Medicare Program; Option for Prescription Drug Plans To Lower Their Premiums for Low-Income Subsidy Beneficiaries, 1301-1306 [08-15]
Download as PDF
<![CDATA[
Federal Register / Vol. 73, No. 5 / Tuesday, January 8, 2008 / Proposed Rules
rmajette on PROD1PC64 with PROPOSALS
Four-year Private Institutions: Janet
Dodson, Director of Financial Aid,
Doane College.
Scott Fleming, Government Relations,
Georgetown University.
Ellis Salim, Director of Financial Aid,
Baker College.
Alternates: Bernard Pekala, Director of
Financial Strategies, Boston College.
Thomas O’Neill, Jr., President,
Association of Independent Colleges
and Universities of Nebraska.
Two-year Public Institutions: Patrick
Moore, Director of Financial Aid,
Delaware Technical and Community
College.
For-Profit Institutions: Marry Dorrell,
Corporate Vice President of Student
Finance, Career Education Corporation.
Students: Carmen Berkeley, United
States Students Association.
Alternate: Cedric Lawson, United
Council of University of Wisconsin
Students.
Associations: Terry Hartle, Senior
Vice President, American Council of
Education.
Alternate: Cyndy Littlefield,
Association of Jesuit Colleges and
Universities.
Department of Education: Gail
McLarnon.
We have scheduled a total of three
negotiated rulemaking sessions, all of
which will be held at our offices on
1990 K Street, NW., Washington, DC
20006. The following schedule is
subject to change. We will announce
any changes to this schedule on the
Department’s Web site at https://
www.ed.gov/policy/highered/reg/
hearulemaking/2008/index2008.html.
Session 1: January 8–January 10.
Session 2: January 22–January 24.
Session 3: February 6–February 8.
For the first negotiating session, the
TEACH Grant committee is scheduled to
meet from 9 a.m. to 5 p.m. each day.
For Session 2, the committee is
scheduled to meet from 9 a.m. to 5 p.m.
each day.
For Session 3, the committee is
scheduled to meet from 1 p.m. to 5 p.m.
on February 6 and from 9 a.m. to 5 p.m.
on February 7 and 8.
Student Loan Committee Topics,
Members, and Meeting Schedule
The topics the Student Loan
Committee is likely to address are:
Income-based Repayment Plan (IBR).
Conforming the Economic Hardship
Deferment with IBR.
Public Service Loan Forgiveness.
Definition of Not-for-Profit Holder.
Harmonizing HEROES Waivers with
Other Benefits Provided to Returning
and Active Duty Military.
Federal Preemption of State Laws
Related to improper inducements and
VerDate Aug<31>2005
15:24 Jan 07, 2008
Jkt 214001
arrangements between schools, lenders
and other entities in the student loan
programs.
This list of topics is tentative. Topics
may be added as the process continues.
The members of the Student Loan
Committee and the interests they are
representing are:
Students: Luke Swarthout, United
States PIRG.
Alternate: Rebecca Thompson, United
States Student Association.
Graduate and Professional Students:
Carrie Steere-Salazar, American
Association of Medical Colleges.
Alternate: Radhika Miller, National
Lawyers Guild Partnership for Civil
Justice.
Legal Aid: Deanne Loonin, National
Consumer Law Center.
Alternate: Lauren Saunders, National
Consumer Law Center.
Four-year Public Institutions: Allison
Jones, California State University.
Alternate: Anna Griswold,
Pennsylvania State University.
Four-year Private Institutions: Eileen
O’Leary, Stonehill College.
Alternate: Kathleen Koch, Seattle
University School of Law.
Two and Four-year Public
Institutions: George Chin, City
University of New York.
For-profit Institutions: Mark Pelesh,
Corinthian Colleges.
Alternate: Tammy Halligan, Career
College Association.
Lenders—For-Profit: Tom
Levandowski, Wachovia Corporation.
Alternate: Walter Balmas,
MyRichUncle.
Lenders—Non-Profit: Scott Giles,
Vermont Student Assistance
Corporation.
Alternate: Phil Van Horn, Wyoming
Student Loan Corporation.
Guaranty Agencies: Gene Hutchins,
New Jersey Higher Education Student
Assistance Authority.
Alternate: Dick George, Great Lakes
Higher Education Guaranty
Cooperation.
Servicers: Wanda Hall, EDFinancial
Services.
Alternate: Rob Sommers, Sallie Mae.
Collection Agencies: Martin Darnian,
Windham Professionals.
Alternate: Carl Perry, Progressive
Financial Services.
Associations: Anne Gross, NACUBO.
Department of Education: Dan
Madzelan.
We have scheduled a total of three
negotiated rulemaking sessions, all of
which will be held at our offices on
1990 K Street, NW., Washington, DC
20006. The following schedule is
subject to change. We will announce
any changes to this schedule on the
PO 00000
Frm 00003
Fmt 4702
Sfmt 4702
1301
Department’s Web site at https://
www.ed.gov/policy/highered/reg/
hearulemaking/2008/index2008.html.
Session 1: January 14–January 16.
Session 2: February 4–February 6.
Session 3: March 4–March 6.
For the first negotiating session, the
Student Loan Committee is scheduled to
meet from 9 a.m. to 5 p.m. each day.
For Session 2, the committee is
scheduled to meet from 9 a.m. to 5 p.m.
on February 4th and 5th; and from 9
a.m. to 12 noon on February 6th.
For Session 3, the committee is
scheduled to meet from 9 a.m. to 5 p.m.
each day.
Electronic Access to This Document
You may view this document in text
or Adobe Portable Document Format
(PDF) on the Internet at the following
site: https://www.ed.gov/news/
fedregister.
To use PDF you must have Adobe
Acrobat Reader, which is available free
at this site. If you have questions about
using PDF, call the U.S. Government
Printing Office toll free at 1–888–293–
6498; or in the Washington, DC area at
(202) 512–1530.
Note: The official version of this document
is the document published in the Federal
Register. Free Internet access to the official
edition of the Federal Register and the Code
of Federal Regulations is available on GPO
Access at: https://www.gpoaccess.gov/nara/
index.html.
Program Authority: 20 U.S.C. 1098a.
Dated: January 3, 2008.
Diane Auer Jones,
Assistant Secretary for Postsecondary
Education.
[FR Doc. E8–121 Filed 1–7–08; 8:45 am]
BILLING CODE 4000–01–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
42 CFR Parts 422 and 423
[CMS–4133–P]
RIN 0938–AP25
Medicare Program; Option for
Prescription Drug Plans To Lower
Their Premiums for Low-Income
Subsidy Beneficiaries
Centers for Medicare &
Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
AGENCY:
SUMMARY: This proposed rule would
provide for an option for Medicare
E:\FR\FM\08JAP1.SGM
08JAP1
1302
Federal Register / Vol. 73, No. 5 / Tuesday, January 8, 2008 / Proposed Rules
Prescription Drug Plan (PDP) Sponsors
to offer a separate prescription drug
premium amount for low-income
subsidy (LIS) individuals subject to
certain conditions. We are proposing to
allow PDP Sponsors to offer a reduced
premium amount for LIS-eligible
individuals to ensure that at least five
PDP Sponsors in every PDP region
would have a PDP with a premium at or
below the premium subsidy amount.
This provision will help to ensure there
are a sufficient number of organizations
offering zero-premium plans in each
region and reduce the number of LIS
beneficiary reassignments to other
organizations.
To be assured consideration,
comments must be received at one of
the addresses provided below, no later
than 5 p.m. on March 10, 2008.
ADDRESSES: In commenting, please refer
to file code CMS–4133–P. Because of
staff and resource limitations, we cannot
accept comments by facsimile (FAX)
transmission.
You may submit comments in one of
four ways (no duplicates, please):
1. Electronically. You may submit
electronic comments on specific issues
in this regulation to https://
www.cms.hhs.gov/eRulemaking. Click
on the link ‘‘Submit electronic
comments on CMS regulations with an
open comment period.’’ (Attachments
should be in Microsoft Word,
WordPerfect, or Excel; however, we
prefer Microsoft Word.)
2. By regular mail. You may mail
written comments (one original and two
copies) to the following address ONLY:
Centers for Medicare & Medicaid
Services, Department of Health and
Human Services, Attention: CMS–4133–
P, P.O. Box 8010, Baltimore, MD 21244–
8010.
Please allow sufficient time for mailed
comments to be received before the
close of the comment period.
3. By express or overnight mail. You
may send written comments (one
original and two copies) to the following
address ONLY: Centers for Medicare &
Medicaid Services, Department of
Health and Human Services, Attention:
CMS–4133–P, Mail Stop C4–26–05,
7500 Security Boulevard, Baltimore, MD
21244–1850.
4. By hand or courier. If you prefer,
you may deliver (by hand or courier)
your written comments (one original
and two copies) before the close of the
comment period to one of the following
addresses. If you intend to deliver your
comments to the Baltimore address,
please call telephone number (410) 786–
9994 in advance to schedule your
arrival with one of our staff members.
rmajette on PROD1PC64 with PROPOSALS
DATES:
VerDate Aug<31>2005
15:24 Jan 07, 2008
Jkt 214001
Room 445–G, Hubert H. Humphrey
Building, 200 Independence Avenue,
SW., Washington, DC 20201; or 7500
Security Boulevard, Baltimore, MD
21244–1850.
(Because access to the interior of the
HHH Building is not readily available to
persons without Federal Government
identification, commenters are
encouraged to leave their comments in
the CMS drop slots located in the main
lobby of the building. A stamp-in clock
is available for persons wishing to retain
a proof of filing by stamping in and
retaining an extra copy of the comments
being filed.)
Comments mailed to the addresses
indicated as appropriate for hand or
courier delivery may be delayed and
received after the comment period.
FOR FURTHER INFORMATION CONTACT:
Deondra Moseley, (410) 786–4577.
Meghan Elrington, (410) 786–8675.
SUPPLEMENTARY INFORMATION:
Submitting Comments: We welcome
comments from the public on all issues
set forth in this rule to assist us in fully
considering issues and developing
policies. You can assist us by
referencing the file code CMS–4133–P
and the specific ‘‘issue identifier’’ that
precedes the section on which you
choose to comment.
Inspection of Public Comments: All
comments received before the close of
the comment period are available for
viewing by the public, including any
personally identifiable or confidential
business information that is included in
a comment. We post all comments
received before the close of the
comment period on the following Web
site as soon as possible after they have
been received: https://www.cms.hhs.gov/
eRulemaking. Click on the link
‘‘Electronic Comments on CMS
Regulations’’ on that Web site to view
public comments.
Comments received timely will also
be available for public inspection as
they are received, generally beginning
approximately 3 weeks after publication
of a document, at the headquarters of
the Centers for Medicare & Medicaid
Services, 7500 Security Boulevard,
Baltimore, Maryland 21244, Monday
through Friday of each week from 8:30
a.m. to 4 p.m. To schedule an
appointment to view public comments,
phone 1–800–743–3951.
I. Background
[If you choose to comment on issues in
this section, please include the caption
‘‘BACKGROUND’’ at the beginning of
your comments.]
The beneficiary premiums for
Prescription Drug Plans (PDP) are based
PO 00000
Frm 00004
Fmt 4702
Sfmt 4702
on an annual bidding process. Each year
the beneficiary premium for a Part D
plan can change as a result of this
bidding process. In addition, each year,
as required by statute, CMS recalculates
the Federal Part D premium subsidy
available to low-income beneficiaries
based on the new premiums for plans in
each region. As a result of these
premium and subsidy changes, the
premium for a Part D plan can be fully
covered by the low-income subsidy
(LIS) in one year and not the following
year.
The amount of the premium subsidy
available to LIS-eligible individuals
cannot be calculated until after bids are
submitted for the calendar year in
question, because the subsidy amount is
based on the bids that are submitted.
Therefore, a PDP sponsor whose
premium for LIS-eligible enrollees is
currently zero does not know at the time
its bid is submitted whether the
premium that would result from its bid
will be higher or lower than the
premium subsidy amount.
LIS-eligible individuals enrolled in a
PDP that does not charge them a
premium are faced with the possibility
that the plan they are enrolled in will
impose a premium during the next
calendar year that would require them
to make monthly payments. Section
1860D–1(b)(1)(C) of the Social Security
Act (the Act) mandates the initial
enrollment of full-benefit dual eligible
individuals not choosing a plan into a
PDP where they would not pay a
premium. It does not, however, require
that individuals be reassigned to a plan
that would not charge them a premium,
if they would be required to pay a
premium in their plan the following
calendar year. Using our authority
under Section 1860D–1(b)(1)(A) of the
Act to, ‘‘establish a process for the
enrollment, disenrollment, termination,
and change of enrollment of Part D
eligible individuals in prescription drug
plans,’’ we have specified that LISeligible individuals facing the above
situation may ‘‘elect’’ a PDP with no
premium (to which they would be
randomly assigned) by taking no action.
We have referred to this process as our
reassignment process. Beneficiaries
eligible for the full low-income
premium subsidy, including
beneficiaries dually eligible for benefits
under Titles XVIII and XIX of the Social
Security Act, are subject to
reassignment. Beneficiaries eligible for a
partial premium subsidy are not subject
to reassignment.
For 2008, the number of beneficiaries
reassigned to a different organization
under this process varied widely by
region, ranging from as few as 17
E:\FR\FM\08JAP1.SGM
08JAP1
rmajette on PROD1PC64 with PROPOSALS
Federal Register / Vol. 73, No. 5 / Tuesday, January 8, 2008 / Proposed Rules
beneficiaries to approximately 402,322
beneficiaries. The average number of
beneficiaries reassigned to an
organization other than the one with
which they were enrolled was 34,044
per region.
Alternatively, LIS beneficiaries can
affirmatively elect to stay in their plan
and begin paying a premium, or choose
another plan with or without a
premium. While this policy prevents an
LIS-eligible individual who did not
choose to elect a plan from being
charged a premium, it disrupts
continuity and stability in coverage.
Currently, under the demonstration
project entitled, ‘‘Medicare
Demonstration to Transition Enrollment
of Low-Income Subsidy Beneficiaries’’
(established in 2007 and extended to
2008), if the premium amount for a LISeligible individual in the above
situation is lower than a specified de
minimis amount, the individual would
not be charged this de minimis amount,
and could remain in his or her current
plan without paying a premium. This
demonstration also transitions the
calculation of the low-income
benchmark premium amount for a
region from a method that weights the
standardized Part D bids for PDPs
equally to the statutory method, which
calculates the benchmarks by weighting
the bids for PDPs and MA–PD plans in
that region based on plan enrollment.
While the evaluation for this
demonstration project is still underway,
we believe the de minimis policy has
demonstrated the advantages of the
continuity of care and stability that
result from permitting LIS-eligible
individuals effectively to be charged a
lower total premium than the total
premium amount charged in the case of
non-LIS-eligible individuals.
Accordingly, we believe that PDP
Sponsors should have this option on an
ongoing basis under regular program
rules, subject to limitations that ensure
the integrity of the bid process, and
retain incentives to submit competitive
bids.
We believe that the statute could
reasonably be interpreted to permit,
consistent with limitations that would
be set forth in regulations, PDP
Sponsors to establish a separate
premium for LIS-eligible individuals in
the amount of the low-income premium
subsidy. Section 1860D–13(a)(1)(F) of
the Act ordinarily requires that a
prescription drug premium be uniform.
This rule applies, however, ‘‘except as
provided in subparagraphs (D) (which
provides for the late enrollment penalty)
and (E) (which governs LIS-eligible
individuals) * * *’’. In addition 1860D–
13(a)(1)(E) of the Act provides that in
VerDate Aug<31>2005
15:24 Jan 07, 2008
Jkt 214001
the case of an LIS-eligible individual,
the premium ‘‘is subject to decrease
* * *’’. While we initially interpreted
this language to refer only to the
decrease in the amount paid by the LISeligible individual in the amount of the
low-income premium subsidy, we
believe that the statutory language
would also permit an interpretation that
would allow PDP Sponsors to charge a
decreased premium amount in the case
of such individuals. When subject to the
limitations as proposed here, this
reasonable interpretation of the statute
supports our goal of ensuring continuity
of care and stability, while ensuring the
integrity of the bid process and retaining
incentives for organizations to submit
competitive bids. We believe that our
earlier interpretation of the statute did
not take into account the flexibility
afforded by section 1860D–13(a)(1)(E) of
the statute, which is broadly worded to
provide that for a LIS eligible
individual, ‘‘[t]he monthly beneficiary
premium is subject to decrease[.]’’
II. Provisions of the Proposed
Regulations
[If you choose to comment on issues in
this section, please include the caption
‘‘PROVISIONS OF THE PROPOSED
REGULATIONS’’ at the beginning of
your comments.]
We are proposing to make revisions to
the regulations in order to implement an
option for PDP Sponsors to reduce PDP
beneficiary premiums for LIS-eligible
individuals. This option would not be
made available to plans that offer
enhanced alternative coverage.
Specifically, we are proposing to revise
§ 422.262 and § 423.286(e), to provide
for an exception to the general rule for
uniformity of premiums. We are also
proposing to revise § 423.286(e), to state
that the monthly beneficiary premium
paid by the beneficiary may be
eliminated as provided in § 423.780.
We are proposing to amend
§ 423.34(d), to clarify that PDPs that
have a separate premium for LIS-eligible
individuals under our proposed option
would not be eligible to receive ‘‘autoenrollees’’ under section 1860D–
1(b)(1)(C) of the Act. However, PDP
Sponsors that have separate premiums
for LIS enrollees in their PDPs would
keep their existing LIS enrollees. An
auto-enrollment would continue to be
available only to PDPs with a standard
prescription drug premium that is equal
to, or below, the LIS amount.
In addition, we are proposing to
revise § 423.780, to permit a PDP
sponsor, subject to the conditions
discussed below, to establish a separate
premium for LIS-eligible individuals in
the amount of the low-income premium
PO 00000
Frm 00005
Fmt 4702
Sfmt 4702
1303
subsidy amount when the premium that
would otherwise apply would exceed
this amount.
Several options were considered as
we developed this proposed rule. We
considered allowing all PDP Sponsors to
make a business judgment, after the LIS
amount was established, whether to
reduce their premium to the subsidy
amount for LIS-eligible individuals
without regard to the amount by which
their premium would otherwise exceed
the amount of the subsidy. We did not
choose this approach for two reasons.
First, if the difference between the two
amounts were too great, this would
produce a significant disparity between
the revenue needs assumed in the bid,
and the revenue that would be received
under the reduced premium, and
undermine the integrity of the bid
process. More importantly, if a PDP
sponsor knew that it could be assured
of reducing its premium for LIS-eligible
individuals to the LIS amount no matter
how much the premium produced by its
bid exceeded this amount, this would
greatly reduce existing incentives to bid
as low as possible.
Second, we considered changing our
approach to re-assignment from
allowing LIS-eligible individuals to be
re-assigned if they take no action to an
approach that would allow LIS-eligible
individuals to be informed of zeropremium PDP options, but would
remain in their current plan if they take
no action. We consulted with
beneficiary advocate groups about this
approach, and many expressed concerns
about LIS-eligible individuals being
subjected to premium costs without
them electing to pay them. We further
considered only reassigning LIS
individuals if the premium they would
have to pay were above a certain level,
on the assumption that a relatively low
premium amount may not present a
financial hardship. However, this would
raise complicated issues regarding
collection of these premium amounts.
We are proposing to retain the current
reassignment policy and permit certain
PDP Sponsors to reduce premiums for
LIS-eligible individuals to the subsidy
amount, while limiting the amount the
premium produced by bids could be
reduced to reach the LIS amount. We
considered proposing a fixed dollar
amount, as is employed under the
current de minimis demonstration, and
would be employed under the change in
reassignment policy discussed above.
However, we again were concerned
about an approach that permanently
would employ a fixed dollar figure, and
decided that a methodology under
which the number is not known in
E:\FR\FM\08JAP1.SGM
08JAP1
rmajette on PROD1PC64 with PROPOSALS
1304
Federal Register / Vol. 73, No. 5 / Tuesday, January 8, 2008 / Proposed Rules
advance would better preserve
incentives to submit a low bid.
We are proposing to apply this rule to
PDPs only, as current auto-assignment
rules do not apply to beneficiaries
enrolled in MA-PDs. For this same
reason, we do not plan to apply this rule
to partial subsidy eligible enrollees.
Furthermore, partial subsidy eligible
enrollees already pay a premium, as
their subsidy is only a percentage of the
subsidy amount. A change from the
subsidy amount to a higher premium
does not have the same impact on them
that it does on a full-subsidy eligible
beneficiary, who would go from a zeropremium to paying one.
We accordingly propose to set the
amount at a region-specific level that
would ensure LIS-eligible individuals in
each region a robust choice among zeropremium PDPs. Specifically, we are
proposing that the limit on the amount
by which premiums could be reduced
for LIS-eligible individuals be an
amount that ensures that at least five
PDP Sponsors (i.e., organizations
offering PDPs) in every PDP region
would have a PDP with a premium at or
below the premium subsidy amount. We
chose the minimum number of five PDP
Sponsors per region because this
represents the mid-range number of PDP
Sponsors in key regions that qualified
for assignment of low-income subsidyeligible beneficiaries in 2008.
Specifically, in 2008 the number of PDP
Sponsors with zero-premium plans for
LIS individuals ranges from a low of
two to a high of eight organizations in
key regions with significant MA
enrollment. The option of five
organizations as a minimum threshold
was selected to maintain the average
2008 level of competitiveness. This
proposed rule would not affect regions
in which there would be at least five
PDP Sponsors offering zero-premium
plans without this rule in place. In order
to achieve the goal of stability for
beneficiaries and plans, and offer
multiple provider options, this test will
be applied at the organizational level
(PDP sponsor), rather than the plan
(PDP) level. We believe that capping the
number of premium differential
organizations at a number that would
produce zero-premium plans from at
least five PDP Sponsors would maintain
or possibly improve upon the current
competitiveness of bids. We invite
public comments on our choice of the
minimum number five as the minimum
number of Sponsors offering zeropremium plans, as well as on the other
options discussed above that we
considered, and any additional options
that we are not proposing in this
proposed rule.
VerDate Aug<31>2005
15:24 Jan 07, 2008
Jkt 214001
PDP Sponsors will be required to elect
this option in their bids. CMS will add
a checkbox to the current Bid Pricing
Tool submitted by PDP Sponsors in June
of each year for each PDP to be offered.
Sponsors will use this checkbox to
indicate that the PDP will have two
premiums—one for enrollees not
eligible for the full LIS subsidy and
another for LIS-eligible enrollees if they
qualify under this rule. This rule will
not increase the amount of the lowincome premium subsidy paid to plans
to account for the difference between
the low-income premium subsidy and
the premium produced by the plan’s
bid.
We note that PDP Sponsors that elect
this option would be obligated, under
our proposed regulations, to charge all
LIS-eligible enrollees in affected plans a
premium amount that would be the
premium subsidy amount if the
prescription drug premium produced by
their bid did not exceed the amount
established to ensure at least five PDP
Sponsors offer zero-premium plans in
each region. This premium would be
part of the benefit package they would
be obligated under their contract to
cover.
III. Collection of Information
Requirements
The information collection
requirements contained in
§ 423.780(f)(i) of this proposed rule are
subject to the Paperwork Reduction Act
(PRA). However, the burden associated
with the requirement for the PDP
sponsor to elect the option of providing
for a separate prescription drug
premium amount for LIS individuals is
included in the burden estimate
associated with the Bid Pricing Tool for
Prescription Drug Plans which is
currently approved under OMB
approval number 0938–0944.
IV. Response to Comments
Because of the large number of public
comments we normally receive on
Federal Register documents, we are not
able to acknowledge or respond to them
individually. We will consider all
comments we receive by the date and
time specified in the DATES section of
this preamble, and, when we proceed
with a subsequent document, we will
respond to the comments in the
preamble to that document.
V. Regulatory Impact Statement
A. Overall Impact
We have examined the impact of this
rule as required by Executive Order
12866 (September 1993, Regulatory
Planning and Review), the Regulatory
PO 00000
Frm 00006
Fmt 4702
Sfmt 4702
Flexibility Act (RFA) (September 19,
1980, Pub. L. 96–354), section 1102(b) of
the Social Security Act, the Unfunded
Mandates Reform Act of 1995 (Pub. L.
104–4), Executive Order 13132 on
Federalism, and the Congressional
Review Act (5 U.S.C. 804(2)).
Executive Order 12866 directs
agencies to assess all costs and benefits
of available regulatory alternatives and,
if regulation is necessary, to select
regulatory approaches that maximize
net benefits (including potential
economic, environmental, public health
and safety effects, distributive impacts,
and equity). A regulatory impact
analysis (RIA) must be prepared for
major rules with economically
significant effects ($100 million or more
in any 1 year). This rule permits
Prescription Drug Plan (PDP) Sponsors,
subject to conditions, to lower their
premiums for low-income subsidy
beneficiaries to ensure there are a
sufficient number of organizations
offering zero-premium plans in each
region and reduce the number of
reassignments compared to the current
regulatory framework. We believe this
proposed rule would lead to Federal
savings of approximately $20 million
per year. This assumes full enrollment
weighting for the calculations of the
low-income benchmark premium
amounts. The estimate was developed
by applying this rule against the 2008
bids and this impact was projected
throughout the forecast period. The
estimate does not anticipate any change
in bidding strategies or outcomes. All
organizations with existing LIS
beneficiaries that could be assigned out
of the organization are assumed to elect
the option to retain their beneficiaries
including receiving reduced premiums
for such LIS members. LIS beneficiaries
that are assigned out of organizations
are assumed to be randomly assigned to
organizations that have premiums below
the low income premium subsidy
benchmark. We invite public comment
on the assumptions included in this
assessment.
We also evaluated the potential for
non-Federal costs and savings
associated with this rule. A small
number of Part D sponsors would forego
revenue associated with the reduction
in their beneficiary premium for low
income beneficiaries. In addition, we
anticipate a reduction in administrative
costs for these sponsors, as well as for
sponsors to which the beneficiaries
would have been reassigned in the
absence of this rule. However, we
believe that these costs and savings
would be relatively small. We invite
public comment on this assessment of
non-Federal costs and savings. This rule
E:\FR\FM\08JAP1.SGM
08JAP1
rmajette on PROD1PC64 with PROPOSALS
Federal Register / Vol. 73, No. 5 / Tuesday, January 8, 2008 / Proposed Rules
does not reach the economic threshold
and thus is not considered a major rule.
The RFA requires agencies to analyze
options for regulatory relief of small
businesses. For purposes of the RFA,
small entities include small businesses,
nonprofit organizations, and small
governmental jurisdictions. Most
hospitals and most other providers and
suppliers are small entities, either by
nonprofit status or by having revenues
of $6.5 million to $31.5 million in any
1 year. Individuals and States are not
included in the definition of a small
entity. We are not preparing an analysis
for the RFA because we have
determined, and the Secretary certifies,
that this regulation will not have a
significant economic impact on a
substantial number of small entities.
In addition, section 1102(b) of the Act
requires us to prepare a regulatory
impact analysis if a rule may have a
significant impact on the operations of
a substantial number of small rural
hospitals. This analysis must conform to
the provisions of section 603 of the
RFA. For purposes of section 1102(b) of
the Act, we define a small rural hospital
as a hospital that is located outside of
a Metropolitan Statistical Area for
Medicare payment regulations and has
fewer than 100 beds. We are not
preparing an analysis for section 1102(b)
of the Act because we have determined,
and the Secretary certifies, that this
regulation will not have a significant
impact on the operations of a substantial
number of small rural hospitals.
Section 202 of the Unfunded
Mandates Reform Act of 1995 also
requires that agencies assess anticipated
costs and benefits before issuing any
rule whose mandates require spending
in any 1 year of $100 million in 1995
dollars, updated annually for inflation.
That threshold level is currently
approximately $127 million. This rule
will have no consequential effect on
State, local, or tribal governments in the
aggregate, or by the private sector.
Executive Order 13132 establishes
certain requirements that an agency
must meet when it promulgates a
proposed rule (and subsequent final
rule) that imposes substantial direct
requirement costs on State and local
governments, preempts State law, or
otherwise has Federalism implications.
Since this regulation does not impose
any costs on State or local governments,
the requirements of E.O. 13132 are not
applicable.
B. Anticipated Effects
The number of PDP Sponsors offering
PDPs that had low enough premiums to
qualify for low-income assignments for
2008 ranged from two to eight
VerDate Aug<31>2005
15:24 Jan 07, 2008
Jkt 214001
organizations per region in key regions
that had a relatively high proportion of
beneficiaries enrolled in MA plans. Five
is the average number of PDP Sponsors
offering plans that qualified for lowincome assignments in these regions; we
selected the five PDP Sponsor option to
maintain the 2008 level of
competitiveness in the bidding process.
The 5 plan requirement is an attempt to
balance the two goals of introducing
beneficiary stability, particularly in
regions with very low LIS premium
subsidy benchmarks, together with
maintaining the incentives in the
competitive bidding process. There may
be negative consequences if the 5
organizational requirement is too high
and the plans bid less competitively or
if the 5 organizational requirement is
too low and there are an even greater
number of low-income beneficiary
reassignments. In addition, based on
analysis of the 2008 bids, and assuming
no de minimis demonstration is in
place, CMS anticipates that seven
regions would be affected by having a
minimum of five plans. CMS estimates
that a three Sponsor minimum would
have affected five regions, while a seven
Sponsor minimum would have affected
ten regions. Therefore, we anticipate
that this regulation will increase the
number of PDP Sponsors offering zeropremium PDPs that would be available
to full low-income subsidy-eligible
beneficiaries. This proposed regulation
would also decrease the number of
reassignments of LIS-eligible
beneficiaries to other PDPs, compared to
the level of reassignment under the
current regulation absent a de minimis
policy. This decrease in beneficiary
movement across plans would boost
program stability for both beneficiaries
and plans. Based on an analysis of 2008
bids, the five-organization minimum
requirement results in 0.2 million fewer
beneficiary assignments as compared to
the current regulatory framework. The
five-organization minimum requirement
results in 0.5 million more beneficiary
reassignments than would occur under
the de minimis policy.
Lastly, CMS expects the improved
program continuity and stability that
would be produced by this rule would
help prevent an increase in costs and
risks imposed on PDP Sponsors. The
higher the threshold for the number of
PDP Sponsors per region offering zeropremium PDPs, the greater the negative
impact on competitive bidding. We are
seeking to strike a balance between
minimizing LIS reassignments and
preserving the integrity of the
competitive bidding process. The results
of competitive bidding in 2008
PO 00000
Frm 00007
Fmt 4702
Sfmt 4702
1305
generated an average of five PDP
Sponsors per region eligible for
reassignments in certain key regions
with relatively high MA enrollment.
Selecting five as the minimum
organization threshold under this
proposed rule is intended to achieve
this balance.
This approach maintains a strong
incentive to bid low to keep and
possibly add LIS beneficiaries. Absent
the rule, there may be a ‘‘winner take
all’’ outcome in certain regions with one
organization acquiring all of the LIS
beneficiaries in the region. It is difficult
to predict what would happen in the
absence of this rule, but we would
expect some organizations would be
induced to bid even lower while other
organizations would give up on this
population and bid higher. From a cost
perspective these factors may offset
relative to the proposed rule, but the
volatility issue would remain.
C. Alternatives Considered
As stated in the Background section of
this proposed rule, we considered
allowing PDP Sponsors to reduce their
premium to the subsidy amount after it
was established for LIS-eligible
individuals without regard to the
amount of their premium. We also
considered allowing plans with
premiums under a fixed dollar amount
to reduce their low-income premiums to
the premium subsidy amount. We
determined, however, that these options
would undermine the integrity and
competitiveness of the bidding process.
We also considered changing our
approach to reassignment to an
approach that would allow LIS-eligible
individuals to be informed of zeropremium PDP options, but would
remain in their current plan, regardless
of the premium, if they take no action.
Beneficiary advocacy groups were
concerned about beneficiaries being
charged a premium without electing to
pay it. We further considered only
reassigning LIS individuals if the
premium they would have to pay were
above a certain relatively low premium
amount; however, this would raise
complicated issues regarding collection
of these premium amounts.
We chose to propose to retain the
current reassignment policy and, in
regions that would not otherwise have
at least five zero-premium plans for LIS
enrollees, permit a sufficient number of
PDPs to reduce their premiums for LIS
individuals so that the region includes
five zero-premium plans. We believe
this option would both maintain or
possibly improve upon the current
competitiveness of bids and reduce
reassignments for beneficiaries.
E:\FR\FM\08JAP1.SGM
08JAP1
1306
Federal Register / Vol. 73, No. 5 / Tuesday, January 8, 2008 / Proposed Rules
In accordance with the provisions of
Executive Order 12866, this regulation
was reviewed by the Office of
Management and Budget.
PART 423—VOLUNTARY MEDICARE
PRESCRIPTION DRUG BENEFIT
List of Subjects
Authority: Secs 1102, 1860D–1 through
1860D–42, and 1871 of the Social Security
Act (42 U.S.C. 1302, 1395w–101 through
1395w–152, and 1395hh).
42 CFR Part 422
Administrative practice and
procedure, Grant programs—health,
Health care, Health insurance, Health
maintenance organizations (HMO), Loan
programs—Health, Medicare, Reporting
and recordkeeping requirements.
42 CFR Part 423
Administrative practice and
procedure, Emergency medical services,
Health facilities, Health maintenance
organizations (HMO), Medicare,
Penalties, Privacy, Reporting and
recordkeeping.
For the reasons set forth in the
preamble, the Centers for Medicare &
Medicaid Services proposes to amend
42 CFR chapter IV as set forth below:
PART 422—MEDICARE ADVANTAGE
PROGRAM
1. The authority citation for part 422
continues to read as follows:
Authority: Secs. 1102 and 1871 of the
Social Security Act (42 U.S.C. 1302 and
1395hh).
Subpart F—Submission of Bids,
Premiums, and Related Information
and Plan Approval
2. Amend § 422.262 to revise
paragraph (c)(1) to read as follows:
rmajette on PROD1PC64 with PROPOSALS
§ 422.262
Beneficiary premiums.
(c) * * *
(1) General rule. Except as permitted
for supplemental premiums pursuant to
§ 422.106(d), for MA contracts with
employers and labor organizations, the
MA monthly bid amount submitted
under § 422.254, the MA monthly basic
beneficiary premium, the MA monthly
supplemental beneficiary premium, the
MA monthly prescription drug premium
(except as provided in § 423.780), and
the monthly MSA premium of an MA
organization may not vary among
individuals enrolled in an MA plan (or
segment of the plan as provided for
local MA plans under paragraph (c)(2)
of this section). In addition, the MA
organization cannot vary the level of
cost-sharing charged for basic benefits
or supplemental benefits (if any) among
individuals enrolled in an MA plan (or
segment of the plan).
*
*
*
*
*
VerDate Aug<31>2005
15:24 Jan 07, 2008
Jkt 214001
3. The authority citation for part 423
continues to read as follows:
Subpart B—Eligibility and Enrollment.
4. Amend § 423.34 by—
A. Revising paragraph (d)(1).
B. Adding a new paragraph (d)(3).
The revisions and additions read as
follows:
§ 423.34 Enrollment of full-benefit dual
eligible individuals.
*
*
*
*
*
(d) * * *
(1) General rule. Except as provided
in paragraph (d)(3) of this section, CMS
must automatically enroll full-benefit
dual eligible individuals who fail to
enroll in a Part D plan into a PDP
offering basic prescription drug
coverage in the area where the
individual resides that has a monthly
beneficiary premium that does not
exceed the low-income premium
subsidy amount (as defined in
§ 423.780(b)). In the event that there is
more than one PDP in an area with a
monthly beneficiary premium at or
below the low-income premium subsidy
amount, individuals must be enrolled in
such PDPs on a random basis.
(2) * * *
(3) PDPs whose premiums were
reduced for LIS beneficiaries under
§ 423.780(f) would not be entitled to
automatic enrollment under paragraph
(d)(1) of this section.
*
*
*
*
*
Subpart F—Submission of Bids and
Monthly Beneficiary Premiums; Plan
Approval
5. Amend § 423.286 by revising
paragraph (e) to read as follows:
§ 423.286
Rules regarding premiums.
(f) Option for a reduced premium
amount for full subsidy eligible
individuals. PDP sponsors have the
option of providing for a separate
prescription drug premium amount for
full subsidy eligible individuals for
prescription drugs plans under
§ 423.104(d) or (e) subject to the
following conditions—
(1) The PDP sponsor must elect this
option at the time its bid is submitted,
and agree to set its prescription drug
premium for all full subsidy eligible
individuals at the premium subsidy
amount under paragraph (b) of this
section for the entire coverage year if
(i) The PDP sponsor puts forward no
other PDP in the PDP region that is
offering a premium below the premium
subsidy amount or closer to the
premium subsidy amount; and
(ii) Its premium amount would
otherwise equal or be below the amount
established under paragraph (f)(ii) of
this section.
(2) Following the establishment of the
premium subsidy amount, CMS will
review the bids of PDP sponsors that
have elected the option under paragraph
(f)(i) of this section, and determine an
amount that, when added to the
premium subsidy amount, would
produce a premium amount that is no
greater than the amount that would
equal or exceed the prescription drug
premium amount produced by bids for
at least five PDP sponsors in every PDP
region.
(Catalog of Federal Domestic Assistance
Program No. 93.773, Medicare—Hospital
Insurance; and Program No. 93.774,
Medicare—Supplementary Medical
Insurance Program)
Dated: December 13, 2007.
Kerry Weems,
Acting Administrator, Centers for Medicare
& Medicaid Services.
Approved: December 28, 2007.
Michael O. Leavitt,
Secretary.
[FR Doc. 08–15 Filed 1–3–08; 10:12 am]
BILLING CODE 4120–01–P
*
*
*
*
(e) Decrease in monthly beneficiary
premium for low-income assistance. The
FEDERAL COMMUNICATIONS
monthly beneficiary premium paid by
COMMISSION
the beneficiary may be eliminated as
provided in § 423.780.
47 CFR Parts 61 and 69
*
*
*
*
*
*
[WC Docket No. 07–135; DA 07–5082]
Subpart P—Premiums and CostSharing Subsidies for Low-Income
Individuals
6. Amend § 423.780 by adding a new
paragraph (f) to read as follows:
§ 423.780
Premium subsidy.
*
*
PO 00000
*
Frm 00008
*
Fmt 4702
*
Sfmt 4702
Establishing Just and Reasonable
Rates for Local Exchange Carriers
Federal Communications
Commission.
ACTION: Proposed rule; extension of
comment period.
AGENCY:
E:\FR\FM\08JAP1.SGM
08JAP1
]]>Agencies
[Federal Register Volume 73, Number 5 (Tuesday, January 8, 2008)]
[Proposed Rules]
[Pages 1301-1306]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 08-15]
=======================================================================
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 422 and 423
[CMS-4133-P]
RIN 0938-AP25
Medicare Program; Option for Prescription Drug Plans To Lower
Their Premiums for Low-Income Subsidy Beneficiaries
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
-----------------------------------------------------------------------
SUMMARY: This proposed rule would provide for an option for Medicare
[[Page 1302]]
Prescription Drug Plan (PDP) Sponsors to offer a separate prescription
drug premium amount for low-income subsidy (LIS) individuals subject to
certain conditions. We are proposing to allow PDP Sponsors to offer a
reduced premium amount for LIS-eligible individuals to ensure that at
least five PDP Sponsors in every PDP region would have a PDP with a
premium at or below the premium subsidy amount. This provision will
help to ensure there are a sufficient number of organizations offering
zero-premium plans in each region and reduce the number of LIS
beneficiary reassignments to other organizations.
DATES: To be assured consideration, comments must be received at one of
the addresses provided below, no later than 5 p.m. on March 10, 2008.
ADDRESSES: In commenting, please refer to file code CMS-4133-P. Because
of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission.
You may submit comments in one of four ways (no duplicates,
please):
1. Electronically. You may submit electronic comments on specific
issues in this regulation to https://www.cms.hhs.gov/eRulemaking. Click
on the link ``Submit electronic comments on CMS regulations with an
open comment period.'' (Attachments should be in Microsoft Word,
WordPerfect, or Excel; however, we prefer Microsoft Word.)
2. By regular mail. You may mail written comments (one original and
two copies) to the following address ONLY: Centers for Medicare &
Medicaid Services, Department of Health and Human Services, Attention:
CMS-4133-P, P.O. Box 8010, Baltimore, MD 21244-8010.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments (one
original and two copies) to the following address ONLY: Centers for
Medicare & Medicaid Services, Department of Health and Human Services,
Attention: CMS-4133-P, Mail Stop C4-26-05, 7500 Security Boulevard,
Baltimore, MD 21244-1850.
4. By hand or courier. If you prefer, you may deliver (by hand or
courier) your written comments (one original and two copies) before the
close of the comment period to one of the following addresses. If you
intend to deliver your comments to the Baltimore address, please call
telephone number (410) 786-9994 in advance to schedule your arrival
with one of our staff members.
Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue,
SW., Washington, DC 20201; or 7500 Security Boulevard, Baltimore, MD
21244-1850.
(Because access to the interior of the HHH Building is not readily
available to persons without Federal Government identification,
commenters are encouraged to leave their comments in the CMS drop slots
located in the main lobby of the building. A stamp-in clock is
available for persons wishing to retain a proof of filing by stamping
in and retaining an extra copy of the comments being filed.)
Comments mailed to the addresses indicated as appropriate for hand
or courier delivery may be delayed and received after the comment
period.
FOR FURTHER INFORMATION CONTACT:
Deondra Moseley, (410) 786-4577.
Meghan Elrington, (410) 786-8675.
SUPPLEMENTARY INFORMATION:
Submitting Comments: We welcome comments from the public on all
issues set forth in this rule to assist us in fully considering issues
and developing policies. You can assist us by referencing the file code
CMS-4133-P and the specific ``issue identifier'' that precedes the
section on which you choose to comment.
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. We post all comments
received before the close of the comment period on the following Web
site as soon as possible after they have been received: https://
www.cms.hhs.gov/eRulemaking. Click on the link
``Electronic Comments on CMS Regulations'' on that Web site to view
public comments.
Comments received timely will also be available for public
inspection as they are received, generally beginning approximately 3
weeks after publication of a document, at the headquarters of the
Centers for Medicare & Medicaid Services, 7500 Security Boulevard,
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30
a.m. to 4 p.m. To schedule an appointment to view public comments,
phone 1-800-743-3951.
I. Background
[If you choose to comment on issues in this section, please include the
caption ``BACKGROUND'' at the beginning of your comments.]
The beneficiary premiums for Prescription Drug Plans (PDP) are
based on an annual bidding process. Each year the beneficiary premium
for a Part D plan can change as a result of this bidding process. In
addition, each year, as required by statute, CMS recalculates the
Federal Part D premium subsidy available to low-income beneficiaries
based on the new premiums for plans in each region. As a result of
these premium and subsidy changes, the premium for a Part D plan can be
fully covered by the low-income subsidy (LIS) in one year and not the
following year.
The amount of the premium subsidy available to LIS-eligible
individuals cannot be calculated until after bids are submitted for the
calendar year in question, because the subsidy amount is based on the
bids that are submitted. Therefore, a PDP sponsor whose premium for
LIS-eligible enrollees is currently zero does not know at the time its
bid is submitted whether the premium that would result from its bid
will be higher or lower than the premium subsidy amount.
LIS-eligible individuals enrolled in a PDP that does not charge
them a premium are faced with the possibility that the plan they are
enrolled in will impose a premium during the next calendar year that
would require them to make monthly payments. Section 1860D-1(b)(1)(C)
of the Social Security Act (the Act) mandates the initial enrollment of
full-benefit dual eligible individuals not choosing a plan into a PDP
where they would not pay a premium. It does not, however, require that
individuals be reassigned to a plan that would not charge them a
premium, if they would be required to pay a premium in their plan the
following calendar year. Using our authority under Section 1860D-
1(b)(1)(A) of the Act to, ``establish a process for the enrollment,
disenrollment, termination, and change of enrollment of Part D eligible
individuals in prescription drug plans,'' we have specified that LIS-
eligible individuals facing the above situation may ``elect'' a PDP
with no premium (to which they would be randomly assigned) by taking no
action. We have referred to this process as our reassignment process.
Beneficiaries eligible for the full low-income premium subsidy,
including beneficiaries dually eligible for benefits under Titles XVIII
and XIX of the Social Security Act, are subject to reassignment.
Beneficiaries eligible for a partial premium subsidy are not subject to
reassignment.
For 2008, the number of beneficiaries reassigned to a different
organization under this process varied widely by region, ranging from
as few as 17
[[Page 1303]]
beneficiaries to approximately 402,322 beneficiaries. The average
number of beneficiaries reassigned to an organization other than the
one with which they were enrolled was 34,044 per region.
Alternatively, LIS beneficiaries can affirmatively elect to stay in
their plan and begin paying a premium, or choose another plan with or
without a premium. While this policy prevents an LIS-eligible
individual who did not choose to elect a plan from being charged a
premium, it disrupts continuity and stability in coverage.
Currently, under the demonstration project entitled, ``Medicare
Demonstration to Transition Enrollment of Low-Income Subsidy
Beneficiaries'' (established in 2007 and extended to 2008), if the
premium amount for a LIS-eligible individual in the above situation is
lower than a specified de minimis amount, the individual would not be
charged this de minimis amount, and could remain in his or her current
plan without paying a premium. This demonstration also transitions the
calculation of the low-income benchmark premium amount for a region
from a method that weights the standardized Part D bids for PDPs
equally to the statutory method, which calculates the benchmarks by
weighting the bids for PDPs and MA-PD plans in that region based on
plan enrollment. While the evaluation for this demonstration project is
still underway, we believe the de minimis policy has demonstrated the
advantages of the continuity of care and stability that result from
permitting LIS-eligible individuals effectively to be charged a lower
total premium than the total premium amount charged in the case of non-
LIS-eligible individuals. Accordingly, we believe that PDP Sponsors
should have this option on an ongoing basis under regular program
rules, subject to limitations that ensure the integrity of the bid
process, and retain incentives to submit competitive bids.
We believe that the statute could reasonably be interpreted to
permit, consistent with limitations that would be set forth in
regulations, PDP Sponsors to establish a separate premium for LIS-
eligible individuals in the amount of the low-income premium subsidy.
Section 1860D-13(a)(1)(F) of the Act ordinarily requires that a
prescription drug premium be uniform. This rule applies, however,
``except as provided in subparagraphs (D) (which provides for the late
enrollment penalty) and (E) (which governs LIS-eligible individuals) *
* *''. In addition 1860D-13(a)(1)(E) of the Act provides that in the
case of an LIS-eligible individual, the premium ``is subject to
decrease * * *''. While we initially interpreted this language to refer
only to the decrease in the amount paid by the LIS-eligible individual
in the amount of the low-income premium subsidy, we believe that the
statutory language would also permit an interpretation that would allow
PDP Sponsors to charge a decreased premium amount in the case of such
individuals. When subject to the limitations as proposed here, this
reasonable interpretation of the statute supports our goal of ensuring
continuity of care and stability, while ensuring the integrity of the
bid process and retaining incentives for organizations to submit
competitive bids. We believe that our earlier interpretation of the
statute did not take into account the flexibility afforded by section
1860D-13(a)(1)(E) of the statute, which is broadly worded to provide
that for a LIS eligible individual, ``[t]he monthly beneficiary premium
is subject to decrease[.]''
II. Provisions of the Proposed Regulations
[If you choose to comment on issues in this section, please include the
caption ``PROVISIONS OF THE PROPOSED REGULATIONS'' at the beginning of
your comments.]
We are proposing to make revisions to the regulations in order to
implement an option for PDP Sponsors to reduce PDP beneficiary premiums
for LIS-eligible individuals. This option would not be made available
to plans that offer enhanced alternative coverage. Specifically, we are
proposing to revise Sec. 422.262 and Sec. 423.286(e), to provide for
an exception to the general rule for uniformity of premiums. We are
also proposing to revise Sec. 423.286(e), to state that the monthly
beneficiary premium paid by the beneficiary may be eliminated as
provided in Sec. 423.780.
We are proposing to amend Sec. 423.34(d), to clarify that PDPs
that have a separate premium for LIS-eligible individuals under our
proposed option would not be eligible to receive ``auto-enrollees''
under section 1860D-1(b)(1)(C) of the Act. However, PDP Sponsors that
have separate premiums for LIS enrollees in their PDPs would keep their
existing LIS enrollees. An auto-enrollment would continue to be
available only to PDPs with a standard prescription drug premium that
is equal to, or below, the LIS amount.
In addition, we are proposing to revise Sec. 423.780, to permit a
PDP sponsor, subject to the conditions discussed below, to establish a
separate premium for LIS-eligible individuals in the amount of the low-
income premium subsidy amount when the premium that would otherwise
apply would exceed this amount.
Several options were considered as we developed this proposed rule.
We considered allowing all PDP Sponsors to make a business judgment,
after the LIS amount was established, whether to reduce their premium
to the subsidy amount for LIS-eligible individuals without regard to
the amount by which their premium would otherwise exceed the amount of
the subsidy. We did not choose this approach for two reasons. First, if
the difference between the two amounts were too great, this would
produce a significant disparity between the revenue needs assumed in
the bid, and the revenue that would be received under the reduced
premium, and undermine the integrity of the bid process. More
importantly, if a PDP sponsor knew that it could be assured of reducing
its premium for LIS-eligible individuals to the LIS amount no matter
how much the premium produced by its bid exceeded this amount, this
would greatly reduce existing incentives to bid as low as possible.
Second, we considered changing our approach to re-assignment from
allowing LIS-eligible individuals to be re-assigned if they take no
action to an approach that would allow LIS-eligible individuals to be
informed of zero-premium PDP options, but would remain in their current
plan if they take no action. We consulted with beneficiary advocate
groups about this approach, and many expressed concerns about LIS-
eligible individuals being subjected to premium costs without them
electing to pay them. We further considered only reassigning LIS
individuals if the premium they would have to pay were above a certain
level, on the assumption that a relatively low premium amount may not
present a financial hardship. However, this would raise complicated
issues regarding collection of these premium amounts.
We are proposing to retain the current reassignment policy and
permit certain PDP Sponsors to reduce premiums for LIS-eligible
individuals to the subsidy amount, while limiting the amount the
premium produced by bids could be reduced to reach the LIS amount. We
considered proposing a fixed dollar amount, as is employed under the
current de minimis demonstration, and would be employed under the
change in reassignment policy discussed above. However, we again were
concerned about an approach that permanently would employ a fixed
dollar figure, and decided that a methodology under which the number is
not known in
[[Page 1304]]
advance would better preserve incentives to submit a low bid.
We are proposing to apply this rule to PDPs only, as current auto-
assignment rules do not apply to beneficiaries enrolled in MA-PDs. For
this same reason, we do not plan to apply this rule to partial subsidy
eligible enrollees. Furthermore, partial subsidy eligible enrollees
already pay a premium, as their subsidy is only a percentage of the
subsidy amount. A change from the subsidy amount to a higher premium
does not have the same impact on them that it does on a full-subsidy
eligible beneficiary, who would go from a zero-premium to paying one.
We accordingly propose to set the amount at a region-specific level
that would ensure LIS-eligible individuals in each region a robust
choice among zero-premium PDPs. Specifically, we are proposing that the
limit on the amount by which premiums could be reduced for LIS-eligible
individuals be an amount that ensures that at least five PDP Sponsors
(i.e., organizations offering PDPs) in every PDP region would have a
PDP with a premium at or below the premium subsidy amount. We chose the
minimum number of five PDP Sponsors per region because this represents
the mid-range number of PDP Sponsors in key regions that qualified for
assignment of low-income subsidy-eligible beneficiaries in 2008.
Specifically, in 2008 the number of PDP Sponsors with zero-premium
plans for LIS individuals ranges from a low of two to a high of eight
organizations in key regions with significant MA enrollment. The option
of five organizations as a minimum threshold was selected to maintain
the average 2008 level of competitiveness. This proposed rule would not
affect regions in which there would be at least five PDP Sponsors
offering zero-premium plans without this rule in place. In order to
achieve the goal of stability for beneficiaries and plans, and offer
multiple provider options, this test will be applied at the
organizational level (PDP sponsor), rather than the plan (PDP) level.
We believe that capping the number of premium differential
organizations at a number that would produce zero-premium plans from at
least five PDP Sponsors would maintain or possibly improve upon the
current competitiveness of bids. We invite public comments on our
choice of the minimum number five as the minimum number of Sponsors
offering zero-premium plans, as well as on the other options discussed
above that we considered, and any additional options that we are not
proposing in this proposed rule.
PDP Sponsors will be required to elect this option in their bids.
CMS will add a checkbox to the current Bid Pricing Tool submitted by
PDP Sponsors in June of each year for each PDP to be offered. Sponsors
will use this checkbox to indicate that the PDP will have two
premiums--one for enrollees not eligible for the full LIS subsidy and
another for LIS-eligible enrollees if they qualify under this rule.
This rule will not increase the amount of the low-income premium
subsidy paid to plans to account for the difference between the low-
income premium subsidy and the premium produced by the plan's bid.
We note that PDP Sponsors that elect this option would be
obligated, under our proposed regulations, to charge all LIS-eligible
enrollees in affected plans a premium amount that would be the premium
subsidy amount if the prescription drug premium produced by their bid
did not exceed the amount established to ensure at least five PDP
Sponsors offer zero-premium plans in each region. This premium would be
part of the benefit package they would be obligated under their
contract to cover.
III. Collection of Information Requirements
The information collection requirements contained in Sec.
423.780(f)(i) of this proposed rule are subject to the Paperwork
Reduction Act (PRA). However, the burden associated with the
requirement for the PDP sponsor to elect the option of providing for a
separate prescription drug premium amount for LIS individuals is
included in the burden estimate associated with the Bid Pricing Tool
for Prescription Drug Plans which is currently approved under OMB
approval number 0938-0944.
IV. Response to Comments
Because of the large number of public comments we normally receive
on Federal Register documents, we are not able to acknowledge or
respond to them individually. We will consider all comments we receive
by the date and time specified in the DATES section of this preamble,
and, when we proceed with a subsequent document, we will respond to the
comments in the preamble to that document.
V. Regulatory Impact Statement
A. Overall Impact
We have examined the impact of this rule as required by Executive
Order 12866 (September 1993, Regulatory Planning and Review), the
Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354),
section 1102(b) of the Social Security Act, the Unfunded Mandates
Reform Act of 1995 (Pub. L. 104-4), Executive Order 13132 on
Federalism, and the Congressional Review Act (5 U.S.C. 804(2)).
Executive Order 12866 directs agencies to assess all costs and
benefits of available regulatory alternatives and, if regulation is
necessary, to select regulatory approaches that maximize net benefits
(including potential economic, environmental, public health and safety
effects, distributive impacts, and equity). A regulatory impact
analysis (RIA) must be prepared for major rules with economically
significant effects ($100 million or more in any 1 year). This rule
permits Prescription Drug Plan (PDP) Sponsors, subject to conditions,
to lower their premiums for low-income subsidy beneficiaries to ensure
there are a sufficient number of organizations offering zero-premium
plans in each region and reduce the number of reassignments compared to
the current regulatory framework. We believe this proposed rule would
lead to Federal savings of approximately $20 million per year. This
assumes full enrollment weighting for the calculations of the low-
income benchmark premium amounts. The estimate was developed by
applying this rule against the 2008 bids and this impact was projected
throughout the forecast period. The estimate does not anticipate any
change in bidding strategies or outcomes. All organizations with
existing LIS beneficiaries that could be assigned out of the
organization are assumed to elect the option to retain their
beneficiaries including receiving reduced premiums for such LIS
members. LIS beneficiaries that are assigned out of organizations are
assumed to be randomly assigned to organizations that have premiums
below the low income premium subsidy benchmark. We invite public
comment on the assumptions included in this assessment.
We also evaluated the potential for non-Federal costs and savings
associated with this rule. A small number of Part D sponsors would
forego revenue associated with the reduction in their beneficiary
premium for low income beneficiaries. In addition, we anticipate a
reduction in administrative costs for these sponsors, as well as for
sponsors to which the beneficiaries would have been reassigned in the
absence of this rule. However, we believe that these costs and savings
would be relatively small. We invite public comment on this assessment
of non-Federal costs and savings. This rule
[[Page 1305]]
does not reach the economic threshold and thus is not considered a
major rule.
The RFA requires agencies to analyze options for regulatory relief
of small businesses. For purposes of the RFA, small entities include
small businesses, nonprofit organizations, and small governmental
jurisdictions. Most hospitals and most other providers and suppliers
are small entities, either by nonprofit status or by having revenues of
$6.5 million to $31.5 million in any 1 year. Individuals and States are
not included in the definition of a small entity. We are not preparing
an analysis for the RFA because we have determined, and the Secretary
certifies, that this regulation will not have a significant economic
impact on a substantial number of small entities.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis if a rule may have a significant impact on
the operations of a substantial number of small rural hospitals. This
analysis must conform to the provisions of section 603 of the RFA. For
purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of a Metropolitan
Statistical Area for Medicare payment regulations and has fewer than
100 beds. We are not preparing an analysis for section 1102(b) of the
Act because we have determined, and the Secretary certifies, that this
regulation will not have a significant impact on the operations of a
substantial number of small rural hospitals.
Section 202 of the Unfunded Mandates Reform Act of 1995 also
requires that agencies assess anticipated costs and benefits before
issuing any rule whose mandates require spending in any 1 year of $100
million in 1995 dollars, updated annually for inflation. That threshold
level is currently approximately $127 million. This rule will have no
consequential effect on State, local, or tribal governments in the
aggregate, or by the private sector.
Executive Order 13132 establishes certain requirements that an
agency must meet when it promulgates a proposed rule (and subsequent
final rule) that imposes substantial direct requirement costs on State
and local governments, preempts State law, or otherwise has Federalism
implications. Since this regulation does not impose any costs on State
or local governments, the requirements of E.O. 13132 are not
applicable.
B. Anticipated Effects
The number of PDP Sponsors offering PDPs that had low enough
premiums to qualify for low-income assignments for 2008 ranged from two
to eight organizations per region in key regions that had a relatively
high proportion of beneficiaries enrolled in MA plans. Five is the
average number of PDP Sponsors offering plans that qualified for low-
income assignments in these regions; we selected the five PDP Sponsor
option to maintain the 2008 level of competitiveness in the bidding
process. The 5 plan requirement is an attempt to balance the two goals
of introducing beneficiary stability, particularly in regions with very
low LIS premium subsidy benchmarks, together with maintaining the
incentives in the competitive bidding process. There may be negative
consequences if the 5 organizational requirement is too high and the
plans bid less competitively or if the 5 organizational requirement is
too low and there are an even greater number of low-income beneficiary
reassignments. In addition, based on analysis of the 2008 bids, and
assuming no de minimis demonstration is in place, CMS anticipates that
seven regions would be affected by having a minimum of five plans. CMS
estimates that a three Sponsor minimum would have affected five
regions, while a seven Sponsor minimum would have affected ten regions.
Therefore, we anticipate that this regulation will increase the number
of PDP Sponsors offering zero-premium PDPs that would be available to
full low-income subsidy-eligible beneficiaries. This proposed
regulation would also decrease the number of reassignments of LIS-
eligible beneficiaries to other PDPs, compared to the level of
reassignment under the current regulation absent a de minimis policy.
This decrease in beneficiary movement across plans would boost program
stability for both beneficiaries and plans. Based on an analysis of
2008 bids, the five-organization minimum requirement results in 0.2
million fewer beneficiary assignments as compared to the current
regulatory framework. The five-organization minimum requirement results
in 0.5 million more beneficiary reassignments than would occur under
the de minimis policy.
Lastly, CMS expects the improved program continuity and stability
that would be produced by this rule would help prevent an increase in
costs and risks imposed on PDP Sponsors. The higher the threshold for
the number of PDP Sponsors per region offering zero-premium PDPs, the
greater the negative impact on competitive bidding. We are seeking to
strike a balance between minimizing LIS reassignments and preserving
the integrity of the competitive bidding process. The results of
competitive bidding in 2008 generated an average of five PDP Sponsors
per region eligible for reassignments in certain key regions with
relatively high MA enrollment. Selecting five as the minimum
organization threshold under this proposed rule is intended to achieve
this balance.
This approach maintains a strong incentive to bid low to keep and
possibly add LIS beneficiaries. Absent the rule, there may be a
``winner take all'' outcome in certain regions with one organization
acquiring all of the LIS beneficiaries in the region. It is difficult
to predict what would happen in the absence of this rule, but we would
expect some organizations would be induced to bid even lower while
other organizations would give up on this population and bid higher.
From a cost perspective these factors may offset relative to the
proposed rule, but the volatility issue would remain.
C. Alternatives Considered
As stated in the Background section of this proposed rule, we
considered allowing PDP Sponsors to reduce their premium to the subsidy
amount after it was established for LIS-eligible individuals without
regard to the amount of their premium. We also considered allowing
plans with premiums under a fixed dollar amount to reduce their low-
income premiums to the premium subsidy amount. We determined, however,
that these options would undermine the integrity and competitiveness of
the bidding process.
We also considered changing our approach to reassignment to an
approach that would allow LIS-eligible individuals to be informed of
zero-premium PDP options, but would remain in their current plan,
regardless of the premium, if they take no action. Beneficiary advocacy
groups were concerned about beneficiaries being charged a premium
without electing to pay it. We further considered only reassigning LIS
individuals if the premium they would have to pay were above a certain
relatively low premium amount; however, this would raise complicated
issues regarding collection of these premium amounts.
We chose to propose to retain the current reassignment policy and,
in regions that would not otherwise have at least five zero-premium
plans for LIS enrollees, permit a sufficient number of PDPs to reduce
their premiums for LIS individuals so that the region includes five
zero-premium plans. We believe this option would both maintain or
possibly improve upon the current competitiveness of bids and reduce
reassignments for beneficiaries.
[[Page 1306]]
In accordance with the provisions of Executive Order 12866, this
regulation was reviewed by the Office of Management and Budget.
List of Subjects
42 CFR Part 422
Administrative practice and procedure, Grant programs--health,
Health care, Health insurance, Health maintenance organizations (HMO),
Loan programs--Health, Medicare, Reporting and recordkeeping
requirements.
42 CFR Part 423
Administrative practice and procedure, Emergency medical services,
Health facilities, Health maintenance organizations (HMO), Medicare,
Penalties, Privacy, Reporting and recordkeeping.
For the reasons set forth in the preamble, the Centers for Medicare
& Medicaid Services proposes to amend 42 CFR chapter IV as set forth
below:
PART 422--MEDICARE ADVANTAGE PROGRAM
1. The authority citation for part 422 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
Subpart F--Submission of Bids, Premiums, and Related Information
and Plan Approval
2. Amend Sec. 422.262 to revise paragraph (c)(1) to read as
follows:
Sec. 422.262 Beneficiary premiums.
(c) * * *
(1) General rule. Except as permitted for supplemental premiums
pursuant to Sec. 422.106(d), for MA contracts with employers and labor
organizations, the MA monthly bid amount submitted under Sec. 422.254,
the MA monthly basic beneficiary premium, the MA monthly supplemental
beneficiary premium, the MA monthly prescription drug premium (except
as provided in Sec. 423.780), and the monthly MSA premium of an MA
organization may not vary among individuals enrolled in an MA plan (or
segment of the plan as provided for local MA plans under paragraph
(c)(2) of this section). In addition, the MA organization cannot vary
the level of cost-sharing charged for basic benefits or supplemental
benefits (if any) among individuals enrolled in an MA plan (or segment
of the plan).
* * * * *
PART 423--VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT
3. The authority citation for part 423 continues to read as
follows:
Authority: Secs 1102, 1860D-1 through 1860D-42, and 1871 of the
Social Security Act (42 U.S.C. 1302, 1395w-101 through 1395w-152,
and 1395hh).
Subpart B--Eligibility and Enrollment.
4. Amend Sec. 423.34 by--
A. Revising paragraph (d)(1).
B. Adding a new paragraph (d)(3).
The revisions and additions read as follows:
Sec. 423.34 Enrollment of full-benefit dual eligible individuals.
* * * * *
(d) * * *
(1) General rule. Except as provided in paragraph (d)(3) of this
section, CMS must automatically enroll full-benefit dual eligible
individuals who fail to enroll in a Part D plan into a PDP offering
basic prescription drug coverage in the area where the individual
resides that has a monthly beneficiary premium that does not exceed the
low-income premium subsidy amount (as defined in Sec. 423.780(b)). In
the event that there is more than one PDP in an area with a monthly
beneficiary premium at or below the low-income premium subsidy amount,
individuals must be enrolled in such PDPs on a random basis.
(2) * * *
(3) PDPs whose premiums were reduced for LIS beneficiaries under
Sec. 423.780(f) would not be entitled to automatic enrollment under
paragraph (d)(1) of this section.
* * * * *
Subpart F--Submission of Bids and Monthly Beneficiary Premiums;
Plan Approval
5. Amend Sec. 423.286 by revising paragraph (e) to read as
follows:
Sec. 423.286 Rules regarding premiums.
* * * * *
(e) Decrease in monthly beneficiary premium for low-income
assistance. The monthly beneficiary premium paid by the beneficiary may
be eliminated as provided in Sec. 423.780.
* * * * *
Subpart P--Premiums and Cost-Sharing Subsidies for Low-Income
Individuals
6. Amend Sec. 423.780 by adding a new paragraph (f) to read as
follows:
Sec. 423.780 Premium subsidy.
* * * * *
(f) Option for a reduced premium amount for full subsidy eligible
individuals. PDP sponsors have the option of providing for a separate
prescription drug premium amount for full subsidy eligible individuals
for prescription drugs plans under Sec. 423.104(d) or (e) subject to
the following conditions--
(1) The PDP sponsor must elect this option at the time its bid is
submitted, and agree to set its prescription drug premium for all full
subsidy eligible individuals at the premium subsidy amount under
paragraph (b) of this section for the entire coverage year if
(i) The PDP sponsor puts forward no other PDP in the PDP region
that is offering a premium below the premium subsidy amount or closer
to the premium subsidy amount; and
(ii) Its premium amount would otherwise equal or be below the
amount established under paragraph (f)(ii) of this section.
(2) Following the establishment of the premium subsidy amount, CMS
will review the bids of PDP sponsors that have elected the option under
paragraph (f)(i) of this section, and determine an amount that, when
added to the premium subsidy amount, would produce a premium amount
that is no greater than the amount that would equal or exceed the
prescription drug premium amount produced by bids for at least five PDP
sponsors in every PDP region.
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)
Dated: December 13, 2007.
Kerry Weems,
Acting Administrator, Centers for Medicare & Medicaid Services.
Approved: December 28, 2007.
Michael O. Leavitt,
Secretary.
[FR Doc. 08-15 Filed 1-3-08; 10:12 am]
BILLING CODE 4120-01-P
