EGWP & PDE REPORTING

1. CMS logo EGWP & PDE REPORTING Amanda Johnson Division of Payment Reconciliation Medicare Plan Payment Group September 5, 2012 Image of spilled med capsules

2. Disclaimer • This presentation is not meant to replace existing guidance or forthcoming official guidance. 2

3. Purpose • To have a discussion with plan sponsors and submitters on Prescription Drug Event (PDE) issues for Employer Group Waiver Plans (EGWPs) 3

4. Learning Objectives • 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 4

5. PDE Reporting for EGWPs with EA Benefit • 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. 5

6. Calculating NPP • NPP is calculated using the following formula: NPP = GDC – (Patient Pay + CPP + PLRO + Other TrOOP + LICS + Reported Gap Discount) 6

7. NPP Values • 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 7

8. PDE Example 1 • Beneficiary purchases $100 drug in Initial Coverage Phase • Patient co-pay is $10 • NPP = $100 – ($10 + $75) 8

9. PDE Reporting When There is OHI • 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 9

10. General Approach for PDEs with OHI • 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 10

11. PDE Example 2 • 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 11

12. PDE Example 2 • PDE fields $10.00 will count towards TrOOP 12

13. PDE Example 3 • 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 13

14. PDE Example 3 • PDE fields $30.00 will count towards TrOOP 14

15. Steps for Coverage Gap PDEs • 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 15

16. Steps for Coverage Gap PDEs • 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 *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

17. Questions 17