Retiree prescription drug program: time to move to an Employer Group Waiver Plan (EGWP)?

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1 Retiree prescription drug program: time to move to an Employer Group Waiver Plan (EGWP)? Gail Levenson and Rich Stover

2 Today s areas of focus Overview of Medicare Part D plan Impact of health care reform and Medicare changes on retiree prescription drug options Benefits of an EGWP Implementation considerations Gail Levenson Principal, H&P Rich Stover Principal, H&P 2

3 Employer retiree Rx options pre-health care reform Retiree Drug Subsidy (RDS) Plan sponsor continues current prescription drug program Plan sponsor receives a subsidy for maintaining prescription drug benefits that is Actuarially Equivalent (AE) to standard Part D benefit RDS covers 20% to 25% of prescription drug cost Double tax benefit for corporate employers Employer Group Waiver Plan (EGWP) Employer contracts with a vendor (usually a PBM) to provide benefits that can match the employer s current plan design Eligible for direct subsidy instead of RDS Advantageous for plan that cannot satisfy AE requirements Governmentals can reflect under GASB 4

4 EGWP: how it works Employer PBM CMS Employer contracts with PBM Contract can be either self-insured or fully-insured PBM implements employer s plan design PBM receives financial subsidy from CMS PBM plan passes back all subsidies (in a self-insured plan) and charges administrative fee PBM assumes CMS compliance responsibilities 5

5 Value of RDS and EGWP pre-health care reform $ Retiree Drug Subsidy EGWP Plan 6

6 Employer retiree Rx options post-health care reform Retiree Drug Subsidy (RDS) RDS payments taxable starting in Reduces real value of RDS to taxable groups Standard Part D benefit donut hole phased out by No impact to actuarial equivalence testing Employer Group Waiver Plan Plus Wrap (EGWP+Wrap) Standard Part D benefit donut hole phased out by Additional federal funds available to EGWP - Direct subsidy - Catastrophic reinsurance - 50% brand discount from drug manufacturers in coverage gap 7

7 Medicare Part D benefits 2013 $325 Deductible 25% coinsurance between $325 and $2,970 TrOOP (True Out-of-Pocket) Limit of $4,750 5% coinsurance (or nominal copayment) after TrOOP All thresholds indexed to trend $35 estimated average monthly premium Available through PDP (Prescription Drug Plan) or MA-PD (Medicare Advantage PDP) ~$7,000 $2,970 $325 Generic Brand Medicare Reinsurance 80% Plan Pays 21% 50% Pharma Discount 79% Coinsurance Plan Pays 2.5% Plan Pays 75% $325 Deductible Plan Pays15% 47.5% Coinsurance 5% Coins 25% Coinsurance 8

8 Medicare Part D benefit changes for Deductible $325 $310 Initial Coverage Limit $2,970 $2,850 True Out-of-Pocket (TrOOP) $4,750 $4,550 Catastrophic coverage copayment for generic drugs Catastrophic coverage copayment for brand-name drugs $2.65 $2.55 $6.60 $6.35 9

9 Medicare Part D benefits 2011 and beyond Donut Hole Coverage Expanded generic and brand coverage - Donut hole filled in by % discount on brand drugs - Discount determined after any PDP provided gap coverage Year Generic Benefit Brand Benefit Brand Discount % 0% 50% % 0% 50% % 2.5% 50% % 2.5% 50% % 5% 50% % 5% 50% % 10% 50% % 15% 50% % 20% 50% % 25% 50% - Pharmacy discounts and additional federal subsidies make EGWP more valuable relative to RDS 10

10 Health care reform changes value of RDS and EGWP Direct subsidy and catastrophic reinsurance $ Tax exclusion eliminated in % brand discount Retiree Drug Subsidy EGWP+Wrap Plan 11

11 Projected Part D External Financing for EGWP+Wrap vs. RDS DS, Catastrophic, Brand Discount Direct Subsidy (DS) RDS Average annual external financing amounts expected per enrollee EGWP+Wrap will enjoy federal direct subsidy, catastrophic reinsurance and manufacturer brand discounts Source for RDS and Direct Subsidy: 2010 Annual Report of the Board of Trustees of the Federal Hospital Insurance and Federal Supplemental Medical Insurance Trust Funds (8/5/2010) Brand discount is estimated. 12

12 Medicare Trustees expect RDS participation to decline 100% 90% 80% 70% 60% 50% 40% 30% 20% About 20% of beneficiaries participating in Part D were covered by [the retiree drug] subsidy in As a result of [healthcare reform] changes, RDS program participation is assumed to decline quickly to about 2% in 2016 and beyond. 10% 0% Source: 2010 Annual Report of the Board of Trustees of the Federal Hospital Insurance and Federal Supplemental Medical Insurance Trust Funds (8/5/2010) PDP & MA-PD RDS 13

13 Employer Group Waiver Plan Plus Wrap (EGWP+Wrap): alternative to RDS Employer contracts with a vendor (usually a PBM) to provide prescription drug benefits that can match the employer s current plan design through two Rx plans: - EGWP provides standard Part D benefits - Wrap Plan fills in the gaps to keep retirees whole This approach leverages Pharma discounts and government subsidies - Can take advantage of the closing of the Medicare Part D donut hole Member disruption is limited (but not zero as with RDS) - One ID card for two Rx plans single transaction coordination of benefits 14

14 EGWP examples Plan design (in donut hole) $200 cost for brand drug 20% coinsurance Rx Payment Coverage Current Plan EGWP EGWP + Wrap Gross Cost $200 $200 $200 Base Plan Pays $160 $160 $5 Discount N/A $20 $100 Wrap Plan Pays N/A N/A $55 Retiree Pays $40 $20 $40 15

15 Recent regulatory guidance CMS guidance on wrap - Guidance issued in 2012 appeared to eliminate need for wrap - Subsequent CMS guidance confirms wrap is still required ACA guidance has clarified the application of various ACA fees and taxes to EGWPs - Transitional reinsurance fee - Insurer fee Insured wrap programs may be subject to state regulations 16

16 Key variables in financial analysis Risk Score Size of LIS Population Contribution Strategy Generic Utilization Cash Flow Admin Fees Discounts and Rebates Formulary Volatility CMS provides greater reimbursement to EGWP plans covering sicker retirees CMS provides greater reimbursement for low-income retirees. These funds passed to the retiree What savings are shared with retirees through contributions. Particularly under a capped retiree medical plan CMS reimbursement to EGWP is independent of changes in generic substitution rates CMS reimbursement via EGWP is provided substantially sooner than RDS annual filers EGWP fees may not be very competitive yet; consider RDS admin costs as an offset EGWP is a separate contract from your normal Rx benefit; watch for lost economies with the non-medicare population. Any difference in formulary restrictions between RDS plan and replicated EGWP plan could impact savings EGWP provides the ability to gain stability in yearly costs by insuring 17

17 Are you a candidate for an EGWP? An employer participating in the RDS program A non-taxable entity A taxable entity with little or no tax liability An employer offering prescription drugs to Medicare-eligible retirees A plan sponsor with a drug plan that does not pass the actuarially equivalence test for RDS A government entity that wishes to reflect Medicare D impact in its GASB 43/45 accounting A post-65 retiree program with more than 100 eligible retirees and dependents 18

18 Implementation considerations Number of post-65 Medicare-eligible retirees and Medicare-eligible dependents - Fully insured vs self insured - Minimum number of lives vary by PBM - There are several PBMs who will self insure a relatively small number of retirees (e.g., 250) Internal resources to support implementation Timing of implementation: preferably 6 months 19

19 Implementation considerations Clinical Formulary - CMS requires certain drugs to be covered and others to be excluded - Brand drugs covered on the formulary are limited to eligible drugs by manufacturers who agreed to participate in the coverage gap discount program. This list is updated periodically by CMS. - PBM can perform formulary disruption analysis - Formal formulary exception process available to retirees for nonformulary drugs (can cover in wrap) Special programs (e.g., step therapy, prior authorization, dose optimization, etc.) may be impacted - CMS has more stringent requirements on the management of medications for the Med D program 20

20 Plan design considerations No mandatory mail - 90-day supply must be allowed at retail if a mail service benefit is offered - May charge 3 copays for retail 90-day supply No mandatory generic - No penalties allowed for dispensing brand when generic is available Catastrophic coverage - Plan cannot exceed the CMS standard member cost-share limit of approximately 5% - Benefit to both member and Plan as government reimburses 80% of the cost 21

21 How does the Wrap work? Covers drugs not included on the PBM s Medicare Part D formulary Covers drugs excluded by Medicare, such as prescription drugs for cough and cold, erectile dysfunction, etc. Allows you to offer the same plan design available through your commercial plan, including copayments, coinsurance, and maximum out-of-pocket, if applicable 22

22 Employer administrative issues Member Health Insurance Claim Number (HICN) required for eligibility - Can be very difficult to gather HICNs Low income subsidies - Provides premium and benefit assistance for low income participants - Represents those up to 150% of the FPL - Premium subsidies must be reimbursed directly to the individual within 45 days of receipt (on a monthly basis) - Administrative challenge for most employers Benefit assistance happens at point of service - Lower coinsurance/copays for low-income participants - Plans reimbursed on an annual basis for the reduced costs to the participant 23

23 Employer administrative issues (cont d) High income penalties - Individuals/couples making greater than $85,000/$170,000 pay higher premium for Medicare Part D coverage - Determined by Social Security Administration (SSA) and happens directly through Social Security deductions - Employer is not notified - Employer can choose to reimburse retiree Late enrollment penalties Integrated deductibles/maximum out-of-pockets - Will not work for EGWP plans Split Families - EGWP and non-egwp family members - Each retiree must be provided separately 24

24 Member communications Integral part of a successful implementation - Plethora of Medicare-required communication sent by PBM - PBMs vary on what customization they will allow - Customized employer communication recommended as other communication from government/pbm may be confusing and not applicable - Recommend having comprehensive communication plan to coordinate between PBM-generated communication and employer-generated communication 25

25 Retiree issues New Rx card/new rules - Generally transparent and/or beneficial to retiree Late enrollment penalties and additional premium for high-income - disruptive Required communications to retirees Employer can not force retirees to enroll in EGWP must allow them to opt out Medication Therapy Management Program (MTM) - Auto-enroll required for those with certain conditions or drugs - Participant can opt out Minor differences may exist in formulary, network, and therapeutic management Retiree confusion 26

26 Case study Large self-funded employer Approximately 15,000 Medicare-eligible retirees Previously receiving RDS Implementation - Implemented for 1/1/ Started implementation in March 2012 Savings - Implemented Cash savings approximately $5 million over RDS - The associated FAS Expense savings for 2012 were roughly $38 million - Employer s year-end 2011 APBO was reduced by $340 million due to the EGWP. 27

27 EGWP + Wrap Considerations Pros: Economic savings expected with this approach Can account for now even if delay implementation to 2015 Efficient approach to obtain federal Part D subsidies and the 50% brand discount Can replicate current level of Rx benefits No more RDS compliance Cons: Can PBM administer almost seamlessly Communicating and implementing changes may be challenging Formulary control Restrictive generic not allowed Mandatory mail not allowed Caps on employer cost can limit employer savings 28

28 Next steps If you are considering moving to an EGWP - Contact your Buck Account Executive to set up a call to discuss next steps - Savings analysis - EGWP 101 discussion - Schedule a call with our EGWP experts 29

29 Questions? Gail Levenson Rich Stover

30 Join the conversation on Buck s social media channels blog.buckconsultants.com linkedin.com/company/buck-consultants twitter.com/buckconsultants facebook.com/buckconsultants

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