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Part D Data Implementation November 1, 2005

Part D Data Implementation November 1, 2005. Shannah Koss Avalere Health LLC. Part D Ramp Up. The intersection of business strategy and public policy. Medicare Modernization Act Creates Medicare Part D Prescription Drug Benefit.

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Part D Data Implementation November 1, 2005

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  1. Part D Data ImplementationNovember 1, 2005 Shannah Koss Avalere Health LLC

  2. Part D Ramp Up The intersection of business strategy and public policy

  3. 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

  4. 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.

  5. Estimated Transaction Volumes Illustrative transaction volumes using prescription estimates based on CMS and Partnerships For Solutions data

  6. The intersection of business strategy and public policy Part D Complexities

  7. PDP Plan Options 41 41 ME WA 45 MT VT ND 44 NH MN OR NY 46 WI 45 MA 52 ID CT SD MI 40 RI WY PA NJ 44 44 IA OH 43 NE DE IL 42 IN MD 47 NV 44 UT WV 42 D.C. VA 41 CA 47 CO 43 KS 40 MO 41 KY NC 38 TN 41 SC 41 AR 40 OK 42 NM 43 AZ 43 GA 42 AL MS 38 LA 39 TX 47 AK 27 FL 43 HI 29 Data released 09/30/05 by CMS

  8. Primary Claim-Direct Connect Claim & Eligibility Transactions Claims Router Claims Router Claims Router TrOOP Facilitation Request transaction Response transaction Enrollment & COB Transactions Enrollment Files Medicare Eligibility Employers VDSAs Primary Claim -OR- Pharmacy Part D Plan Payers TPAs Medicare Eligibility Bene IEQs Enrollment Files OHI Second Claim… E1 Eligibility Query available to pharmacies COB Contractor Part D Plan RxBIN, RxPCN, RxGRP, RxID COB Part D Membership File With RxBIN, RxPCN, RxGRP, RxID Primary, Secondary… MBD ThirdParty N Transaction Check Elig? Change Transaction Secondary Payers may create N to TF in certain situations MARx Part D Plan SecondaryPayer(s) Copies of N Enrollment 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 PDE Plan Discovers other Coverage? DDPS Source: CMS 8/30/05 conference presentation Transaction formats are NCPDP V5.1

  9. How Will It Work? • CMS slides excerpt from Medicare Advantage and Prescription Drug PlansEnrollment 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.

  10. 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

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