Medicare Part D Retiree Drug SubsidyMedicarePartD_Compliance#3_WilkinsonBenefitConsultants

Many health plan sponsors that provide retiree medical benefits have utilized the available prescription drug subsidies to help offset the growing costs of prescription drugs for their retirees.  These subsidies are made available through the Retiree Drug Subsidy (“RDS”) or Employer Group Waiver Program (“EGWP”) under Medicare Part D.

These subsidies can be significant and require a thorough understanding of the Centers for Medicare and Medicare Services (“CMS”) rules along with specialized processes and software to fully maximize the value of these subsidies.

In order to serve our clients with the best pharmacy benefit consulting services available, Wilkinson Benefit Consultants (“WBC”) has endorsed Part D Advisors, the leading provider of Part D RDS services.

Part D Advisors

Part D Advisors (“PDA”) is the nation’s most experienced Retiree Drug Subsidy (RDS) administrator for both the ongoing and reopening processes in order to enhance and optimize the value of available subsidies. Founded in 2005, PDA has processed more than 1,000 RDS applications for more than 200 Plan Sponsors who have collected over $1,000,000,000 in Retiree Drug Subsidies.  As the RDS industry’s innovator and leader, PDA handles every aspect of both ongoing and reopening RDS processes to help Plan Sponsors meet all RDS requirements and maximize their subsidy potential.

Through a unique approach and use of proprietary tools, PDA reduces the effort for Plan Sponsors which enables the plans to focus on other areas of administration. WBC conducted a thorough review of available resources for these projects, including an RFP to evaluate potential vendors.  We selected PDA due to their experience, technology and specialized staffing. They are the finest in their field.  PDA’s one-of-a-kind process and proprietary software were designed in direct alignment with the RDS program requirements, meaning they set the standard in subsidy recovery services for Plan Sponsors. With a decade of experience, PDA is the best choice for Retiree Drug Subsidy services for you and your group health plan.

Our goal is to maximize the RDS for Plan Sponsors, whether we’re working to increase a Plan Sponsor’s monthly cash flow from the RDS program or investigating previous plan years’ filings to recover additional subsidy dollars. PDA’s proprietary, custom software focuses on three primary areas:

  • Member eligibility
  • Claims matching
  • Drug filtering

PDA unmatched approach increases a Plan Sponsor’s subsidy between 8% and 15% on average, however, some plans have seen increases in their subsidy by as much as 60%!.  WBC can help you find out how to maximize the value of your plan’s Retiree Drug Subsidy.


Employer Group Waiver Plans (“EGWPs”)

The second type of retiree drug subsidy available to plan sponsors are known as EGWPs.  They can be self-funded or fully insured and may offer additional benefits beyond those available under RDS. However, the additional potential benefits come with additional clinical and administrative requirements that may or may not be the best choice for a particular group.

Plan sponsors have a number of EGWP alternatives to review and potentially choose.  Many pharmacy benefit managers (“PBMs”) offer their version, as well as programs from insurance companies and other forms of prescription drug plans (“PDPs”).

The comparison between the choices available to plan sponsors can be challenging. The offerings may vary widely based on the assumptions that are used to calculate and project the anticipated subsidy, as well as differences in administrative fees.  At WBC, we have found many PBMs overstate the EGWP subsidy in an attempt to steer their clients toward electing this option. Our experience and software enables us to fully evaluate and compare RDS vs. EGWP and the impact on your specific population, as well as alternative EGWP proposals from multiple vendors.

No one retiree drug subsidy option is best for all situations. Let us provide you with an independent and objective analysis.

New Final Regulations Create Additional Service Requirements for Plan Sponsors Receiving RDS or EGWP Subsidies


On May 18, 2016, the Department of Health and Human Services (“HHS”) published a final rule to implement Section 1557 of the Affordable Care Act (“ACA”), which prohibits discrimination in health coverage and care based on race, color, national origin, age, disability and sex.  These provisions incorporate existing federal non-discrimination law and policy and also contain some new protections. Key provisions include:

  • Extending protections against sex discrimination to health coverage and care for the first time, including gender identity discrimination within the definition of sex discrimination;
  • Codifying long-standing guidance regarding meaningful access for individuals with Limited English Proficiency (“LEP”), including the provision of free, accurate and timely language assistance services;
  • Incorporating existing law that requires reasonable modifications, effective communication, and readily accessible buildings and information technology to avoid disability-based discrimination; and
  • Prohibiting discriminatory health insurance benefit designs and including specific coverage protections for transgender individuals.

Who Must Comply?

 Covered entities subject to these rules include:

  • Group health plans that accept federal funding from HHS;
  • Insurers that participate in the Marketplace/state exchanges or otherwise receive federal funding and their related third-party administration business;
  • Employers whose primary business is related to health care; and
  • State or local governments that accept federal funding from HHS for services such as Medicaid or community health programs, but only for those programs.


Employers are covered entities if they accept the Retiree Drug Subsidy (“RDS”) from the Centers for Medicare & Medicaid Services (“CMS”) or receive funds from HHS, including for self-insured Employer Group Waiver Plan (“EGWP”), Medicare Advantage or Medicare Prescription Drug plans.


Language Services (“LEP”)

 The Limited English Proficiency (“LEP”) services may be the biggest challenge in these rules for some covered entities. The final rule requires a covered entity to provide language assistance services free of charge, and the services must be accurate, timely, and protect the privacy of LEP individuals. The final rule, as designed by the Office of Civil Rights (“OCR”) requires that a covered entity offer qualified oral interpreters or written translations to LEP individuals, if these services would reasonably provide meaningful access to that individual.

Covered entities must also post notices of nondiscrimination and taglines alerting LEP individuals that language assistance services are available. The final rule uses a state threshold, requiring these notices be posted in at least the top 15 non-English languages spoken in the state in which the entity is located or does business.

The number and type of documents that may need translated has not been defined by HHS (open enrollment materials, SPDs, etc.)  It is reasonable to assume that at a minimum, the Summary of Benefits and Coverage (“SBC”) would be deemed necessary to provide in translated versions.


Effective Date

The provisions of the final rule generally will be effective on July 18, 2016. If provisions of the final rule require changes in health insurance or group health benefit design, the rule is effective on the first day of the first plan year beginning on or after January 1, 2017.

Covered entities need to comply with the notice and tagline requirements within 90 days of the effective date (October 16, 2016).


We Have The Solution

Wilkinson Benefit Consultants (“WBC”) has created a turnkey solution for any plan sponsor that would like assistance in meeting these ACA Section 1557-related compliance requirements. Services include:

  • Support for 200+ languages
  • Document translation and interpreter experts with healthcare subject matter expertise
  • Advanced written and verbal fluency in both English and their native language
  • U.S. based translators and interpreters
  • HIPAA certified and bound by strict confidentiality and privacy agreements
  • Robust encrypted network, current certificate of PCI DSS compliance and are Safe Harbor certified
  • “Live” video conferencing for enhanced interpretation needs
  • LEP testing
  • 4-Step assessment for Individualized Covered Entity compliance to determine level of LEP services
  • 5-step written implementation plan to show documentation of a compliance program in the event of an OCR review.

If you would like to discuss these or other WBC services, please contact us for a free, no-obligation consultation.

Please note, this description is a brief summary and overview of some of the notable provisions in the ACA Section 1557 rule as it may pertain to covered entities receiving retiree drug subsidies. Plan sponsors should consult with their own legal counsel to determine whether these provisions are applicable to their plan.