Revolutionize Medicare Part D, Save Pharmacy
Here at PDS, we have many incredible solutions partners that have the ability to revolutionize pharmacies through their products and services. We’re so excited to share with you one of them — iMedicare. They would like to share with you the blog they wrote below about how you can join the revolution to reshape Medicare Part D. Read on!
Like PDS, iMedicare shares the same dedication and passion to helping community pharmacies win. Recently, we conducted a survey that polled 5,000+ of our pharmacy customers and discovered that many want to see real change in the industry. A change that serves the independent community, while being patient-focused. So we decided to investigate how pharmacies like you could create a profitable Medicare Part D plan.
Curious? We hoped you’d be! The following will be a thorough step-by-step plan on how to get started building your profitable Medicare Part D plan and help patients along the way:
Step 1: Start an insurance company.
All Medicare plans must have a license from the Department of Insurance (DOI) of the state they want to do business in. Each state has different requirements, the most important one being the capital and surplus requirement.Capital and surplus refers to cash in the bank (assets minus liabilities) and some states require as much as $10 million, as in the case of Iowa.Find each state’s capital requirements from the NAIC (National Association of Insurance Commissioners) here.
So what do you do? You start the new insurance company in North Carolina, which has a $1.1 million capital requirement, then fill out all the forms and get a Certificate of Authority for Insurance. Next, you apply toNAICto get a risk-bearing entity code. Now, you can apply in other states as an out-of-state insurance company to get the Certificate of Authority for each state. Note: you will still need to fulfill the capital requirements for each state. So,you will need around $10 million to ensure all state requirements are satisfied.
Why would you want to apply in every state? Because more states equals more Medicare patients, and more premiums. Having a large number of patients on your plan is key to Medicare plan financials.
But here’s the real reason: Around 400,000 LIS (low income subsidy) patients lose their coverage due to plan and premium changes every year. These low income patients are auto-assigned into one of the LIS-eligible Medicare Part D plans offering a $0 premium for LIS patients. There are 6 LIS-eligible plans in each state, on average. So, if you have a LIS-eligible Part D plan, you will capture 400,000 / 6 = 66,000 new patients in your plans without doing anything – simply due to the way the system works. Let me say this again:
If you have a plan with a premium below the benchmark in all 50 states, you will automatically get 66,000 Medicare patients on your plan each year.
But before you get too excited, you must start a Part D plan and go through the Center of Medicare and Medicaid (CMS) application process. There’s an important CMS rule to be aware of: In the2014 Final CMS Rule, CMS introduced the requirement thatall new Medicare plans must have 2 years of experience in health insurance OR 5 years of experience as a PBM for health insurance.
This CMS rule makes it much harder for new plans to enter the market. You have 2 choices:
- Run your new health insurance company for 2 years before applying to CMS.
(i.e., offer Medicare Supplement plans)
- Buy a failing insurance company with 2 years of experience.
Based on our research, the buying route seems to be the preferred method for many companies.
- Ascension Health (a hospital system) bought a small Health Insurer in February of 2015 for $50 million.Click here for press release.
- Symphonix, now a national Medicare Part D plan, acquired Vista Health for around the same amount.Click here for details of the deal.
The most cost-effective option is to buy aninsurance shell company. These companies go for about $80,000 per state license (that’s about $4 million for 50 states). This does not include the capital and surplus, soyou are looking at a minimum investment of $14 million. The risk with these transactions is the unknown liabilities they bring from previous insurance policies they may have used in the past. While there are some preventive measures to minimize this, trust is a big factor in these transactions.
Step 2: Hire a Pharmacy Benefit Manager (PBM)
While the health insurance company has the licenses, the name, marketing, and contract with CMS, the day-to-day operations of a Part D plan are done by a pharmacy benefit manager.
PBMs do the work behind the scenes. PBMs create and administer the plan formularies, pharmacy networks, rebates, reimbursements, enrollments, phone calls, prescription claims processing, reporting to CMS, and compliance.
You may be tempted to start your own PBM, but it is unlikely that you can comply with all the CMS requirements your first few years.Others have tried, and failed:
By freezing all new enrollments, CMS can put any plan out of business with a stroke of a pen.
To hire a large PBM for all the functions above, you will likely have to pay a signup credit of a few hundred thousand, and then $10-$15 per member per month (PMPM). Or you can get a smaller PBM for $4-$5 PMPM.
Besides the PBM cost, you will need to spend an additional $550k per year: Actuary ($100k), a lawyer ($100k), CMS consultants ($100k), and a Statuary Accountant required on staff full-time ($250k)
Step 3: Create a business plan for your Part D plan
Every year, Medicare plans place a bid on the premium for their plan. For 2017, the average premium was $35.63/month.Click here for the CMS announcement.
CMS subsidizes the premium with an additional $25.45/month per patient, depending on the health risk score of each patient. Moreover, CMS covers 80% of the costs in the Catastrophic phase through what is called “Federal Reinsurance,” which will be around $70 in 2017, judging from theMillimanandKaiser Family Foundationreports. So, added up,Part D plans will receive over $1,500 per member in 2017.
Then there’s DIR. Direct and Indirect Remuneration (DIR), refers to rebates and fees from manufacturers and pharmacies that the PBM negotiates on the plan’s behalf.From 2012 to 2015, DIR has increased from $10 billion to 23 billionaccording to a recent CMS factsheet.The same study shows that DIRs lower the plan’s liability from $1,077 to $666 per member per year (PMPY).
A Part D Plan’s gross profit is $1,500 – $666 = $834 PMPY. PBMs take at most $180 PMPY. Other G&A expenses such as compliance, IT, rent, employees take another $216 PMPY.So the EBITDA of a Medicare Part D plan comes to around $438 per member per year.
So given the $438 in profit per member per year, what do we need to make this a reality?
- Q: First, how many enrollments do you need to make a Part D plan profitable?
A: Depends on the expenses to win an enrollment. With $0 marketing expenses, 100,000 enrollments would put a plan definitively in the black. By pricing the plan premium below the low income benchmark (as we discussed in the last article), your national Medicare Part D plan will receive ~60,000 enrollments automatically from the low-income patients auto-assigned in a plan each year across all 50 states. However, for a Part D plan to truly win the market, it will need closer to 1 million enrollments.
- Q: How does the competition get enrollments?
A: Some Part D plans price their premium below profitability in order to beat the competition. Other plans use insurance brokers to drive enrollments. The commission for these enrollments are around $28 per patient per year for a Part D plan, and ~$400 for a Medicare Advantage plan.
- Q: How can a start-up plan beat the competition?
A: One of the best ways is by partnering with pharmacies.
A start-up plan can partner with pharmacies in each community to drive down patient costs. By lowering patient costs, the Medicare Plan would surpass any other plan’s profitability, and have a key stakeholder in each community.
- Q: Why would pharmacies partner with a Part D Plan?
A: Because pharmacies would have ownership in the Medicare Plan entity.
Hence, the best way for a new Medicare Plan to succeed is if pharmacies themselves own the majority of the new entity.
To make this collective plan a reality, pledge below.
The moment $50 million in pledges is reached, iMedicare will help with the plan setup, to help make pharmacies a real player in the insurance market.