Transcript Part D COB and States The MMA requires unprecedented

Part D Data Sharing
Harry Gamble
Office of Financial Management
CMS
The MMA requires unprecedented coordination
between CMS, State agencies, insurers, and
employers to ensure that the benefits provided
to Part D beneficiaries are maximized. States
have special coordination concerns because of
their dual status as employers and insurers.
Areas where States currently provide health
benefits that will be affected by the MMA are:
• Benefits provided to state employees, retirees, and
dependants, many of whom may be Medicare
beneficiaries.
• Medicaid coverage provided to low-income beneficiaries,
many of whom may be Medicare dual-eligibles who will
now receive most drug coverage from Medicare Part D.
• Supplemental drug coverage offered to seniors through
the State Pharmaceutical Assistance Programs (SPAPs).
Coordination with SPAPs is a high priority for CMS.
In 1999, CMS named Group Health, Inc. (GHI) as
the Coordination of Benefits (COB) Contractor.
The COB Contractor consolidated activities to
support the collection, management, and
reporting of all health insurance coverage of
Medicare beneficiaries to implement an improved
plan for coordinating Medicare benefits with other
insurance coverage.
These coordination activities include:
• Various questionnaires sent to beneficiaries and
employers about group health plan coverage.
• Voluntary Data Sharing Agreements (VDSAs) between
CMS and employers and insurers to exchange
enrollment information on Medicare beneficiaries.
• Coordination of Benefits Agreements (COBAs) between
CMS and supplemental health insurers to coordinate the
payment of claims after Medicare has made its payment.
CMS is modifying its Coordination of
Benefits activities to collect and share drug
enrollment data. All of these modifications
will assist States in administering their
employer and insurer benefits programs.
These modifications will:
• Facilitate the calculation of TrOOP by the Part D Plans.
• Facilitate billing in the appropriate order at the pharmacy
point of sale.
• Ensure that SPAPs have the information they need to
develop their benefit structures
• Ensure that Medicaid agencies know which of their
beneficiaries are dual-eligibiles.
• Simplify the exchange of enrollment files for employers
claiming the Employer Subsidy
Voluntary Data Sharing Agreements
(VDSAs)
• VDSAs were originally developed to enable CMS,
insurers and employers to coordinate benefits and
reduce mistaken payments and administrative expenses.
• VDSAs allow an exchange of employer Group Health
Plan (GHP) coverage information for Medicare
entitlement information.
• VDSAs allow GHPs to meet Medicare Secondary Payer
reporting requirements and provides them with Medicare
entitlement info so they can determine when Medicare
should be the primary payer.
VDSAs continued
• CMS is adding a process to the VDSA to collect drug
coverage info supplemental to Medicare for TrOOP
facilitation in exchange for Part D entitlement info.
• CMS will allow employers with VDSAs to use the
process to submit drug coverage enrollment files to claim
the Employer Subsidy.
• CMS has 84 signed VDSAs, including the States of New
Jersey, Alabama, and Louisiana. CMS is currently in
negotiations with multiple other States.
Coordination of Benefits Agreements (COBAs)
CMS is currently consolidating the claims crossover
Trading Partner Agreements with Medicare contractors
into the COBA process at the COB Contractor.
Agreements are negotiated and maintained between
CMS and supplemental health insurers (and Medicaid
State Agencies, and their fiscal agents) for the exchange
of entitlement and paid claims data.
COBA Continued
This process will coordinate correct claim payments by
Medicare and supplemental health insurers. This
process is being expanded to report other drug coverage
that is supplemental to Part D to facilitate the tracking of
TrOOP and to facilitate billing at the pharmacy.
SPAP Data Sharing
CMS is developing a process similar to the
VDSA program for SPAPs to receive Medicare
Part D entitlement information.
Proposed SPAP Data Sharing Process:
• The SPAP would submit a monthly electronic file of all its
enrollees to the Coordination of Benefits (COB)
Contractor.
• The COB Contractor would respond with a file detailing
the Medicare Part D entitlement of those enrollees. This
information will include:
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Part D entitlement dates;
the enrollee’s Part D Plan;
the monthly Part D Plan premium amount;
effective dates and level of the low-income subsidy.
Further Information
• For further info about data sharing with CMS, contact:
– John Albert, (410) 786-7457, [email protected]
– Aaron Wesolowski, (410) 786-8075,
[email protected]
– Bill Decker, (410) 786-0125,
[email protected]
– or visit http://www.cms.hhs.gov/medicare/cob