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Dco slides new hire training Dco slides new hire training Presentation Transcript

  • Deductibles, CAPs, Out-of-Pocket (OOP)
  • DED, CAP and OOP
    • Commonly referred to as DCO
    • Critical Concepts
      • DED and OOP are driven by what the MEMBER pays
      • CAP is driven by what the CLIENT pays
    • Basic Example of plan Design with DCO
  • Deductibles/Caps/OOP Benefit Phases (Definitions)
    • DED and OOP are driven by what the member pays
    • CAP is driven by what the client pays
    TERM ABBREVIATION DEFINITION Deductible, Cap, Out of pocket operations DCO ops DCO ops can be reached via email at Medco DED Group Deductible DED Deductible is the amount which the member must pay before the full prescription benefit takes effect. (Copay) Out of Pocket OOP Out of Pocket tracks the amount which the member spends, such as copay and at times the DED. Once the OOP is met the member’s copay is either lowered or eliminated based on how the client requires the benefit to be administered. Cap CAP Cap is the amount which the client chooses to cover for a benefit period (Net Check amt) Lifetime cap LTC LTC is the amount which the client chooses to cover over the lifetime of a member Drug specific cap RX specific Drug specific cap ID can be used to manage drug specific Ded, Cap and Oop benefits (inclusion and exclusion)
  • DCO Plan Phase Examples Basic DED, CAP and OOP only Complex DED, CAP, OOP, Life Time Cap and Rx Specific CAP
  • Deductibles/Caps/OOPs (Member and Family Options)
    • Deductibles, Caps and OOPs can apply to a single member, family, or combination.
    OPTION DETAILS Individual with Family Total Applied to each member with a family total or limit. This is also knows as embedded benefits. No member will pay more than the individual limit and no family will pay more then the family limit. Individual Applied to each member in a family without a family total. Family Total Applied when any of the family members reach the total. Non-embedded Applied to individual or family benefits based on eligibility coverage code. Non-embedded options are available for DED and OOP (options N)
  • Individual with Family Example Claims are applied to each member with a family total or limit. This is also knows as embedded benefits. No member will pay more than the individual limit and no family will pay more then the family limit. $50 Dollar Individual Limit $75 Family Limit No member will pay more than the individual limit and no family will pay more then the family limit.
  • Individual Only Each claim applied to each member’s individual accumulation. Each member must meet their individual accumulation before moving to next phase.
  • Family Only Claims are applied to a family limit only. Once the family limit is meet every member will move into the next benefit phase .
  • Individual or Family (Non Embedded) Members in the same group either have a individual or family limit based on eligibility coverage code. Individual Coverage Code Family Coverage Code
  • Deductibles/Caps/OOPs (Claim Types)
    • Clients may establish Deductibles, Caps, and OOP limits for the following claim types (channels):
        • Retail card
        • Home delivery
        • Retail Mail Separate
        • Combined – includes all retail and mail claims
        • Direct claims either separately or in combination (Directs default to retail unless other wise specified in the setup)
    • The channel of the benefits are driven by the DCO types on Client Profile screens 8, 9 and 10.
  • Channel Example Retail Only. Retail claims would apply to accumulation. Mail Claims would bypass phase. Mail Only. Mail claims would apply to accumulation. Retail Claims would bypass phase. Retail Mail Combined. Retail and Mail claims would apply to same accumulation. Retail Mail Separate. Retail apply to retail accumulation and Mail apply to mail accumulation.
  • Deductibles/Caps/OOPs (Benefit Accumulation Period)
    • DCO benefits accumulations are driven by the combination of the following fields:
    • DCO data effective dates
      • These dates drive when the DCO types, options and features such as apply brand generic difference, become effective.
    • DCO benefit period start dates
      • These dates drive when the benefit starts accumulating
    • DCO benefit period
      • This is the length of the benefit period.
      • It works along with the benefit period start date to determine when the benefits start and roll to the new benefit period.
      • Lifetime cap (LTC) does not have a benefit period start date or a benefit period. The benefit start date is the same as the data effective date
      • Rx specific cap benefit period start date is driven by the effective date of the drug specific drug list
  • Deductibles/Caps/OOPs (Drug Specific benefits)
    • DCO benefits can be setup with various features to drive which claims apply towards the benefits such as:
      • Drugs by source code (single source, multi source, generic)
      • Formulary status
    • Benefits can also be setup at the drug specific level using cap drug lists
      • Cap Drug lists can be used to include or exclude specific drugs from the benefits by using the cap drug type, option and cap ID and cap drug lists
  • Driving Member Behavior Using DCO
    • DCO functionality can be leveraged to promote member behavior.
      • Excluding penalties from applying to members accumulators to keep member in phase longer.
        • Brand Generic Penalties
        • Out of Network Penalties
        • Retail Refill Allowance Penalties
        • Formulary Penalties
  • Accumulation Corrects (Driven by Client Profile Screens)
    • If claims have processed incorrectly two methods exist to correct a members accumulation
      • Re-Pricing
        • Claims are re-adjudicated for a specific period of time
          • Members and or clients may reimbursed
      • Manual Intervention
        • Update records can be written to the members file to update the accumulation
        • Only used under specific situations
  • Deductibles/Caps/OOPs Resources (Driven by Client Profile Screens)
    • Deductible, Cap and Out of Pocket benefits are driven by Client Profile screens:
          • 8 – Deductible (DED)
          • 9 – Out of Pocket (OOP)
          • 10 – Lifetime Cap (LTC ), Rx specific cap and benefit cap
          • 33 – Benefit Calculation Indicator (AAA)
      • For any additional details please contact the Medco DED Group Mail box.