The Part D prescription drug benefit, introduced by the Medicare Prescription Drug, Improvement and Modernization Act of 2003 requires an unprecedented amount of coordination between Medicare and the private industry.  This is evident with the point of sale coordination of benefits system Medicare has worked to develop with the industry.  In 2006, pharmacists will have the ability to bill primary, secondary, and tertiary claims at the point of sale.  This is necessary for the Medicare Part D plans to calculate the True Out-of-Pocket (TrOOP) costs of beneficiaries.  The TrOOP Facilitation Contractor, NDC Health, will capture the paid claims of secondary and tertiary payers and transmit them to Part D plans for TrOOP calculation.

For TrOOP Facilitation to work properly, the Part D plans and TrOOP Facilitation Contractor must be provided with accurate, validated non-Medicare coverage information of Part D beneficiaries.  The Medicare Coordination of Benefits (COB) Contractor, Group Health Incorporated (GHI) is expanding its current Medicare benefits coordination data sharing with insurers and employers to include prescription drug coverage information.  This information will be provided to the Part D plans and TrOOP Facilitation Contractor.  CMS would like to enter into data sharing agreements with PBMs to gain as much of this information as possible.  The PBMs are a much more direct source for prescription drug coverage information than the insurers and employers. 

A PBM that enters into a data sharing agreement with CMS would submit a monthly file of its covered individuals, with personal identifying and coverage information, to the COB Contractor.  The COB Contractor would match against its Medicare entitlement systems, apply matches to the CMS systems to be used for TrOOP Facilitation, and submit to the PBM a response file describing the actions the COB Contractor took with the file.  Any Part D entitlement information for covered individuals found to be Part D beneficiaries would also be included in the response, including start and end dates and which Part D plan the beneficiary is enrolled in.  The PBM can use the Part D entitlement information for its own benefits coordination.

Downloads
PBM Cover Letter (PDF 80 KB) PBM Data Sharing Powerpoint Presentation (PDF 72 KB) PBM Questionnaire (PDF 40 KB) PBM Data Sharing Agreement (PDF 124 KB) PBM Layout (PDF 382 KB) PBM Layout Matrix (PDF 44KB)
Related Links Inside CMS
Employer Services Insurer Services Employer Voluntary Data Sharing Agreements (VDSA) Insurer Voluntary Data Sharing Agreements (VDSA) Coordination of Benefits Agreements (COBA) Retiree Drug Subsidy Program (RDS)
Related Links Outside CMS
There are no Related Links Outside CMS

Page Last Modified: 12/14/2005 12:00:00 AM
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