The U.S. Department of Health and Human Services (HHS) has posted additional documents to help plan sponsors understand which types of medical items and services are not eligible for reimbursement under the Early Retiree Reinsurance Program (ERRP). Created by the Affordable Care Act, the ERRP provides $5 billion in temporary financial help for employer health plans that continue to provide health coverage to “early retirees,” defined as individuals age 55 and older who are neither active employees nor eligible for Medicare, and to the early retirees’ spouses, surviving spouses, and dependents. Under the plan, the HHS will reimburse plan sponsors for certain claims between $15,000 and $90,000. The first new ERRP-related document posted to the HHS’s website – Procedure Codes Ineligible for Reimbursement (pdf) – lists 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 – ERRP Medicare Excluded CPT-HCPCS Codes (CSV file) includes more details about the codes referenced in the first document.

The first document describes several types of items and services within the following categories that the ERRP will not credit toward the program cost threshold or reimburse for claims submission purposes:

• Custodial Care by Non-Medical Personnel
• Routine Foot Care
• Personal Comfort Items
• Routine Services and Appliances For Vision
• Hearing Aids and Auditory implants
• Cosmetic Surgery
• Routine Dental Services
• Services to Promote or Enable Fertility
• Abortion, Except to Preserve Life of Mother, or Case of Rape or Incest

In addition to these specifically excluded services, ERRP will also 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.

With respect to the ERRP’s treatment of prescription drugs, the guidance notes that it is the plan sponsor’s responsibility to determine if a drug could be covered by a standard Medicare Part D plan. The document lists the following agents as specifically excluded from both Medicare Part D coverage as well as credit or reimbursement under the 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 (ED).

The following items, however, are not excluded:

• Prescription drug products that otherwise satisfy the definition of a Part D when used for AIDS wasting and cachexia due to a chronic disease.
• Drugs indicated for the treatment of psoriasis, acne, rosacea, or vitiligo are not considered cosmetic.
• Vitamin D analogs when used for a medically-accepted indication.
• Prescription-only smoking cessation products.
• Prescription Niacin Products (Niaspan, Niacor).
• Cough and cold medications in clinically relevant situations other than those of symptomatic relief of cough and colds.

This entry was written by Ilyse Schuman.