EGWPs - Onstream Media

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Employer Group Waiver Plans
EGWPs
Marty Abeln – Part C
Kathryn Jansak – Part D
September 5, 2012
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Statutory 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
2
Statutory 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 employmentbased 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
3
Chapter 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
4
Two 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
5
Definitions
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
6
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)
7
Eligibility
• 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
8
Enrollment
• 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
notification
9
Same 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
10
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
11
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
12
RDS conversion to EGWPs
• More RDS plans converting to EGWPs
– Recent change in the law
13
Total 2012 MA Plan Enrollment – 13.7
Million Employer and Non Employer
14
Total 2012 PDP Enrollment – 19.9 Million
Employer and Non Employer
15
2010 – 2012 MA Employer Plan Counts
and Enrollment
Number Plans by Year
2500
MSA
PFFS
Regional PPO
Local PPO
HMOPOS
HMO
MSA
2000
PFFS
1500
Regional PPO
1000
Local PPO
500
HMOPOS
HMO
0
2009
CY 2009 CY 2010 CY 2011 CY 2012
HMO
HMOPOS
Local PPO
Regional
PPO
PFFS
MSA
bar chart and data table
bar chart and data table
1400
1200
1000
800
600
400
200
0
Enrollment in 1000s
2009
565
114
411
2010
492
89
352
2011
488
147
265
2012
503
101
308
94
200
7
68
108
3
71
23
2
59
7
2
HMO
HMOPOS
Local PPO
Regional
PPO
PFFS
MSA
2010
2011
2012
2009
972
40
104
2010
1015
40
269
2011
957
89
791
2012
965
122
124
12
723
0
228
418
0
275
15
0
35
0
0
16
2008 – 2012 Employer PDP Enrollment
17
Resources
• Guidance References:
Medicare Managed Care Manual Chapters
• Chapter 2 – Medicare Advantage Enrollment and
Disenrollment (Updated August 2012)
http://www.cms.gov/Medicare/Eligibility-andEnrollment/MedicareMangCareEligEnrol/Downloads/FINAL
MAEnrollmentandDisenrollmentGuidanceUpdateforCY2012Revised872012forCY2013.pdf
• Chapter 4 – Benefits and Beneficiary Protections (Updated
June 2012)
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/mc86c04.pdf
• Chapter 9 – Part C - Employer/Union Sponsored Group
Health Plans (Updated June 2012)
http://www.cms.gov/Medicare/Health18
Plans/HealthPlansGenInfo/index.html
Resources
• Guidance References:
http://www.cms.gov/Medicare/Prescription-DrugCoverage/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-DrugCoverage/PrescriptionDrugCovContra/PartD-EGWP.html
19
Contacts
• Part C – Marty Abeln
[email protected]
• Part D – Kathryn Jansak
[email protected]
20

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