Transcript EGWPs - Third Party Administrator

Medicare Part D
Employer Group Waiver Plans (EGWPs)
Mark Newsom, Director
Division of Payment
Reconciliation/ Medicare Plan
Payment Group
Social Security Act
• Section 1860D-22(b) of the Social Security
Act (the “Act”), establishes that Medicare
Advantage Waiver Authority under section
1857(i) shall apply to prescription drug
coverage in employee retiree plans.
• The authority allows CMS to waive or
modify any requirements that hinder the
design of, the offering of, or the enrollment
in employer plans.
2
Coverage Gap Discount Program
Applies to EGWPs
• EGWPs are included in the Discount
Program because the definition of
“applicable beneficiary” in §1860D14A(g)(1) of the Social Security Act covers
all Part D plan enrollees not eligible for a
low income subsidy. There is no exclusion
for EGWPs.
3
Restricted Enrollment
• All EGWPs must restrict enrollment to
employer/union group health plan Part D
eligible retirees and/or their Part D eligible
spouses and dependents.
4
Key Approved Employer/Union
Sponsored Group Health Plan Waivers
• CMS has waived the annual coordinated
election period described in 42 CFR
423.38(b) for EGWPs. Thus, enrollments in
EGWPs or individual PDPs may have
different annual open enrollment periods
(non-calendar year EGWPs).
• CMS has waived the prior review and
approval requirements for most marketing
materials.
5
Key Approved Employer/Union Sponsored
Group Health Plan Waivers (Cont.)
• Uniform benefits waiver: EGWP entities serving
multiple regions or the entire nation are allowed to
vary premiums and cost sharing between defined
market areas within the same employer/union
sponsored group plan.
• CMS has waived the specific Part D retail pharmacy
access standards contained in 423.120(a)(1) as long
as the EGWP sponsor attests that its networks are
and will continue to be sufficient to meet the needs
of its Part D eligibles, including situations involving
emergency access.
6
Information Provided to CMS about
Part D from EGWPs
• 42 CFR § 423.48 Information about Part D is
waived: Each Part D plan must provide, on an
annual basis, and in a format and using standard
terminology that CMS may specify in guidance, the
information necessary to enable CMS to provide to
current and potential Part D eligible individuals the
information they need to make informed decisions
among the available choices for Part D coverage.
• These data are used for the Medicare Prescription
Drug Plan Finder web tool and the Medicare & You
publication.
7
Information Provided to CMS
about Part D from EGWPs (cont.)
• Waivers are in place for much of the detail
provided in the bids, benefit packages, and
formularies submitted by non-EGWP Part
D sponsors.
8
Traditional EGWP
Benefit Packages
• Employer/union group health plan coverage
has rarely followed the defined standard
benefit design in Part D.
• Most EGWP arrangements offer lower
deductibles or provide coverage for certain
claims incurred in the Part D coverage gap
and/or have a different initial coverage
limit.
9
EGWP Supplemental
Prescription Drug Benefits
• Under the Affordable Care Act, manufacturer discounts are
calculated after Part D supplemental benefits are applied but
before any other health insurance (OHI) gets applied.
• In 2013, EGWPs have the option to provide their supplemental
benefits as either : a) Part D supplemental benefits under an
Enhanced Alternative Part D plan (EA Plan) or b) Other health
insurance (OHI) that is co-administered with their Part D
Defined Standard benefit.
• EGWPs structured as EA plans calculate and apply a 50%
manufacturer discount directly to their enrollee copay or
coinsurance portion of a coverage gap claim only.
• Alternatively, EGWPs that are structured as Defined Standard
plans with OHI wrapping around, calculate and apply the
discount before the OHI wrap.
10
EGWP Supplemental
Prescription Drug Benefits (Cont.)
• Beginning January 1, 2014, CMS will implement the
change to the definition of Part D supplemental benefits
in 42 CFR §423.100 (issued in CMS-4157-FC on April 12,
2012) to simplify this situation.
• This means that all supplemental prescription drug
benefits offered through EGWPs will be considered nonMedicare benefits, thus other health insurance (OHI).
• Accordingly, if the non-Medicare supplemental benefits
provide supplemental gap coverage for applicable drugs,
these benefits are OHI that apply after the Coverage
Gap Discount is calculated.
• Consequently, the discount calculation will be based
upon the Part D Defined Standard benefit for EGWPs.
11
Enrollment Growth in EGWPs with
Prescription Drug Coverage
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000
2,000,000
1,000,000
0
Enrollment April 2011
Enrollment April 2012
Enrollment April 2013
12
Enrollment Growth in EGWPs with
Prescription Drug Coverage (Cont.)
• EGWPs drove much of the growth in Part D
enrollment from 2012 to 2013.
• The elimination of the tax advantage related
to the Retiree Drug Subsidy (RDS) program
beginning in 2013 had many
employers/unions shifting to the EGWP
option.
13
Negative Invoice Amount Update
Joseph Hefter
Division of Payment
Reconciliation/ Medicare Plan
Payment Group
Introduction
• A negative amount on a manufacturer
invoice represents money owed to the
manufacturer from the Part D sponsor and
can also be thought of as the gap discount
amount a manufacturer has overpaid a Part
D sponsor.
15
Introduction
(continued)
• Negative invoice amounts occur when a
discount was invoiced in a prior quarter and
the PDE was deleted or adjusted by the Part D
sponsor in a future quarter and the decrease
in financial fields are reflected in a future
invoice.
• If the particular manufacturer/sponsor
combination does not have enough additional
PDEs to offset the amount due, the result is a
negative amount on the manufacturer
invoice.
16
Two Phased Approach to Resolving
Negative Invoice Amounts
• Phase I- “True-up” of all outstanding
amounts due to manufacturers
• Phase II- Enhance invoice to reduce the
amount and frequency of overpayments to
Part D sponsors
17
Phase I – “True-up”
• The first phase is designed to facilitate a
“true-up” of all outstanding money owed
from Part D sponsors back to
manufacturers. The TPA will distribute a
new report to both Part D sponsors and
Manufacturers to notify each party of the
total amount due.
18
The Negative Invoice Repayment
Facilitation Process
• The TPA collects banking information from all
Manufacturers to document the bank account
where repayments should be directed
• Manufacturer banking information is distributed
securely to Part D Sponsors
• TPA distributes “true-up” reports to
Manufacturers/Part D Sponsors in their CGDP
mailboxes
• Part D sponsors will use this report to issue
repayment to Manufacturers
• There will be no payment confirmation required
19
Time Schedule for Phase I
• “True-up” report distribution will occur
twice:
– The report distributed in Mid-October will
include all negative amounts from Q1 2011
through Q2 2013.
– The report distributed in Mid-April will include
all negative amounts from Q3 2013 through Q4
2013.
20
File Structure for Phase I
• We are currently finalizing the report layout
and the final layout will be distributed in
July.
• Manufacturers should expect a similar file
structure as the invoice reports with
headers/trailers/detail records.
21
Data Elements for Phase I
•
•
•
•
•
•
Starting and Ending Reporting period
Submitting Contract Number
Discounts Paid
Adjustments Due
Net Total
EFT Individual Identification Number
22
Phase II – Invoice Enhancements
• Beginning in Q1 2014, negative balances will be
tracked and carried forward to the next invoice and
offset by future positive CGDP payments to the
extent possible.
• The current invoice format will be revised to reflect
this rolling balance and will indicate clearly the
amount due.
• Manufacturers should expect additional details
(examples, revised invoice file layouts including
additional fields) regarding this approach in early
2014
23
Phase II – Invoice Enhancements
(continued)
• While we believe this approach will handle
the majority of outstanding negative
amounts, our research into current invoices
has shown that it is likely that a “true-up” as
described in Phase I will still be necessary.
• The TPA will distribute reports like those
produced under Phase I annually.
24
Timeline for Phase II
• Manufacturers should expect additional
details (examples, revised invoice file
layouts including new fields) regarding this
approach in early 2014.
25
Part B VS. Part D
Craig Miner
Division of Part D Policy/
Medicare Drug Benefit Group
Background
• CMS continues to receive disputes and appeals
when a manufacturer believes that a drug
should be covered under Part B
• One cannot assume a drug is Part B because:
• it is an injectable, or
• it is on the Part B fee schedule, or
• it is administered in the physician’s office
Part B vs. Part D
Determinations Overview
By statute Part D
drugs exclude
drugs payable
under
Parts A or B
Making coverage
determinations
between Part B
drugs and Part D
drugs is often
difficult
Coverage may be
based on
beneficiary
characteristics or
medical use of the
drug
Distribution Methods for Physician-Administered
Medications are Changing
• Traditionally, physicians have purchased medications,
administered them to patients, and billed for
reimbursement
• Reimbursement practices have changed physician
incentives for purchasing and maintaining medications
• Now beneficiaries may:
– Obtain medications from a network pharmacy and
bring the medication to their physician’s office or
hospital for administration (Brown Bag)
– Use medications delivered directly to physician’s
practice (White Bag)
Part B vs. Part D Determinations
• A drug dispensed by a pharmacy may be covered under Part B or Part D
depending upon the form of the drug, how it is being used in treatment
and the medical condition for which the drug is being prescribed
• A vaccine may be covered under Part B or Part D
• The Part D Sponsor is ultimately responsible for making the initial Part D
coverage determination and review prescription details
– use the pharmacist’s report of information included with the
prescription
– receive information from the beneficiary such as diagnosis (such as
whether it is related to a Medicare covered transplant) or route of
administration (such as delivered via Durable Medical Equipment)
– impose prior authorization requirements to determine Part B vs. Part
D coverage
Examples of Drugs Often
Covered Under Part B
B Drugs
are furnished
“incident
to” a physician’s service
Billed by physicians and Part
typically
provided
in physicians’
offices
• Chemotherapy and Oral Anti-Emetic Drugs used as part of a chemotherapy regimen
• Antigens prepared by a physician (usually an allergist)
Administered through Durable Medical Equipment (DME)
• Respiratory drugs given through a nebulizer
• Parenteral Nutrition – administered intravenously when nutrition cannot be absorbed through the intestinal tract
• Intravenous Immune Globulin (IVIG) – home infusion for the diagnosis of primary immune deficiency disease
Some drugs self-administered by the patient
• Immunosuppressive Drugs for a Medicare-Covered transplant
• Hemophilia clotting factors
Hospital outpatient drugs
• Preoperative sedation
• Barium contrast media
End Stage Renal Disease (ESRD) drugs such as erythropoietin (EPO)
• Furnished by independent and hospital-based ESRD facilities and included in the Medicare composite rate, as
well as when it is furnished by physicians
Part D Drugs
•
•
•
•
Available only by prescription
FDA approved and sold in the United States
Used for a medically-accepted indication
Includes:
• Most prescription drugs and biological products
• Insulin and medical supplies associated with the delivery of insulin
• A vaccine licensed under section 351 of the Public Health Service Act
and the administration of the vaccine
• Prescription-only smoking cessation products
• Excludes:
• Over-the counter products, vitamins, weight loss/weight gain
medications, agents to promote fertility, agents when used for
cosmetic purposes, etc.
Dispute and Appeal Guidance
• Explain why the unfavorable dispute determination was
incorrect and that the discount payment likely is an error
• Specify which Medicare Part B coverage category is the basis for
the appeal
• Confirm the Service Provider ID does not represent a pharmacy
• If a drug that can be covered under Part B or Part D is
dispensed through a pharmacy, the indication or patient
setting supports being billed correctly under Part D
• The manufacturer bears the burden of proof to clearly
demonstrate the issue raised on appeal
References
•
Chapter 6, Section 20.2.2 Part D Sponsor Due Diligence in Prior Authorization of Part B
Versus Part D Coverage Determination, Medicare Prescription Drug Benefit Manual
•
Chapter 6, Section 20.1 Excluded Categories, Medicare Prescription Drug Benefit Manual
•
Chapter 15, Section 50 Definition of a Drug or Biological, Medicare Benefit Policy Manual –
Covered Medical and Other Health Services
•
Chapter 6, Section 10 Definition of a Part D Drug, Medicare Prescription Drug Benefit
Manual
•
Chapter 6, Appendix C Part B Drugs and Part D Drugs Coverage Chart - Medicare Part B
versus Part D Coverage Issues, Medicare Prescription Drug Benefit Manual
•
Memo: Medicare Coverage Gap Discount Program Dispute Resolution (Cheri Rice, 3/5/2012)
•
Memo: Not Part D Covered Drug--Part B Drug Ineligible for Discount (Cynthia Tudor,
5/31/11)
•
Memo: Additional Guidance concerning Closing the Coverage Gap in 2011 (Cynthia Tudor,
9/10/2010)
•
Reimbursement for Vaccines and Vaccine Administration Under Medicare Part D, CMS
Medicare Learning Network Matters Article, Number SE0727, Revised 1/14/2013
TPA Contact Information
Shelly Winston
Division of Part D Policy/
Medicare Drug Benefit Group
Contacting the TPA
• New TPA website - http://tpadministrator.com
• Phone
– Help Line: 1-877-534-2772 – Option 1
– Hours: Monday thru Friday 8am to 7pm ET
• General email inquiries regarding the invoicing and payment process
should be sent to [email protected]
• Webinar slides will be posted to the TPA website
• Suggestions for future webinar topics should be sent to
[email protected]
• Questions related to dispute files, EFT information, invoice
corrections http://tpadministrator.com – Website
• [email protected] - Dispute support documentation
36
Resources
• Medicare Drug Benefit Group
• Questions related to the Manufacturers Agreement, changes of ownership,
terminations, compliance / administrative-related issues, policy
• Email address is [email protected]
• Discount Program Manufacturer’s Page
• http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovGenIn/index.html?redirect=/PrescriptionDrugCov
GenIn/
• HPMS Website
Updating CMS contact and labeler code changes
• https://gateway.cms.gov - Website
• [email protected] - Password Resets
• [email protected] - Non-password access assistance
• Independent Review Entity (IRE) for Discount Program appeals.
• https://cgdpappeals.provider-resources.com/Default.aspx - Website