CMS-10171 SPAP Plan to Wrap-Around Part D for CY 2014

SPAP Plan to Wrap-Around Part D for CY 2014

Program Name and State:
Contact Information:
(SPAP Agency Official, Mailing Address, Email, and Phone):
(RxBIN/RxPCN/RxGroup ID, as applicable)

I. Eligibility
A. Provide who is eligible for your state’s SPAP benefits (specifying income and asset thresholds,
and/or specific diseases/conditions):

B. SPAP eligibility conditioned upon LIS application?
o Yes
o No
C. SPAP eligibility conditioned upon Part D enrollment?
o Yes
o No
II. Financial Assistance/Benefits
A. Does the State use a lump sum approach (outlined in Chapter 14 of the Medicare Prescription Drug
Benefit Manual)? Please check at least one box.
o No, a lump sum approach is not being adopted.
o Yes.
B. If yes to A., please check what type of approach you intend to use and attach the request for proposal
(RFP) and indicate proposed publication date of RFP:
o Risk-based
o Non-risk based
Proposed publication date of RFP: ___________
C. If not adopting lump-sum approach, indicate type of coverage provided:
o Premium only
o Cost sharing only
o Both
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SPAP Plan to Wrap-Around Part D for CY 2014
D. Describe the premium assistance provided by the SPAP, including a description of the member’s
premium obligation after the SPAP benefit is applied:

E. Describe the cost sharing assistance provided by the SPAP, including a description of the member’s
cost sharing obligation after the SPAP benefit is applied:

III. Enrollment
A. Indicate if State can enroll on behalf of your members as their authorized representative under state
law.
o Yes. If yes, please respond to questions B & C below.
o No
B. Provide state’s enrollment/assignment process? Please check at least one box below.
o Random assignment. State enrolls members (spouses or members of the same household)
randomly among:
___All plans in state’s region.
___Plans at or below your region’s low-income benchmark premium amount.
o Non-random assignment. State enrolls members, using a member’s unique characteristics such
as prescription drug utilization. Please attach a detailed description of the algorithm the state
will use, including all of the steps you will use to arrive at the plan assignment.
o Limit enrollment to particular plans based on established coordination criteria.

C. Indicate when the state intends to enroll its members into Part D plans for the upcoming year:

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SPAP Plan to Wrap-Around Part D for CY 2014

Assurances
o I certify that at least annually, the State will submit a template by August 1. If the
information contained in this template changes during the year, the State will submit a
revised template for CMS approval.
o The information contained in this template is correct and in accordance with 42 CFR
423.464, Chapter 14 of the Medicare Prescription Drug Benefit Manual as it applies to
SPAPs, and enrollment guidance provided in the Qualified SPAP Guidelines.
o I certify that the SPAP adheres to the coordination of benefits (COB) process as adopted by
industry and uses the same 4Rx information (RxBIN/RxPCN/RxGroup) used to process
claims secondary to Part D as what is reported on the monthly coordination of benefits
(COBC) file submitted to CMS’ contractor.

Signature of SPAP Official:____________________________________Date:______________

Signature of CMS Official:____________________________________Date:________________
Cynthia Tudor, PhD., Director, Medicare Drug Benefit and C&D Data Group

Signature of CMS Official:____________________________________Date:________________
Arrah Tabe-Bedward, Director, Medicare Enrollment and Appeals Group

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