Medicare Affiliated Plans

A Group Medicare Advantage plan, also known as Employer Group Waiver Plan (EGWP), is a type of Medicare Advantage plan offered by some employers to their retired or retiring employees. It may offer more benefits than traditional Medicare Advantage plans. EGWP are provided by private insurance companies who manage fully-insured large group customer's retiree Membership benefits. The different parts of Medicare that EGWPs cover are:

• Part A - Medicare Part A insurance is the portion that pays for hospital costs, such as inpatient hospital care or rehabilitation facility care related to illness or injury.

• Part B - Medicare Part B is the Medicare portion that pays for doctor visits and related medical costs, including emergency care when you are not admitted.

• Part D - Medicare Part D is the prescription drug coverage portion of Medicare. Most prescription drug coverage plans involve different "tiers" of medications where you may pay little to no costs for generic medications and a greater portion of costs for name-brand medicines.

The system enables you to create and edit a policy plan from the user interface or through a health care inbound message. While creating a Medicare Affiliated policy plan, you must set the benefit type to Medicare Affiliated. While defining a Medicare Affiliated policy plan, you need to specify either a price item or at least one pricing rule type. The price item given in the policy plan is used to create a pass-through billable charge for pre-calculated premium amount which is received through a health care inbound message.

Alternatively, you can associate a pricing rule type with a policy plan. You can associate the age based, tier based, pass-through billable charge, and/or benefit pricing rule types with a Medicare Affiliated policy plan. If you associate an age based pricing rule type with the policy plan, the system calculates the Medicare premium for Part A, Part B, and/or Part D for eligible members using the age based pricing rule type. If you associate a tier based pricing rule type with the policy plan, the system calculates the Medicare membership premium for Part A, Part B, and Part D using the tier based pricing rule type. This membership premium is then charged through the SQI based billable charge. The charge is billed to either of the following depending on the billing arrangement which is defined for the Medicare membership:

• Bill Group of the Fully-Insured Group Customer

• Financially Responsible Member Person

The system considers the low income subsidy (LIS) and late enrollment penalty (LEP) while calculating the Medicare Part D premium. If you associate a benefit pricing rule type with the policy plan, the system determines the price items through which LIS and LEP should be charged.

If you associate a pass-through billable charge pricing rule type with the policy plan, the system creates an SQI based billable charge using the pass-through billable charge pricing rule type whenever the price item information is given, but the account information is not given in a health care inbound message. Note that if both the price item and account details are given in the billable charge information of a health care inbound message, the system directly creates the SQI based billable charge for the pre-calculated premium and does not refer to the pass-through billable charge pricing rule type which is associated with the policy plan.

The system enables you to prorate the Medicare premium using the proration rules defined for the fully-insured group policy plan. A proration rule indicates how you want to prorate the membership premium on various events, such as enrollment, termination, etc. For more information, refer to Premium Proration Rules.