Q&A: Your Top Questions About EGWP


As the popularity of Group Medicare Advantage, or Employer Group Waiver Plans (EGWP), continues to build, so too has the interest from health plans considering expanding into this market type.

As experts in EGWP Convey along with our affiliate business, HealthScape Advisors understand the complexities of operating these types of plans, and the requirements for EGWP success.

Together, we addressed commonly asked questions regarding EGWP during our latest webinar “How to Successfully Operate a Group Retiree Plan for MA (EGWP).”

EGWP Question #1: What is the regulatory environment around EGWP?


EGWP Question & Answer AudioFollowing regulations is a critical component to operating any health plan, whether it is a Medicare Advantage (MA) plan or an employer group waiver plan.

When writing EGWPs, people often overlook the fact that despite the many waivers, plans must adhere to all other CMS regulatory requirements. EGWPs can have different enrollment periods that are specific to each employer, allow for mid-year benefit customizations, and more, making this type of program more complex to operate than a traditional MA plan. Read more about Group vs. Individual Medicare Advantage

Employer group waiver plans are still subject to the same program audits, the same reporting requirements, and the same quality measurements as identified in Chapter 9 of CMS’ Medicare Managed Care Manual (MMCM).

Regulations apply just like any other MA plan, and EGWP beneficiaries are subject to those same regulatory requirements; however, employers will probably have their own set of requirements as well.

It is not uncommon on the employer side, or the client side, to have performance guarantees both on the premium and on the operational performance. This could include how your customer service representatives answer phone calls and how your service quality extends well beyond Medicare.

Suppose you are considering entering the EGWP market or are re-evaluating your existing EGWPs. You cannot overlook evaluating whether you have the right administrative pieces in place to perform at the level necessary to succeed. The unique requirements to be successful touch all areas within a health plan organization, including front office, middle office, back office, and most importantly, compliance.

Read “How to Run a Successful EGWP” for additional information.


EGWP Question #2: Where should EGWP underwriting live–in commercial underwriting, in actuary, or in the Medicare unit?

EGWP Question & Answer AudioThis question comes up often because, in a health plan, EGWP is a hybrid product where you have commercial sales, government programs, and your financial disciplines working together to solve one solution for the client.

Customers have asked whether underwriting should be

                      1. housed and protected in the financial section,
                      2. deposited in the customer-facing sections, or
                      3. a warehouse in between underwriting.

To answer this question, you must look at both the Field Underwriting and the Financial Underwriting.

You want the Field Underwriting to be close to the client. Usually, this is an agreement between the company's financial arm, the procurement team, and sales and marketing. The agreement identifies the groups we want to underwrite, what we look for when we solicit these groups, and how we will apply those rates. This type of agreement, usually called Underwriting Guidelines, is a type of treaty between acquisition and retention of those clients and the financial performance.

Always look for those types of agreements and operating guidelines first, and then the underwriting is much easier to place.


EGWP Question #3: Do regulatory requirements differ between EGWP, MAPD (Medicare Advantage Prescription Drug), and PDP (Prescription Drug Plan) plans?

EGWP Question & Answer AudioThe regulatory requirements are consistent and do not differ a lot for EGWP or retiree participants.

In terms of audits, CMS will look at plan type first before they look at any specifics. The one exception is if CMS gets a complaint.

If you receive a complaint from a group retiree via the Complaint Tracking Module (CTM), this can be problematic because you have CMS and your commercial client seeking solutions that can add to the already intense scrutiny of determining the resolution. You want to make sure that your group retirees, the government program representatives, and your administration are tightly woven into your compliance and oversight, just as you do with any other MA plans.

Pharmacy requirements for an EGWP plan follow the MA requirements for the most part. The same waivers are available based on each employer group. For PDP, members generally only need to have Part A or Part B, not both like they do for an MA; however, one of the EGWP waivers is that a specific employer group may require both, and you need to support that requirement. 

Download Summary of Group vs. Individual Medicare Differences

Another difference in terms of PDPs is that if a plan benefit does not cover a drug, you still must maintain a high level of coordination to ensure appropriate financial liability for prescription drugs. This can cause some challenges for health plans and sponsors if they are not set up to handle these complexities to the degree necessary.

The Next Steps

Employer group waiver plans deserve consideration by health plan executives. These types of plans are complex to operate and require health plans to evaluate all aspects of their administration capabilities to ensure operational success.

Watch our on-demand webinar, “How to Successfully Operate a Group Retiree Plan for MA (EGWP)” to learn more about EGWP. We discuss the basic plan categories, Group vs. Individual Medicare Advantage, EGWP trends, opportunities and challenges, EGWP success requirements, and EGWP as a diversification strategy for MA plans.

We have answered the top three questions about EGWPs, but additional questions are sure to arise as you delve further into researching the EGWP market.

To connect with a Medicare Advantage expert, or to schedule an introduction to  our EGWP administration solutions,contact us today.


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