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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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Presentation Transcript
egwp pde reporting
CMS logoEGWP & 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

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