Egwp pde reporting
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CMS logo. EGWP & PDE REPORTING. Amanda Johnson Division of Payment Reconciliation Medicare Plan Payment Group . September 5, 2012. Image of spilled med capsules. Disclaimer. This presentation is not meant to replace existing guidance or forthcoming official guidance. . 2. Purpose.

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Egwp pde reporting

CMS logo

EGWP & PDE REPORTING

Amanda Johnson

Division of Payment Reconciliation

Medicare Plan Payment Group

September 5, 2012

Image of spilled med capsules


Disclaimer
Disclaimer

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

2


Purpose
Purpose

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

3


Learning objectives
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


Pde reporting for egwps with ea benefit
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


Calculating npp
Calculating NPP

  • NPP is calculated using the following formula:

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

6


Npp values
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


Pde example 1
PDE Example 1

  • Beneficiary purchases $100 drug in Initial Coverage Phase

  • Patient co-pay is $10

  • NPP = $100 – ($10 + $75)

8


Pde reporting when there is ohi
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


General approach for pdes with ohi
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


Pde example 2
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


Pde example 21
PDE Example 2

  • PDE fields

$10.00 will count towards TrOOP

12


Pde example 3
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


Pde example 31
PDE Example 3

  • PDE fields

$30.00 will count towards TrOOP

14


Steps for coverage gap pdes
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


Steps for coverage gap pdes1
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.

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