2025年D部分雇主团体豁免计划（EGWP）的财务影响

2025Financial Impactsfor Part DEmployer Group Waiver Plans (EGWPs)2.Federalreinsurancewill decreasefrom 80%of allowedcost in the catastrophic phase for all drugs to20% ofapplicable(brand)drugand 40% of non-applicable(generic)drugallowedcost abovetheMOOP.This isexpected to increase EGWPnet premiums.3.Pharmaceutical manufacturerpayments will changefrom 70% of applicable (brand) drug costin thecoveragegapfor non-low incomemembersto10% of applicable(brand)drug cost above the deductible/below MOOP,and 20% of applicable(brand)drugcostabove MOOP forallmembers.Manufacturerpaymentswill bephased-in for“specified”and“specified small”manufacturers.This mayincrease or decrease EGWPnet premiums, depending onlow-income and drug type mix.AppendicesA.1 andA.2illustratethe defined standard Part Dplan design for2024 and 2025, respectively.For additionaldetail on theIRAchanges, please refer toMilliman’sarticle:Weathering the Reform Storm.Results andAnalysisHIGH-LEVEL IMPACTSFigure 1 illustrates theestimatednet premiumimpact due tothe Part D benefit redesignfor three EGWP scenarios, asdescribed below. Please refer to theAssumptions andMethodology section for additional detail oneach scenario.1.Defined Standard: Part D defined standard benefit, with fulldeductible and 25% coinsurancefor all drugs.2.Coinsurance Design: No deductible, $0 generic copays,25% preferred brand coinsurance, 50% non-preferredbrand coinsurance, and 33% specialty drug coinsurance.3.Copay Design: No deductible, $0 generic copays, $25preferred brand copays, and $50 non-preferred brand /specialty drug copays.As illustrated in Figure 1, all tested scenarios result in a Part DEGWPnet premiumincrease. The impact is higher for thecoinsurance-based design, withnet premiumincreasesupto$50PMPM,approximately40%greaterthanthe impactfor thecopay design, which shows animpact of$35PMPM.FIGURE1:ESTIMATED PART D EGWPNET PREMIUMIMPACT,2024-2025$75$110$170$120$160$205$0$50$100$150$200$250Defined StandardCoinsurance DesignCopay Design20242025+$35+$50+$45 January 2024EGWPsare facing both financial headwinds and tailwinds for2025 thatwill affect groupsdifferently:▪As aheadwind, member cost-sharing will decrease due tothePart DMOOP. The impact of the MOOP will varybased on the existing benefits anddrug mix.▪As an additionalheadwind, federal reinsurance isdecreasingdue to the benefit redesign. This change ismore impactful forgroupswith leaner benefit designs,such as the coinsurance design illustrated here.▪As a tailwind, the direct subsidy is expected to increase, atleast partially offsetting the plan liability changes.▪Pharmaceutical manufacturer payments could increase ordecrease, depending on the underlying population anddrug mix for a particular group.We estimate the net impact of these changes,combined withtrends into 2025 for drugutilization and cost, will increasenetpremiumfor thetestedEGWPdesigns.Many of the changesaffecting EGWPs are similar to dynamics we expect to occur inthe Individual Medicare market, butchanges in EGWPpremiums do notinfluencethevalue of thedirect subsidy.IMPACTS BY STAKEHOLDERFigure 2 illustratesthe breakdown ofPart Dstakeholder costsfor 2024and2025 for the coinsurance andcopaydesigns,respectively.These exhibits illustrate the following impacts bystakeholder:1.Member: Member cost-sharing decreases for both thecoinsuranceand copaydesigns in 2025, due to theintroduction of the MOOP.Memberswith a coinsurance-based design see a large decrease in cost-sharing, onaverage, whilemembers in the copay-based design see amore limited impact. We explore member cost-sharingimpacts in more detail in the next section.2.Pharmaceutical Manufacturers:We estimatepharmaceutical manufacturer paymentscould increase ordecrease in2025 for EGWPs as a percentage of allowedcost. We expectEGWPs with greater specialty drug useand/or a higher concentrationof low income (LI) membersare more likely to see an increase in manufacturerpayments, while EGWPs with a lower concentration inbrand drug costs are more likely to see a decrease.3.Federal Government: We estimate a material decrease infederal reinsurance, which will be at least partially offset byan increase in the direct subsidy. The reinsurancedecrease will be more impactful for coinsurance-baseddesigns, where members accelerate more quickly tothecatastrophic phasein 2024compared to copay-baseddesign. Direct subsidy impacts will vary based on the riskscoreof the underlying population, after accounting forthe2025 risk score model change. January 2024Figure 3 illustrates the average member cost-sharing formemberswith greater than $10,000 in annual allowed cost foreach of the three benefit designs tested. Although all memberswith this level of spendingare expected to reach the MOOP,the cost-sharing varies by benefit design, due to theaccumulation of cost-sharing to the MOOP (i.e.,thegreater ofdefined standard and actual cost-sharing).ThisMOOPaccumulationdynamic results insome members paying far lessthan the $2,000 MOOP, particul