Do a plan’s programs and procedures for chronic and high-cost conditions have to be in place at the time the sponsor submits the application?
Yes. The program’s regulations state that as part of the application, the applicant must include a summary of the programs and procedures it has in place that have generated, or have a potential to generate, cost-savings with respect to participants with chronic and high-cost conditions. The regulation defines a chronic and high-cost condition as a condition for which $15,000 or more in health benefit claims are likely to be incurred during a plan year by any one plan participant. It would be helpful in the summary for the applicant to explain how it determined which conditions to address (i.e. how was it determined that the chronic and high-cost condition has generated, or is likely to generate, $15,000 in claims in a plan year), how the program and procedures will generate cost savings with respect to plan participants with these conditions, a description of the programs and procedures, and who benefits from the cost savings (i.e. the plan sponsor and/or plan participants). This list
