree + Family Benefit O tion 2: Effective _/_/_ (a different contribution level is a different benefit option) Pharmacy Only (if available) by Non -Pharmacy Medical Only (if available) by Total (if not separated) by Category Re- Em- Re- Em- Re- I Em - tiree I ployer Total tiree ployer Total tiree ployer Total Retirees Re- Em - tiree ployer. Total Retirees Retiree + Spouse Retiree + Children Retiree + Family Retiree + Children Benefit Option 3: Effective / / (a different contribution level is a different benefit option) Pharmacy Only (if available) by Non -Pharmacy Medical Only (if available) by Total (if not separated) by Category Re- Em- Re- Em- tiree ployerTotal tiree Toyer Total Re- Em - tiree ployer. Total Retirees Retiree + Spouse Retiree + Spouse Retiree + Family Retiree + Children Retiree + Family Benefit Option 4: Effective / / (a different contribution level is a different benefit option Pharmacy Only (if available) by Non -Pharmacy Medical Only (if available) by Total (if not separated) by Category Re -Em- Re- Em- Re- Em - tiree Toyer Total tiree ployer Total tiree ployer Total Retirees Retiree + Spouse Retiree + Children Retiree + Family Policy years ending in 2022 Kevin Wolf & Associates, LLC 5. Current Contract Counts and Members covered. Please fill in the following grid for each benefit option: Number of Medicare Eligible Retirees Contract Counts and Covered Members as of 05 / 31 / 2021 bv Benefit Option Option 1 Option 2 Option 3 Option 4 Single contracts 31 Retiree & Spouse Retiree & Children Family Total contracts Members 6. Claim Experience. Please fill in the following grid for the most recent experience available. Member months should be counted for each month covered (e.g. if one retiree is covered for 6 months in the experience period, he or she should be counted as 6 member months). If more detailed claim experience is available (e.g. pharmacy generic vs. brand claims) then attach separate documents with this information. Member Months & Claim Experience for Medicare Eligible Retirees for the Time Period from / / through / / Benefit Member Months Pharmacy Paid Option Claims Non -Pharmacy Paid Claims Option 1 Option 2 Option 3 Option 4 7. Please provide the percentage distribution of your Medicare eligible retirees based on the type of work they did when last employed by the plan sponsor. Percent Distribution of Retirees by Type of Work when last em to ed; blank lines should s pecif , the type of work Private Employer Union S onsor Government Em plover T e (specify) % Type (specify) % Type (specify) % Administration Administration n/a Administration n/a Teacher n/a Custodial n/a Police/Fire n/ Total 100% Total 100% Total 100% 4 Contract counts are the count of the units covered (e.g. a family covered would be counted as one contract, regardless of family size). Members are the count of the Medicare eligible retirees and each covered dependent (spouses and children). Policy years ending in 2022 7 Kevin Wolf & Associates, LLC 8. If the Percent of Premium method is being requested, please confirm that each pharmacy benefit option for Medicare eligible retirees is fully insured and not self-insured. Only fully insured benefit options can have their RDS developed using the simplified, Percent of Premium method. This does not require the use of claim experience for the interim payment reports. However, the Reconciliation must still be developed using claim experience. a. Option 1 is fully insured: Yes or No b. Option 2 is fully insured: Yes or No c. Option 3 is fully insured: Yes or No d. Option 4 is fully insured: Yes or No e. If available, provide the administrative and risk charges, included in the premiums for each benefit option.. 9. Provide this claim information as frequently (i.e. monthly, quarterly or annually) as RDS payments are requested from the CMS on the RDS application. This information should be in Excel or Access format or a format importable into Excel or Access. This information should come from the employer group's prescription drug claim payer (such as a Pharmacy Benefit Manager (PBM), Third Party Administrator (TPA) or insurer). a. Claim policy year covered is from _/_/ through /_/ Note: The RDS will only be paid for time periods that the RDS application was approved for (prior periods in the same policy year approved in the application can be used to help meet RDS deductible and maximum limits.) b. Provide the following claim information for each Medicare eligible retiree (we will not confirm their eligibility) for prescription drug claims incurred from the start of each policy year through the most recent month available when the data is produced. Once a policy year is reconciled that time period should no longer be provided. c. Each prescription drug claim record should include the following data elements: i. Vendor Name (provider of the claims data) ii. Employer Group Number iii. Employer Group Name iv. Pharmacy Benefit (this should match the labels on the RDS application) v. Patient's Social Security Number (this will likely be required when the reconciliation is done, but for interim reports only a unique identifier is needed; data provider to confirm Medicare eligibility) vi. Patient's First Name vii. Patient's Last Name viii. Date prescription is filled ix. Date prescription is paid x. NDC (National Drug Code; 10 -digit 3 segment number) xi. Drug Name xii. Prescription Count (typically 1; should be 0 or -1 if adjusting another claim record) xiii. Retail vs. Mail Order Code Identifier (e.g. R for retail, M for mail order) Policy years ending in 2022 8 Kevin Wolf & Associates, LLC xiv. Optional: Days Supplied (7, 30 90, etc.) xv. Optional: Metric Quantity of each pill xvi. Optional: Average Wholesale Price (AWP) xvii. Optional (unless needed for deriving the rebates, then mustprovide this information) Generic/Brand Formulary/Brand Non -Formulary xviii. Optional: Billed Amount (can be negative for an adjustment to another claim record) xix. Paid Amount (can be negative for an adjustment to another claim record) xx. Co -pay amount (can be negative for an adjustment to another claim record) xxi. Total Cost = Paid Amount + Co -pay Amount (can be negative for an adjustment to another claim record) xxii. Prescription eligible for RDS (Y for yes; N for No). This field means that the NDC is on the list provided by CMS as covered under Medicare Part D d. For Interim Payment Reporting, provide rebate and other cost concession amounts for each policy year time period incurred for Medicare eligible retirees for each employer group in total dollars or as a percentage of total costs (= paid amounts + co -pays). For Reconciliation Reporting, provide actual rebates (not estimated, which is allowed for interim payment reporting) by month for the Medicare D eligible retirees. The Plan Sponsor can provide the formula to derive the rebate information, if enough data is given in 8c, above (e.g. specific dollar amount for each mail order or retail prescription). e. The claim provider should remove the Medicare Part A and Medicare Part B eligible pharmacy claims from the claim file provided to KW&A. If these claims can not be removed by the claim file provider, then KW&A will reduce the claims by .3% following allowed procedures developed by CMS. Download the Reconciliation Job Aid from the RDS website at: http://rds.cms.hhs.gov/reference materials/job aids/job aid recon.htm. Complete steps I through 3 of the Reconciliation Process on. your RDS application fcr the application year being reconciled. Download the retiree list from the RDS website. Make any corrections to finalize the retiree list. This is the last chance to correct the retiree list for this application. Download the final list and send this final list to us. We will use it to make sure the claims (item 9c, above) match these retirees. Policy years ending in 2022 9