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Medicare Advantage: Part C Pricing for MA-PD Plans Boot Camp for Health Actuaries

November 5 - 6, 2018
Sheraton San Diego Hotel & Marina
San Diego, CA


External Forces & Industry Knowledge Professional Values Technical Skills & Analytical Problem Solving

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This boot camp course has been offered annually for the past nine years and has emphasized Part C pricing with some years covering less of Part D. This year the course will be one and a half days and will focus primarily on the Part C medical side of the bids. There will be some mention of Part D, but a thorough explanation of Part D pricing will not be covered. The course is aimed at participants from beginner to intermediate levels. Beginners are welcome but are expected to prepare more thoroughly prior to the course. All participants, regardless of level and prior experience, are expected to complete a package of reading and preparation in advance of the course. 

During the course, we will be working with the Part C and Part D Bid Pricing Tools (BPTs). Each of these is a complex multi-sheet Excel workbook that Centers for Medicare & Medicaid Services (CMS) requires actuaries to develop and complete to submit a Medicare Advantage bid.  All course participants are expected to familiarize themselves with the structure and worksheets of the Part C BPT prior to the course if they are not already.

This course focuses on pricing and the large body of product knowledge and regulatory requirements that affect MA-PD. Some HMO and/or PPO health pricing experience is a prerequisite for this course.  Basic knowledge of the fee-for-service Medicare program is also expected—eligibility and benefit. Many advanced concepts in health pricing will be touched on during the course. There will be little time to slow down and explain concepts like coordination of benefits, member cost-sharing, trend and incurred but not reported (IBNR) to those unfamiliar with them. This course is not intended as an entry-level course on health pricing for those who have no health pricing experience. Although the course will focus almost entirely on Part C (medical), it will mention the Part D (pharmacy) component of the MA-PD bid and sometimes compare and contrast the MA vs PD (BPTs).

Medicare Advantage evolves annually which means new rules are announced each year and product changes occur. As expected, these new developments do not typically lessen the actuaries’ workload or otherwise make things easier during the limited time of the “bid season.”  We will cover the recent changes in the bid instructions and other regulations that affect BPT development. We will discuss the relationship between the Part C and D BPTs and the PBP (Plan of Benefits Package).

There will be some class discussion and hands-on in-class exercises conducted in small groups. Participants will need their laptops and will work with several peers to develop a BPT during the course. MA-PD is a rigorously regulated product and the pricing process is highly structured. Documentation, desk review and bid audit will be covered to some extent. Some discussion of professionalism will take place as it relates to bid development and certification, the Code of Conduct, relevant ASOPs and the bid instructions.