<aside> 📔 Table of Contents

• Open Me! </aside>

What Have I Learned?

• [ ] 60 - General Rules for Calculating MA Plan Payments
• [ ] 70 - Special Payment Rules
• [ ] 80 - Adjustment of Payments to Reflect the Number of Medicare Enrollees
• [ ] 90 - Risk Sharing with MA Regional Plans
• [ ] 100 - Regional Plan Stabilization Fund Payments
• [ ] 110 - Special Rules for Payments to Federally-Qualified Health Centers
• [ ] 120 - Special Rules for Coverage That Begins or Ends During an Inpatient Hospital Stay
• [ ] 130 - Special Rules for MA Payments to Department of Veterans Affairs Facilities
• [ ] 140 - Source of Payment and Effect of MA Plan Election on Payment
• [ ] 150 - Special Rules for Payment to MA Organizations for Direct Graduate Medical Education Costs

60 - General Rules for Calculating MA Plan Payments

(Rev. 89; Issued: 11-02-07; Effective/Implementation: 11-02-07)

See Chapter 7 of the manual (forthcoming) for information on the bidding methodology. In short, under the bidding methodology each plan’s bid for coverage of Part A and Part B benefits (i.e., its revenue requirements for offering original Medicare benefits) is compared to the plan benchmark (i.e., the upper limit of CMS’ payment, developed from the county capitation rates in the local plan’s service area or from the MA regional benchmarks for regional plans).

<aside> 💡 The purpose of the bid-benchmark comparison is to determine whether the plan must offer supplemental benefits or must charge a basic beneficiary premium for A/B benefits.

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60.1 - Bidding Rules for Coordinated Care Plans (CCPs) and Private Fee-For-Service (PFFS) Plans

(Rev. 89; Issued: 11-02-07; Effective/Implementation: 11-02-07)

<aside> 💡 If the plan A/B bid is less than plan A/B benchmark, 75% of that difference is “rebate” that must be used to offer mandatory supplemental benefits or premium reductions. The other 25% is retained by the Trust Funds as savings.

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<aside> 💡 If the plan A/B bid is greater than the plan A/B benchmark, the plan must charge a basic beneficiary premium for A/B benefits, where the premium is defined as the standardized bid minus the standardized benchmark.

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60.2 - Bid-Based Payment Rules for CCPs and PFFS Plans

(Rev. 89; Issued: 11-02-07; Effective/Implementation: 11-02-07)

Effective CY 2006, there are three general Part C payment rules for bid-based payments for aged and disabled enrollees of CCPs and PFFS plans, summarized in Figure 1. See §70.2 for ESRD Enrollee Payment Rules and §70.3 for payment rules for enrollees who have elected hospice.

Under the bidding methodology, per capita payment rates are plan-specific, because they are calculated as the standardized (“1.0”) plan bid multiplied by the plan’s county ISAR factor. (See §60.3.1 on the ISAR factor.)

Figure 1. Part C Payments for CCPs and PFFS Plans