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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.
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Purpose
• To have a discussion with plan sponsors and
submitters on Prescription Drug Event (PDE)
issues for Employer Group Waiver Plans
(EGWPs)
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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
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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.
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Calculating NPP
• NPP is calculated using the following formula:
NPP = GDC – (Patient Pay + CPP + PLRO + Other
TrOOP + LICS + Reported Gap Discount)
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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
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PDE Example 1
• Beneficiary purchases $100 drug in Initial
Coverage Phase
• Patient co-pay is $10
Patient Pay
Amount
CPP
NPP
$10.00
$75.00
$15.00
• NPP = $100 – ($10 + $75)
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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
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General Approach for PDEs with OHI
• Determine beneficiary and plan cost-sharing
under the Defined Standard benefit for nonCoverage 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 costsharing
• Determine TrOOP Amount
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PDE Example 2
• Beneficiary purchases $100 drug in Initial
Coverage Phase
•
•
•
•
Patient Pay Amount
CPP
$25.00
$75.00
Under OHI beneficiary pays $10
PLRO = $25.00 - $10.00 = $15.00
Patient Pay amount = $10.00
TrOOP amount for this PDE = $10.00
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PDE Example 2
• PDE fields
GDCB
Patient Pay
Amount
CPP
PLRO
$100.00
$10.00
$75.00
$15.00
$10.00 will count towards TrOOP
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PDE Example 3
• Beneficiary purchases $100 drug in Initial
Coverage Phase
•
•
•
•
Patient Pay Amount
CPP
$25.00
$75.00
Under OHI beneficiary pays $30
PLRO = $25.00 - $30.00 = -$5.00
Patient Pay amount = $30.00
TrOOP amount for this PDE = $30.00
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PDE Example 3
• PDE fields
GDCB
Patient Pay
Amount
CPP
PLRO
$100.00
$30.00
$75.00
-$5.00
$30.00 will count towards TrOOP
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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
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Steps for Coverage Gap PDEs
• Determine beneficiary cost-sharing*
– OHI applies after the Gap Discount is applied
*Current policy of placing the dispensing fee and vaccine administration fee
outside of the Coverage Gap when possible will remain in effect in 2013.
• Calculate Covered and non-Covered Portion of
plan paid cost-sharing
• Update Gross Covered Drug Cost Accumulator
and TrOOP Accumulator
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Questions
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