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

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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.

16


Questions

Questions

17


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