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CCH® BENEFITS — 10/26/10

Additional Details On Reimbursement Exclusions In the Early Retiree Reinsurance Program

from Spencer’s Benefits Reports: The Department of Health and Human Services (HHS) has published two new documents regarding reimbursements under the Early Retiree Reinsurance Program (ERRP). The first document, Procedure Codes Ineligible for Reimbursement, contains a detailed listing of Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding System (HCPCS) codes that represent items and services that are excluded from reimbursement under the ERRP and that will not count toward the ERRP cost threshold or cost limit.

The second document is a downloadable spreadsheet with line-by-line codes and descriptions that includes all of the referenced excluded CPT and HCPCS codes contained in Procedure Codes Ineligible for Reimbursement. The documents are followups to earlier guidance published last month.

Excluded Items And Services

In general ERRP will not credit toward the program cost threshold or reimburse for claims submission purposes items and services, such as the following:

• custodial care by non-medical personnel;
• routine foot care, personal comfort items;
• routine services and appliances for vision;
• hearing aids and auditory implants; and
• routine dental services.

ERRP also will not credit or reimburse for assisted suicide, cosmetic surgery (except when required for the prompt repair of an accidental injury or for the improvement of the functioning of a malformed body part), and items or services not furnished in the United States.

Prescription Drugs

The HHS indicated that it is the plan sponsor’s responsibility to determine if a drug would be covered by a standard Medicare Part D plan. The following are excluded from both Medicare Part D coverage and credit or reimbursement under ERRP:

• Agents when used for anorexia, weight loss, or weight gain (even if used for a non-cosmetic purpose (i.e., morbid obesity)).
• Agents when used to promote fertility.
• Agents when used for cosmetic purposes or hair growth.
• Agents when used for the symptomatic relief of cough and colds.
• Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations.
• Nonprescription drugs.
• Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee.
• Barbiturates.
• Benzodiazepines.
• Agents when used for the treatment of sexual or erectile dysfunction.

The HHS also indicated that a sponsor may use the Food and Drug Administration (FDA) National Drug Codes (NDC) Directory to help it determine if a drug could be a Part D drug. If a drug is on the FDA’s NDC Directory and otherwise meets the definition of a Part D drug, as discussed in CMS and Part D Formulary Guidance, the drug is likely a Part D drug.

For more information, visit http://errp.gov/news_events.shtml.

For more information on this and related topics, consult the CCH Pension Plan Guide, CCH Employee Benefits Management, and Spencer's Benefits Reports.

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