12/03/2007
High-Level Summary of All Part D Application Revisions from 2008 Version of Part D Application to 2009 Final Version
Clarification |
Purpose of the Clarification |
Application |
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PDP
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MA-PD |
Cost |
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GENERAL INFORMATION and INSTRUCTIONS |
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1. Added regulatory and Prescription Drug Benefit Manual references for each attestation section; Changed instructions to provide attachments as uploads in HPMS; and amended the instructions related to not accepting any hard copy and CD submissions. |
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Throughout document |
Throughout document |
Throughout document |
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2. Technical change to the instructions to related to automation of the applications. |
All uploads will be required to be in either excel, a CMS provided template or pdf format to be properly uploaded in HPMS. |
Throughout document |
Throughout document |
Throughout document |
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3. Changed the time the applications are due to CMS. |
To coordinate with HPMS and be consistent with the Medicare Advantage Group, we changed the time the Part D application is due to CMS from 5:00PM EST to 11:59PM EST. |
Instructions |
Instructions |
Instructions |
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4. Added language to make the Part D applications consistent with the newly-final Compliance Regulation (CMS-4124-P) |
Attestations and contractual provision requirements were amended to address the new definition of subcontractor. Other changes were made to ensure compliance plan requirements are consistent with provisions in the new regulation. |
Throughout document |
Throughout document |
Throughout document |
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APPLICANT EXPERIENCE, CONTRACTS, LICENSURE AND FINANCIAL STABILITY |
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5. Deleted attestation asking type of product. |
This attestation is no longer necessary due to automation. Applicants will only be given those questions appropriate to the type of product line already identified in HPMS. |
N/A |
3.1.1A1 |
3.1.1A1 |
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6. Deleted “some type” wording in attestation. |
Received a comment stating that the wording made the attestation too broad. |
3.1.3A5 |
N/A |
N/A |
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7. Amend attestations related to licensure waivers. |
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3.1.3B
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N/A |
N/A |
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8. Amended a statutory reference. |
The statutory reference related to staff being excluded by the Department of Health and Human Services Office of the Inspector General or by the General Services Administration has changed. |
3.1.4 |
3.1.4 |
3.1.4 |
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BENEFIT DESIGN |
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9. Added new attestation related to formulary that was in 2008 application. |
The other Part D applications contain this attestation and it was included in the 2008 application. It appears to have been accidentally dropped from the MA-PD and is being reinserted. |
N/A |
3.2.1A1 |
N/A |
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10. Added new attestations related to formulary. |
Added attestations to highlight several aspects of previously existing formulary guidance related to six classes of drugs that CMS wanted to highlight to initial applicants. |
3.2.1A
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3.2.1A |
3.2.1A |
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11. Added new attestations related to bundling home infusion drugs as part of a supplemental benefit. |
Based on the 2008 Call Letter, existing policy clarified how certain Part D sponsors may bundle Part D home infusion drugs as part of the supplemental benefit and how this should be reported on a formulary and the information relayed to beneficiaries. |
N/A |
3.2.1D
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3.2.1D |
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12. Added an attestation related to guidance on vaccine administration. |
Legislation passed in 2007 requires the shift of vaccine administration from Part B to Part D. This guidance implements this legislative change. |
3.2.1B
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3.2.1B |
3.2.1B |
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13. Deleted a new attestation related to the CAHPS survey. |
Based on comments received during the 60-day posting of the Draft 2009 application, this attestation has been deleted since guidance has not been issued related to any follow-up requirements for Part D sponsors in relation to the CAHPS survey thus the attestation has been removed. |
3.2.3A5
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3.2.3A5 |
3.2.3A5 |
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14. Added in clarifying instruction related to how applicants will submit MTM plans to set fees for pharmacists. |
This instructions was inadvertently dropped from the 2009 drafts of the application but was in the 2008 final version. |
3.2.4A10 |
3.2.4A10 |
3.2.4A10 |
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15. Adds a new attestation, which limits the number of bids up to the parent organization. |
Based on the 2008 Call Letter, CMS is implementing a policy that provides parent organizations of multiple Part D sponsors to limit the number of benefit offerings to no more than 2 basic benefit plans throughout all subsidiaries. |
3.2.6A3
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N/A |
N/A |
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PHARMACY ACCESS |
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16. Added new attestations related to Private Fee For Service Part D sponsors. |
Based on the 2008 Call Letter, these new attestations address on line billing and paper claims. |
N/A |
3.4A |
N/A |
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17. Added clarifying language to a mail order attestation related to a level-playing field with retail and providing of extended day supply. |
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3.4.3A3
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3.5.3A3 |
3.3.3A3 |
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18. Clarified language in long-term care attestations. |
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3.4.5
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3.5.5 |
3.3.5 |
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19. Added instructions to provide applicants the choice of software vendors to complete the pharmacy access network reports. |
Based on comments received during the 60-day posting of the Draft 2009 Part D application, added detailed instructions to use either Quest Analytics or GeoNetworks software to produce the required pharmacy network access reports. |
3.4.1B |
3.5.1B |
3.3.1B |
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ENROLLMENT AND ELIGIBILITY |
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20. Added 2 attestations related to involuntary disenrollments. |
Based on the 2008 Call Letter and HPMS guidance, attestations were added to address involuntary disenrollments when beneficiaries fail to pay premiums. |
3.5A19 3.5A20
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3.6A9 3.6A10 |
3.4A9 3.4A10 |
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21. Changed language in attestation related to 4Rx data. |
Based on a comment received from the 30-day comment period, CMS recognized the attestation did not mesh with current operation guidance. The revised attestation incorporates the process for plan-generated and CMS-generated enrollments. |
3.5A18 |
3.6A8 |
3.4A8 |
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COMPLAINTS TRACKING |
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22. Added clarifying language related to applicants’ requirement to monitor and document complaints in CTM. |
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3.6A2
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3.7A2 |
3.5A2 |
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COVERAGE DETERMINATIONS (INCLUDING EXCEPTIONS) AND APPEALS |
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23. Reorganized and clarified language of existing attestations. Added new attestations to further highlight key aspects of coverage determination and appeals policy. |
Attestation language was clarified and the order was redone for a better flow of understanding for the applicants. |
3.9
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3.10 |
3.8 |
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COORDINATION OF BENEFITS |
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24. Added new attestations related to plan-to-plan reconciliation and reconciliation when another payer paid as primary instead of the Part D sponsor. |
Addresses applicant’s responsibility to reconcile payments with other Part D sponsors (where appropriate) and other payers that should not pay for Part D drugs as primary. |
3.10A13 3.10A14
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3.11A11 3.11A12 |
3.9A11 3.9A12 |
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TRUE OUT-OF-POCKET COSTS (TrOOP) |
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25. Added two attestations related to processing of TrOOP-related data. |
Attestations highlight applicant’s system requirements necessary to appropriately process TrOOP-related data in a timely fashion. |
3.11A14 3.11A15
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3.12A15 3.12A16 |
3.10A15 3.10A16 |
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MARKETING/BENEFICIARY COMMUNICATION |
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26. Added a new bullet within an existing attestation related to beneficiary call centers. |
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3.13A5
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3.14A5 |
3.12A5 |
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27. Added new attestation specific to marketing of formularies. |
Based on current practices, this attestation highlights to applicants that they may only market a CMS-approved formulary. |
3.13A7
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3.14A7 |
3.12A7 |
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28. Added a new attestation addressing the release of prescription drug event data for research and other purposes. |
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3.13A11
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3.14A11 |
3.12A11 |
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PROVIDER COMMUNICATIONS |
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29. Clarified attestation related to pharmacist and provider call centers. |
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3.14A1
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3.15A1 |
3.13A1 |
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REPORTING REQUIREMENTS |
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30. Added new attestation related to reporting direct and indirect remuneration dollars for payment reconciliation. |
Based on CMS guidance, this reporting requirement was highlighted to address payment reconciliation with DIR data. |
3.16A17
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3.17A17 |
3.15A17 |
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DATA EXCHANGE BETWEEN PART D SPONSOR AND CMS |
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31. Deleted an attestation related to enrollment transactions and replaced it with new attestations that more specifically highlight system requirements. |
The new attestations focus more appropriately on testing, lifecycle memos and disaster and recovery plans for systems. |
3.17
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3.18 |
3.16 |
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HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 AND RELATED CMS REQUIREMENTS |
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32. Reordered and added new attestations related to data security, off shore contracting, and the National Provider Identifier. |
Added new attestations based on the 2008 Call Letter and implementation of the National Provider Identifier. |
3.18
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3.19 |
3.17 |
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33. Amended and deleted attestations related to offshore subcontracting. |
Consolidated and revised attestations related to offshore subcontracts to be less burdensome for Applicants so that they will submit attestations at an appropriately designated time instead of receiving CMS prior approval under specified conditions. |
3.18 |
3.19 |
3.17 |
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34. Added new section to have Applicants complete an appendix for data use agreements. |
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Appendix XI
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N/A |
N/A |
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CLAIMS PROCESSING |
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35. Clarified attestation related to paper claims processing. |
Based on comments received, clarified an attestation related to paper claims processing timelines for non-network pharmacies compared to claims submitted by beneficiaries. |
3.21A2 |
3.22A2 |
3.20A2 |
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PREMIUM BILLING |
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36. Added a new section to highlight requirements of Applicants related to premium withhold and billing issues. |
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3.22
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3.24 |
3.21 |
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APPENDICES |
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37. Deleted Banking Information Form appendix. |
Appendix is not part of the application review and is not completed in HPMS so it has been removed from the application. |
Appendix I |
Appendix I |
Appendix I |
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38. Updated language throughout Application to Request Federal Waiver of State Licensure Requirement for Prescription Drug Plan. |
Updated language to address automation of the Part D application. Clarified language related to the dates of submission for the waiver application in conjunction with the Part D application. |
Appendix II
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N/A |
N/A |
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39. Deleted Certification of Monthly Enrollment and Payment Data Relating to CMS Payment to a Part D Sponsor. |
Appendix is not part of the application review and is not completed in HPMS so it has been removed from the application. |
Appendix III |
Appendix III |
Appendix III |
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40. Deleted Certification by Prescription Drug Plan Organization that Subcontracts Meet the Requirements of Section 3.1.2D. |
Deleted certification because it is duplicative of statements addressed in the 4.0 Certification. |
Appendix V |
Appendix IV |
Appendix IV |
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41. Clarified language for the Retail Network Pharmacy Access appendix. |
Clarified the instructions for developing the retail network pharmacy access reports. Added in language specific to using the Quest Analytics software to produce the network pharmacy access reports. |
Appendix XIII |
Appendix XII |
Appendix XII |
Rows in red denote a change from the 30-day posted version of the 2009 Draft Part D application to current version.
File Type | application/msword |
File Title | OMB Application Review Table |
Author | Marla Rothouse |
Last Modified By | Marla Rothouse |
File Modified | 2007-12-05 |
File Created | 2007-12-05 |