Transcript Content Slides

Part D Data Implementation
November 1, 2005
Shannah Koss
Avalere Health LLC
Avalere Health LLC | The intersection of business strategy and public policy
Part D Ramp Up
The intersection of business
strategy and public policy
Medicare Modernization Act Creates Medicare Part D
Prescription Drug Benefit
 MMA establishes a Medicare outpatient prescription drug benefit beginning in
2006
» Administered through private, risk-bearing plans; not directly by CMS
 Two types of plans will exist: Prescription Drug Plan (PDP) and
Medicare Advantage Prescription Drug (MA-PD) Plan
 Enrollment is voluntary1
» Of estimated 43.1 million Medicare beneficiaries in 2006, HHS expects 29.3
million (68%) to enroll
» Initial enrollment period starts 11/15/05 and ends 5/15/06
» 6.3M dual eligibles will be automatically enrolled on 1/1/062
» MA-PD plans will automatically enroll the majority of MA beneficiaries, ~4.5-5M
1 6.3
million beneficiaries dually eligible for Medicare & Medicaid will be automatically enrolled into PDPs, but may choose to
disenroll
2 HHS projected enrollment equals 91% when including 9.8 million beneficiaries estimated to have creditable drug coverage
through an employer
© Avalere Health LLC
Page 3
Transaction Complexities
 Limited information available on the program transactions
 Illustrative timing and transactions
» 1/1/06 12M enrolled mostly dual eligibles and MA-PD enrollees—dually
eligibles average 3.5 scripts per month and many will require secondary
payer inquiries
» Remaining estimated 17M beneficiaries will have staggered enrollment from
February through May of 5, 5, 4 and 3 million each month respectively
» Average monthly scripts for all beneficiaries is 2.4
» Fills and refills require eligibility queries and claims that include Medication
Therapy Management Program (MTMP) inquiries supported by each plan
» 60% of beneficiaries have two or more chronic conditions and will be
targeted by MTMP plans.
© Avalere Health LLC
Page 4
Estimated Transaction Volumes
Number of
Enrollees
Monthly Eligibility
Queries & Claims
Monthly Scripts
Monthly MTMP
Checks
January
12M mostly
duals and MA
24-36M
36M
21.6M
February
17M
17-43M
43M
25.8M
March
22M
22-53M
53M
31.8M
April
26M
26-62M
62M
37.2M
May
29M
29-70M
70M
42M
Month
Illustrative transaction volumes using prescription estimates based on CMS and Partnerships For Solutions data
© Avalere Health LLC
Page 5
Part D Complexities
The intersection of business
strategy and public policy
PDP Plan Options
41
41
ME
WA
45
MT
OR
VT
ND
MN
ID
SD
44
CA
47
UT
AZ
43
CO
43
MI
40
IA
MO
41
OK
42
NM
43
TX
47
AK
27
IL
42
KS
40
PA
OH
43
IN
42
WV
KY
MS
38
AL
VA
41
NJ
44
RI
44
DE
MD
D.C.
47
NC
38
TN
41
AR
40
LA
39
NY
46
52
WY
NE
NV
44
WI
45
NH
MA
CT
GA
42
SC
41
FL
43
HI
29
Data released 09/30/05 by CMS
© Avalere Health LLC
Page 7
Claim & Eligibility
Transactions
Enrollment & COB
Transactions
Medicare Eligibility
Primary Claim-Direct Connect
Enrollment Files
Employers
VDSAs
-ORPharmacy
Payers
TPAs
Primary Claim
Part D Plan
Bene
IEQs
Medicare Eligibility
OHI
Enrollment Files
E1 Eligibility
Query
available to
pharmacies
COB
Contractor
Part D Plan
RxBIN, RxPCN, RxGRP, RxID
Second Claim…
COB
Claims Router
Claims Router
Claims Router
MBD
Third
Party
TrOOP Facilitation
Part D Membership File
With
RxBIN, RxPCN, RxGRP, RxID
Primary, Secondary…
Check Elig?
N Transaction
Change
Transaction
Part D Plan
MARx
Copies of N
Secondary
Payer(s)
Enrollment
Plan
Discovers
other
Coverage
?
Other coverage RxGRP+RxID
reported on enrollment transaction
to MARx – If more than one, then
report additional on Change
Transaction
COB Record
parsed by
MARx by
Plan/PBP
Secondary
Payers may
create N to TF
in certain
situations
PDE
DDPS
Request transaction
Source: CMS 8/30/05 conference presentation
Transaction formats are NCPDP V5.1
Response transaction
How Will It Work?
 CMS slides excerpt from Medicare Advantage and Prescription Drug Plans
Enrollment and Payment Conference
The initial implementation of the Part D benefit for Plans/Payers/PBMs,
Pharmacies, switching networks, software vendors, and CMS poses a significant
challenge to maintaining current real-time processing standards for claims
adjudication and back-end financial payment, reconciliation, and audit
processing synchronization.
© Avalere Health LLC
Page 9
Panelists
 Catherine C. Graeff, R.Ph, MBA, Sr. VP Industry Relations and
Communications, National Council for Prescription Drug Programs (NCPDP)
 Dan Kazzaz, Chair, ASC X12, President, Rapid Data Interchange LLC
© Avalere Health LLC
Page 10