Plan Approval. The Secretary will review the submitted information for purposes of conducting negotiations with the plan. The Secretary has the authority to negotiate the terms and conditions of the plans. The authority is similar to the authority the Director of the Office of Personnel Management has with respect to Federal Employee Health Benefits (FEHB) plans. After review and negotiation, the Secretary will approve or disapprove the plan. The Secretary may only approve a plan if certain requirements are met. The plan must comply with Part D requirements, including for actuarial determinations. The Secretary must determine that the portion of the bid that is related to basic coverage is supported by the actuarial bases provided and reasonably and equitably reflects the revenue requirements (as the term is used under Section 1302(8)(c) of the Public Health Service Act) for benefits provided under the plan, less the sum of the actuarial value of the reinsurance payments provided. Similarly, the Secretary must determine that the portion of the bid that is related to supplemental coverage is supported by the actuarial bases provided and reasonably and equitably reflects the revenue requirements for coverage provided under the plan. The Secretary can only approve a plan, if the plan and the benefits (including any formulary and tiered formulary structure) are not likely to discourage enrollment by certain beneficiaries. The agreement provides that the Secretary may only approve a limited risk plan for a PDP region if the access requirements for the region would otherwise not be met except for the approval of a limited risk or fallback plan. Only the minimum number of limited risk plans necessary for a region to meet access requirements may be approved. The Secretary shall provide priority to those with the highest level of risk. In no case can the reduction of risk provide for no (or a de minimus) level of financial risk. There is no limit on the number of full risk plans that may be approved.
Appears in 4 contracts
Samples: Conference Agreement, Conference Agreement, Conference Agreement
