employer group waiver plans egwps marty abeln – part c kathryn jansak – part d september 5, 2012...
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Employer Group Waiver PlansEmployer Group Waiver Plans
EGWPs
Marty Abeln – Part CKathryn Jansak – Part D
September 5, 2012
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Statutory Waiver Authority for MAOsStatutory Waiver Authority for MAOs
• Section 1857(i) of the Social Security Act:[Medicare Advantage] Program Compatibility with Employer or Union Group Health Plans – (1) CONTRACTS WITH MA ORGANIZATIONS – To facilitate the
offering of [Medicare Advantage] plans under contracts between [Medicare Advantage] organizations and employers, labor organizations, or the trustees of a fund established by one or more employers or labor organizations (or combination thereof) to furnish benefits to the entity’s employees, former employees (or combination thereof) or members or former members (or combination thereof) of the labor organizations, the Secretary may waive or modify requirements that hinder the design of, the offering of, or the enrollment in such [Medicare Advantage] plans
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Statutory Waiver Authority for Part DStatutory Waiver Authority for Part D
• Section 1860D-22(b) of the Social Security Act:• Application Of MA Waiver Authority — The provisions of
section 1857(i) shall apply with respect to prescription drug plans in relation to employment-based retiree health coverage in a manner similar to the manner in which they apply to an MA plan in relation to employers, including authorizing the establishment of separate premium amounts for enrollees in a prescription drug plan by reason of such coverage and limitations on enrollment to part D eligible individuals enrolled under such coverage
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Chapter 9 Updated for 2012Chapter 9 Updated for 2012
• Chapter 9 of the Medicare Managed Care manual (Employer/Union Sponsored Group Health Plans) recently updated to include all Part C waivers
• Update to Chapter 12 of the Prescription Drug Benefit manual coming soon
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Two EGWP CategoriesTwo EGWP Categories
Two basic categories of EGWPs:• “800 series” EGWPs – plans offered by third
parties (PDPs and MA organizations) to employer and union group sponsors. Employer contracts with a third party which in turn functions as the plan sponsor (Represents majority of EGWPs)
• Direct Contract EGWPs (“E contracts”) – plans offered by employers or unions that directly contract with CMS to become PDP sponsors or MA organizations for their members
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DefinitionsDefinitions
EGWPs – Employer Group Waiver Plans:• EGWPs are employer-only MA plans (800 series) that
may take advantage of CMS waivers to provide Part C and/or Part D benefits to Medicare beneficiaries
EGHPs – Employer Group Health Plans: • Employer plans offered through individual MA plans
(see Chapter 9, Sections 10.2, 20.0-20.2)• These plans do not qualify for waivers available to
employer only (800 series) MA plans
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Definitions (cont’d)Definitions (cont’d)
Employment-based Coverage - Employer group plans cannot be used to enroll association group members when there is no “employment-based” coverage provided (see Chapter 9, Section 30.1)
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EligibilityEligibility
• Enrollees of both EGHPs and EGWPs must qualify for Part C and D coverage
• In order for a beneficiary to be eligible to enroll in an EGHP or EGWP, he or she must permanently reside in the defined service area of the plan
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EnrollmentEnrollment
• EGHPs and EGWPs may enroll via Group Enrollment Mechanism– Must include an opt-out process with advance
notification requirements– Section 40.6.1 in Ch. 2 and Ch. 3
• EGHP Special Enrollment Period– Enroll in EGHPs during time periods specified by
employer– May disenroll from EGHPs at any time– Always in effect for enrollees of EGHPs– Ends two months after loss of coverage or notification9
Same Rights and ProtectionsSame Rights and Protections
• Beneficiaries in EGWPs and EGHPs are entitled to all rights and protections (e.g., Medicare grievance and appeals processes) that are available to enrollees in individual MA and PDP plans
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Final Rule: 4157-FC on EGWPs(77 Fed Regs 22072, April 12, 2012)
Final Rule: 4157-FC on EGWPs(77 Fed Regs 22072, April 12, 2012)
II.A.1.f(4) Coverage Gap Discount Program• Clarifies that all supplemental benefits offered
by employer group waiver plans are considered other, non-Medicare health coverage always paid after the discount has been applied
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Final Rule: 4157-FC on EGWPs(77 Fed Regs 22072, April 12, 2012) (cont’d)
Final Rule: 4157-FC on EGWPs(77 Fed Regs 22072, April 12, 2012) (cont’d)
II. E.10 Employer Group Waiver Plans Requirement to Follow All Part D Rules Not Explicitly Waived – Underscores that, regardless of CMS waiver of
certain requirements (such as benefit package review), all EGWPs must meet all other Part D requirements unless explicitly waived or modified by CMS
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RDS conversion to EGWPsRDS conversion to EGWPs
• More RDS plans converting to EGWPs– Recent change in the law
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Total 2012 MA Plan Enrollment – 13.7 Million Employer and Non Employer
Total 2012 MA Plan Enrollment – 13.7 Million Employer and Non Employer
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Total 2012 PDP Enrollment – 19.9 Million Employer and Non Employer
Total 2012 PDP Enrollment – 19.9 Million Employer and Non Employer
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2010 – 2012 MA Employer Plan Countsand Enrollment
2010 – 2012 MA Employer Plan Countsand Enrollment
Number Plans by Year
bar chart and data table
CY 2009 CY 2010 CY 2011 CY 20120
200
400
600
800
1000
1200
1400
MSAPFFSRegional PPOLocal PPOHMOPOSHMO
2009 2010 2011 2012HMO 565 492 488 503
HMOPOS 114 89 147 101Local PPO 411 352 265 308Regional
PPO 94 68 71 59PFFS 200 108 23 7MSA 7 3 2 2
Enrollment in 1000s
bar chart and data table2009 2010 2011 2012
0
500
1000
1500
2000
2500
MSAPFFSRegional PPOLocal PPOHMOPOSHMO
2009 2010 2011 2012HMO 972 1015 957 965
HMOPOS 40 40 89 122Local PPO 104 269 791 124Regional
PPO 12 228 275 35PFFS 723 418 15 0MSA 0 0 0 0
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2008 – 2012 Employer PDP Enrollment2008 – 2012 Employer PDP Enrollment
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ResourcesResources
• Guidance References: Medicare Managed Care Manual Chapters
• Chapter 2 – Medicare Advantage Enrollment and Disenrollment (Updated August 2012)
http://www.cms.gov/Medicare/Eligibility-and-Enrollment/MedicareMangCareEligEnrol/Downloads/FINALMAEnrollmentandDisenrollmentGuidanceUpdateforCY2012-Revised872012forCY2013.pdf
• Chapter 4 – Benefits and Beneficiary Protections (Updated June 2012)
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c04.pdf
• Chapter 9 – Part C - Employer/Union Sponsored Group Health Plans (Updated June 2012)
http://www.cms.gov/Medicare/Health-Plans/HealthPlansGenInfo/index.html
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ResourcesResources
• Guidance References:
http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/PartDManuals.html
Prescription Drug Benefit Manual• Chapter 2 PDP – Eligibility, Enrollment, and Disenrollment• Chapter 12 – Part D - Employer/Union Sponsored Group
Health Plans
Part D EGWP website http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/PartD-EGWP.html
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