egwp & pde reporting amanda johnson division of payment reconciliation medicare plan payment...

EGWP & PDE REPORTINGEGWP & PDE REPORTING

Amanda JohnsonDivision of Payment ReconciliationMedicare Plan Payment Group

September 5, 2012

Image of spilled m

ed capsules

CMS logo

• This presentation is not meant to replace existing guidance or forthcoming official guidance.

DisclaimerDisclaimer

2

• To have a discussion with plan sponsors and submitters on Prescription Drug Event (PDE) issues for Employer Group Waiver Plans (EGWPs)

PurposePurpose

3

• Describe current PDE reporting rules for EGWPs offering an Enhanced Alternative plan benefit

• Describe current PDE reporting rules for EGWPs offering additional coverage through OHI

Learning ObjectivesLearning Objectives

4

• Non Covered Plan Paid Amount (NPP) field is used for enhanced alternative benefits.

• Field 39 on the PDE Record Layout• The amount of plan payment for enhanced

alternative benefits. NPP field is excluded from Part D payment reconciliation.

PDE Reporting for EGWPs with EA Benefit

PDE Reporting for EGWPs with EA Benefit

5

• NPP is calculated using the following formula:

NPP = GDC – (Patient Pay + CPP + PLRO + Other TrOOP + LICS + Reported Gap Discount)

Calculating NPPCalculating NPP

6

• When a plan pays more than what is covered in a given benefit phase under the DS benefit, NPP is positive

• When the plan and the DS benefit payment is the same, NPP is zero

• When the plan pays less than what is covered in a given phase under the DS benefit, NPP is negative

NPP ValuesNPP Values

7

• Beneficiary purchases $100 drug in Initial Coverage Phase

• Patient co-pay is $10

• NPP = $100 – ($10 + $75)

PDE Example 1PDE Example 1

Patient Pay Amount

CPP NPP

$10.00 $75.00 $15.00

8

• Patient Liability Reduction Due to Other Payer Amount

• Field 37 on the PDE Record Layout• This field is populated with the dollar amount

paid by entities that reduce patient liability/cost but do not count as TrOOP

• Net change between the original Patient Pay amount and the Patient Pay amount reported by the OHI

PDE Reporting When There is OHIPDE Reporting When There is OHI

9

• Determine beneficiary and plan cost-sharing under the Defined Standard benefit for non-Coverage Gap PDEs

• Determine beneficiary liability under OHI• Determine PLRO, which is the difference between

original patient pay and OHI patient pay• Update patient pay to reflect change in cost-

sharing• Determine TrOOP Amount

General Approach for PDEs with OHIGeneral Approach for PDEs with OHI

10

• Beneficiary purchases $100 drug in Initial Coverage Phase

• Under OHI beneficiary pays $10• PLRO = $25.00 - $10.00 = $15.00• Patient Pay amount = $10.00• TrOOP amount for this PDE = $10.00

PDE Example 2PDE Example 2

Patient Pay Amount CPP$25.00 $75.00

11

• PDE fields

PDE Example 2PDE Example 2

GDCB Patient Pay Amount

CPP PLRO

$100.00 $10.00 $75.00 $15.00

$10.00 will count towards TrOOP

12

• Beneficiary purchases $100 drug in Initial Coverage Phase

• Under OHI beneficiary pays $30• PLRO = $25.00 - $30.00 = -$5.00• Patient Pay amount = $30.00• TrOOP amount for this PDE = $30.00

PDE Example 3PDE Example 3

Patient Pay Amount CPP$25.00 $75.00

13

• PDE fields

PDE Example 3PDE Example 3

GDCB Patient Pay Amount

CPP PLRO

$100.00 $30.00 $75.00 -$5.00

$30.00 will count towards TrOOP

14

• Determine Costs that Fall in the Coverage Gap• Determine Discount Eligible Costs– Supplemental benefits apply before determining

discount eligible cost– Excludes dispensing fee, and vaccine

administration fee• Calculate Gap Discount

Steps for Coverage Gap PDEs Steps for Coverage Gap PDEs

15

• Determine beneficiary cost-sharing*– OHI applies after the Gap Discount is applied

• Calculate Covered and non-Covered Portion of plan paid cost-sharing

• Update Gross Covered Drug Cost Accumulator and TrOOP Accumulator

Steps for Coverage Gap PDEsSteps for Coverage Gap PDEs

*Current policy of placing the dispensing fee and vaccine administration fee outside of the Coverage Gap when possible will remain in effect in 2013.

16

QuestionsQuestions

17