Form CMS-10185 Medicare Part D Reporting Requirements

CMS-10185
OMB Control No. 0938-0992
Expires: TBD

MEDICARE PART D
REPORTING REQUIREMENTS

According to the Paperwork Reduction Act of 1995, no persons are required to respond to
a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-0992. The time required to complete
this information collection is estimated to average 15 hours annually per respondent,
including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.

Effective as of January 1, 2016

Table of Contents
Introduction ……………………………………………………………………………………..3

Section I.

Enrollment and Disenrollment ..................................................................... 5

Section II.

Retail, Home Infusion, and Long-Term Care Pharmacy Access ................. 7

Section III.

Medication Therapy Management Programs............................................... 9

Section IV.

Grievances ................................................................................................ 11

Section V.

Coverage Determinations and Redeterminations ...................................... 13

Section VI.

Employer/Union-Sponsored Group Health Plan Sponsors ........................ 16

Section VII. Sponsor Oversight of Agents..................................................................... 18

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Introduction
In December 2003, Congress passed the Medicare Prescription Drug Benefit,
Improvement and Modernization Act (MMA), allowing coverage of outpatient prescription
drugs under the Medicare Part D benefit. In accordance with Title I, Part 423, Subpart K (§
423.514), the Act requires each Part D Sponsor to have an effective procedure to provide
statistics indicating:
1)
2)
3)
4)
5)

the cost of its operations;
the patterns of utilization of its services;
the availability, accessibility, and acceptability of its services;
information demonstrating it has a fiscally sound operation; and
other matters as required by CMS.

The purpose of this document is to assure a common understanding of reporting
requirements and how these data will be used to monitor the prescription drug benefit
provided to Medicare beneficiaries. CMS will use the following terminology to ensure
consistency in these reporting requirements:



Part D Sponsor –an organization which has one or more contract(s) with CMS to
provide Part D benefits to Medicare beneficiaries. Each contract is assigned a CMS
contract number (e.g. H# or S#).
Plan – a plan benefit package (PBP) offered within a Part D contract (e.g. Plan ID
#).

This document lists reporting timeframes and required levels of reporting. Data elements
may be reported at the Plan (PBP) level, or the individual Contract level. These
requirements are subject to change at the discretion of CMS. According to Subpart O,
sanctions may be imposed on Part D Sponsors who fail to comply with these reporting
requirements.
The following criteria were used in selecting reporting requirements:
1) Minimal administrative burden on Part D Sponsors;
2) Legislative and regulatory authority;
3) Validity, reliability, and utility of data elements requested; and
4) Wide acceptance and current utilization within the Industry.
Sponsors are required to undergo data validation to have some of their Part D data
audited. Each Part D Sponsor shall provide necessary data to CMS to support payment,
program integrity, program management, and quality improvement activities. Additional
reporting requirements are identified in separate guidance documents throughout the year.
Guidance has been separately released for data validation, formulary, TrOOP,
coordination of benefits, payment and 1/3 audit, and low income subsidy.
Part D Sponsors may also be required to submit other information as defined by
requirements in the application, guidances, or other documents (e.g. pharmacy access and
formularies) during the annual contract bidding, application, or renewal process.
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Information is also required to be submitted throughout the contract year as allowable
changes are made (e.g. formulary changes).
In each of the sections that follow, the method of submission (e.g. entered into or uploaded
via the Health Plan Management System (HPMS)) and the level of reporting are specified
following the reporting timeline. Reporting deadlines may occur in the subsequent
calendar year. Unless otherwise specified, drug utilization data should include all covered*
Part D drugs, including compounded drugs.
PACE Organizations offering Part D coverage are exempt from these Part D reporting
requirements.
MA Organizations and Medicare Cost Plans (1876 plans only) that offer Part D benefits will
be required to comply with all reporting requirements contained herein, with the exception
of the Employer/Union-Sponsored Group Health Plan Sponsors reporting section, and the
Plan Oversight of Agents reporting section.
Medicare/Medicaid Plans (MMPs) should refer to the Medicare-Medicaid Financial
Alignment Model Reporting Requirements for additional reporting guidance. Some MMP
measures may have specific timelines that may be different.
*Covered Part D drug as defined by Section 1860D-2(e)(2) of the MMA. Drugs offered
under enhanced or supplemental drug benefits by Sponsors are not covered Part D drugs.

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Section I.

Enrollment and Disenrollment

CMS provides guidance for Part D Sponsors’ processing of enrollment, disenrollment, and
reinstatement requests.
Both Chapter 2 of the Medicare Managed Care Manual and Chapter 3 of the Medicare
Prescription Drug Manual outline the enrollment and disenrollment periods (Section 30)
enrollment (Section 40), disenrollment (Section 50), and reinstatement (Section 60)
procedures for all Medicare health and prescription drug plans.
CMS will collect data on the elements for these requirements, which are otherwise not
available to CMS, in order to evaluate Sponsors’ processing of enrollment, disenrollment, and
reinstatement requests in accordance with CMS requirements. For example, while there are a
number of factors that result in an individual’s eligibility for a Special Enrollment Period (SEP),
Sponsors are currently unable to specify each of these factors when submitting enrollment
transactions. Sponsors’ reporting of data regarding SEP reasons for which a code is not
currently available will further assist CMS in ensuring Sponsors are providing support to
beneficiaries, while complying with CMS policies.
Data elements 1.A-1.O must include all enrollments. Disenrollments must not be included in
Section 1 Enrollment.
Section 2 Disenrollment must include all voluntary disenrollment transactions.
Reporting timeline:
Reporting
Period
Data due to
CMS/HPMS

Period 1
January 1 June 30
Last Monday of August

Period 2
July 1 – December 31
Last Monday of February

Data elements to be entered into the HPMS at the Contract level:
1. Enrollment:
A. The total number of enrollment requests (i.e., requests initiated by the beneficiary or
his/her authorized representative) received in the specified time period. Do not include
auto/facilitated or passive enrollments, rollover transactions or other enrollments
effectuated by CMS.
B. Of the total reported in A, the number of enrollment requests complete at the time of
initial receipt (i.e. required no additional information from applicant or his/her authorized
representative).
C. Of the total reported in A, the number of enrollment requests for which the Sponsor was
required to request additional information from the applicant (or his/her representative).
D. Of the total reported in A, the number of enrollment requests denied due to the
Sponsor’s determination of the applicant’s ineligibility to elect the plan (i.e. individual not
eligible for an election period).
E. Of the total reported in C, the number of incomplete enrollment requests received that
are incomplete upon initial receipt and completed within established timeframes.
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F. Of the total reported in C, the number of enrollment requests denied due to the
applicant or his/her authorized representative not providing information to complete the
enrollment request within established timeframes.
G. Of the total reported in A, the number of paper enrollment requests received.
H. Of the total reported in A, the number of telephonic enrollment requests received (if
Sponsor offers this mechanism).
I. Of the total reported in A, the number of internet enrollment requests received via plan
or affiliated third-party website (if Sponsor offers this mechanism).
J. Of the total reported in A, the number of Medicare Online Enrollment Center (OEC)
enrollment requests received.
K. For stand-alone prescription drug plans (PDPs) only: Of the total reported in A, the
number of enrollment requests effectuated by sales persons (as defined in Chapter 3 of
the Medicare Managed Care Manual).
L. Of the total reported in A, the number of enrollment transactions submitted using the
SEP Election Period code "S" related to creditable coverage.
M. Of the total reported in A, the number of enrollment transactions submitted using the
SEP Election Period code "S" related to SPAP.
N. For stand-alone prescription drug plans (PDPs) only: Of the number reported in A, the
total number of enrollment transactions submitted using the SEP Election Period code
"S" that coordinates with the Medicare Advantage Disenrollment Period.
O. Of the total reported in A, the number of enrollment transactions submitted using the
SEP Election Period Code “S” for individuals affected by a contract nonrenewal, plan
termination or service area reduction.
2. Disenrollment:
A. The total number of voluntary disenrollment requests received in the specified time
period. Do not include disenrollments resulting from an individual’s enrollment in
another plan.
B. Of the total reported in A, the number of disenrollment requests complete at the time of
initial receipt (i.e. required no additional information from enrollee or his/her authorized
representative).
C. Of the total reported in A, the number of disenrollment requests denied by the Sponsor
for any reason.
D. The total number of involuntary disenrollments for failure to pay plan premium in the
specified time period.
E. Of the total reported in D, the number of disenrolled individuals who submitted a timely
request for reinstatement for Good Cause.
F. Of the total reported in E, the number of favorable Good Cause determinations.
G. Of the total reported in F, the number of individuals reinstated.

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Section II.

Retail, Home Infusion, and Long-Term Care Pharmacy Access

As outlined in §423.120, Part D Sponsors are required to maintain a pharmacy network
sufficient for ensuring access to Medicare beneficiaries residing in their service areas. Part D
Sponsors must ensure that they provide convenient access to retail pharmacies, as provided in
§423.120(a)(1); adequate access to home infusion (HI) pharmacies, as provided in
§423.120(a)(4); and convenient access to long-term care (LTC) pharmacies, as provided in
§423.120(a)(5). After their initial pharmacy access submissions are approved at the time of
application, Part D Sponsors are responsible for notifying CMS of any substantive changes in
their pharmacy network that may impact their ability to maintain a Part D pharmacy network
that meets our requirements, as described in section 50 of Chapter 5 of the Prescription Drug
Benefit Manual.
Part D Sponsors will be required to submit certain data elements on an annual basis that will
allow CMS to evaluate Part D Sponsors’ continued compliance with pharmacy access
requirements. For purposes of evaluating compliance with the retail pharmacy access
standards, Part D Sponsors should use the CMS reference file that provides counts of
Medicare beneficiaries by State, region, and ZIP code. This reference file is provided by CMS
for the Part D applications and will be posted on the Prescription Drug Contracting, Application
Guidance section of CMS’ website in January
(http://www.cms.hhs.gov/PrescriptionDrugCovContra/04_RxContracting_ApplicationGuidance.
asp#TopOfPage). Note that this file contains total Medicare beneficiary counts, not plan
enrollee counts, and that the total Medicare beneficiary count is the appropriate number to use
for purposes of ensuring compliance with the standards for convenient access to retail
pharmacies as provided in §423.120(a)(1), and adequate access to home infusion pharmacies
as provided in §423.120(a)(4).
For purposes of evaluating compliance with the LTC and home infusion pharmacy access
standards, CMS will use data elements submitted by Part D Sponsors, as well as information
from CMS reference files containing counts of nursing home beds and Medicare beneficiaries
by State, region, and ZIP code, as detailed in sections 50.4 and 50.5.1 of Chapter 5 of the
Prescription Drug Benefit Manual. MA-PD plans or cost plan Sponsors having received
waivers of the any willing pharmacy requirement and/or the retail convenient access
requirement after the initial pharmacy access submission will submit certain data elements
(subsections 2 and/or 3) on an annual basis for purposes of determining if those plans still
meet CMS standards for a waiver.
Submission of supporting documentation with the data elements below is not required;
however, CMS reserves the right to request appropriate documentation to support a Part D
Sponsor’s submitted pharmacy networks. CMS evaluation of compliance with pharmacy
access standards will be conducted based on point-in-time information about pharmacy
networks submitted by Part D Sponsors once per year.
Employer/Union Direct contracts and “800 series” plans must submit the list of network retail,
home infusion, and long term care pharmacies for their entire individual and employer service
area. For Part D Sponsors that offer both individual and “800 series” plans, compliance with
pharmacy access standards will only be assessed for the individual service area. For Part D
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Sponsors that offer only employer group plans, including Employer/Union Direct contracts,
compliance will be assessed for the entire service area.
Reporting timeline for Section 1 only:
Period 1
Reporting Period
January 1 - March 31
Data due to CMS/HPMS

First Monday of May

Data files to be uploaded through the HPMS at the Contract level, following templates provided
in HPMS.
1. Network Pharmacy data files, as of the last day of the reporting period specified
above:
1. A list of contracted network retail pharmacies, including preferred/non-preferred status
as applicable to network design;
2. A list of contracted Home Infusion pharmacies, and
3. A list of contracted Long-term Care pharmacies.
Please note that contracts will be required to submit pharmacy data using only the NPI
number.
Reporting timeline for Sections 2 and 3 only:
YTD
Reporting Period

January 1 – December 31

Data due to CMS/HPMS

First Monday of February

Data elements to be entered into the HPMS at the Plan (PBP) level:
2. For MA-PD and cost plans that own and operate their own pharmacies and have
received a waiver of the any willing pharmacy requirement:
A. Number of prescriptions provided by all pharmacies owned and operated by the plan.
B. Number of prescriptions provided at all pharmacies contracted by the plan.
3. For MA-PD and cost plans that own and operate their own retail pharmacies and
have received a waiver of the retail pharmacy convenient access standards: (These
plans are not exempt from reporting retail pharmacy data).
A. Number of prescriptions provided by retail pharmacies owned and operated by the plan.
B. Number of prescriptions provided at all retail pharmacies contracted by the plan.

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Section III. Medication Therapy Management Programs
The requirements stipulating that Part D Sponsors provide Medication Therapy Management
(MTM) programs are described in Title I, Part 423, Subpart D, § 423.153. For monitoring
purposes, Part D Sponsors will be responsible for reporting several data elements related to
their MTM program. Data will be uploaded in a data file.
Reporting timeline:
Reporting Period

YTD
January 1 - December 31

Data due to CMS/HPMS

First Monday of February

Sponsors are required to target beneficiaries for the MTM program who meet specific criteria
as specified by CMS in § 423.153(d). Some Sponsors also offer enrollment in the MTM
program to other members who do not meet the specific CMS targeting criteria.
The following information will be collected for each beneficiary identified as being eligible for
the Part D MTM program, whether based on CMS’ specifications or other plan-specific
targeting criteria within the reporting period. Regardless of this designation, the corresponding
MTM services delivered to each beneficiary (such as targeted medication review or
comprehensive medication review) must meet CMS definitions. The reported beneficiaries
must receive MTM services that meet or exceed CMS’ MTM program requirements.
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.

K.
L.

M.
N.
O.
P.

Contract Number.
HICN or RRB Number.
Beneficiary first name.
Beneficiary middle initial.
Beneficiary last name.
Beneficiary date of birth.
Met the specified targeting criteria per CMS – Part D requirements. (Y (yes) or N (no)).
Beneficiary identified as cognitively impaired at time of comprehensive medication
review (CMR) offer or delivery of CMR. (Y (yes), N (no), or U (unknown)).
Date of MTM program enrollment.
Date met the specified targeting criteria per CMS – Part D requirements. Required if
met the specified targeting criteria per CMS – Part D requirements. (May be same as
Date of MTM program enrollment)
Date of MTM program opt-out.
Reason participant opted-out of MTM program (Death; Disenrollment from Plan;
Request by beneficiary; or Other). Required if Date of MTM program opt-out is
applicable.
Offered annual CMR. (Y (yes) or N (no)). Required if met the specified targeting criteria
per CMS – Part D requirements.
If offered, date of (initial) offer.
Received annual CMR with written summary in CMS standardized format. (Y (yes) or N
(no)). Required if offered annual CMR.
Number of CMRs received with written summary in CMS standardized format.
Required if received annual CMR.
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Q. Date(s) of CMR(s) with written summary in CMS standardized format. (If more than 1
CMR is received, up to 2 dates will be allowed.) Required if received annual CMR.
R. Method of delivery for the annual CMR. (Face-to-face; Telephone; Telehealth
consultation; or Other). (If more than 1 CMR is received, report the method of delivery
for the initial CMR). Required if received annual CMR.
S. Qualified Provider who performed the initial CMR. (Physician; Registered Nurse;
Licensed Practical Nurse; Nurse Practitioner; Physician’s Assistant; Local Pharmacist;
LTC Consultant Pharmacist; Plan Sponsor Pharmacist; Plan Benefit Manager (PBM)
Pharmacist; MTM Vendor Local Pharmacist; MTM Vendor In-house Pharmacist;
Hospital Pharmacist; Pharmacist – Other; Supervised Pharmacy Intern; or Other).
Required if received annual CMR.
T. Recipient of CMR. (Beneficiary, Beneficiary’s prescriber; Caregiver; or Other authorized
individual). Required if received annual CMR.
U. Number of targeted medication reviews. Required if met the specified targeting criteria
per CMS – Part D requirements.
V. Number of drug therapy problem recommendations made to beneficiary’s prescriber(s)
as a result of MTM services. (For reporting purposes, a recommendation is defined as
a suggestion to take a specific course of action related to the beneficiary’s drug therapy.
If the same recommendation is made to multiple prescribers or repeated on multiple
dates, then that recommendation should only be counted and reported once. Examples
include, but are not limited to: Needs additional therapy; Unnecessary drug therapy;
Dosage too high; Dosage too low; More effective drug available; Adverse drug reaction;
or Medication Non-compliance/Non-adherence).
W. Number of drug therapy problem resolutions resulting from recommendations made to
beneficiary’s prescriber(s) as a result of MTM recommendations. (For reporting
purposes, a resolution is defined as a change or variation from the beneficiary’s
previous drug therapy. Examples include, but are not limited to: Initiate drug; Change
drug (such as product in different therapeutic class, dose, dosage form, quantity, or
interval); Discontinue or substitute drug (such as discontinue drug, generic substitution,
therapeutic substitution, or formulary substitution); Medication compliance/adherence).
X. Topics discussed with the beneficiary during the CMR, including the medication or care
issue to be resolved or behavior to be encouraged. (If more than 1 topic discussed, up
to 5 topics will be allowed to be reported.) These are the descriptions of the topics
listed on the beneficiary’s written summary in CMS standardized format in the
Medication Action Plan under ‘What we talked about’. Required if received annual
CMR.

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Section IV. Grievances
According to MMA statute, a grievance is any complaint or dispute, other than a
coverage determination, expressing dissatisfaction with any aspect of the
operations, activities, or behavior of a Part D organization, regardless of whether
remedial action is requested. Part D Sponsors are required to notify enrollees of
their decision no later than 30 days after receiving their grievance. An extension
up to 14 days is allowed if it is requested by the enrollee, or if the Part D Sponsor
needs additional information and documents that this extension is in the interest
of the enrollee. An expedited grievance that involves refusal by a Part D
Sponsor to process an expedited coverage determination or redetermination
requires a response from the Part D Sponsor within 24 hours.
When categorizing grievances into core categories, Sponsors may report based
on their investigations subsequent to the enrollees’ filing of the grievances.
For reporting, Sponsors should:



Report data based on the date the grievance decision was made.
Track multiple grievances by a single complainant and report as separate
grievances.

For reporting, Sponsors should not:





Report requests for coverage determinations, exceptions, or redeterminations
inappropriately as grievances.
Limit base grievances reporting to include only CTM data.
Report general inquiries or questions that do not include a complaint as
grievances.
Dismiss or exclude any grievances filed by beneficiaries or their appointed
representatives from this reporting section.

Sponsors will report quarterly data on an annual basis.
Reporting timeline:
Reporting
Period
Data due to
CMS/HPMS

Quarter 1
Quarter 2
Quarter 3
Quarter 4
January 1 April 1 July 1 October 1 March 31
June 30
September 30 December 31
First Monday of February (reporting for all quarters due on this
date)

11

Data to be reported at the Contract level:
Total number
of grievances
Total Grievances
Number of Expedited Grievances
Enrollment/Disenrollment
Grievances
Plan Benefit Grievances
Pharmacy Access Grievances
Marketing Grievances
Customer Service Grievances
Coverage Determination and
Redetermination Process
Grievances
Quality of Care Grievances
Grievances related to “CMS Issues”
Other Grievances

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Number of grievances in
which timely notification
was given

Section V.

Coverage Determinations and Redeterminations

Title I, Part 423, Subpart M describes Part D Sponsors’ requirements for coverage
determinations (including formulary and tier exceptions, and exceptions to established
drug utilization management programs) and redeterminations, including timeframes for
standard and expedited requests. Part B vs. Part D coverage determinations and
redeterminations should be included in this reporting. Sponsors should report data based
on the date the coverage determination or redetermination decision is made. A Sponsor’s
complete decision includes making the determination, appropriately notifying the enrollee
of the determination, and authorizing coverage or sending payment, where applicable.
Coverage decisions (both coverage determinations and redeterminations) may result in a
partially favorable decision.
 Example of a fully favorable decision: Non-formulary exception request approved for
drug and quantity prescribed.
 Example of a partially favorable decision: Non-formulary exception request
approved for drug, but full quantity prescribed not approved.
Sponsors should also include reopened coverage determination and redetermination data
in this reporting, based on the date the revised decision is made. Reopening includes any
revision to a binding determination for any reason, including but not limited to clerical
errors and new and material evidence not available or known at the time of the
determination.
Sponsors will report quarterly data on an annual basis. All data elements to be entered
into the HPMS at the Contract level, except reopenings data in element B to be uploaded
in a data file.
Reporting timeline:
Reporting
Period
Data due to
CMS/HPMS

Quarter 1
Quarter 2
Quarter 3
Quarter 4
January 1 April 1 July 1 October 1 March 31
June 30
September 30 December 31
Last Monday of February (reporting for all quarters due on this
date)

1. Coverage Determinations and Exceptions
Data elements to be entered into the HPMS at the Contract level:
A. The total number of pharmacy transactions in the time period above.
B. Of the total reported in A, the number of pharmacy transactions rejected due to nonformulary status.
C. Of the total reported in A, the number of pharmacy transactions rejected due to prior
authorization (PA) requirements.
D. Of the total reported in A, the number of pharmacy transactions rejected due to step
therapy requirements.
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E. Of the total reported in A, the number of pharmacy transactions rejected due to
quantity limits (QL) requirements based on CMS approved formulary. Safety edits
and rejections due to early refills should be excluded.
F. Did the plan have high cost edits for compounds in place during the time period
above? ((Y (yes) or N (no)).
G. If yes to element F, the cost threshold used.
H. Did the plan have high cost edits for non-compounds in place during the time period
above? ((Y (yes) or N (no)).
I. If yes to element H, the cost threshold used.
J. Of the total reported in A, the total number of claims rejected due to high cost edits
for compounds.
K. Of the total reported in A, the total number of claims rejected due to high cost edits
for non-compounds.
L. The total number of coverage determinations decisions made in the reporting time
period above.
M. Of the number reported in element L, the total number of exception decisions made
in the reporting time period above.
N. Of the number reported in element L, the number processed timely.
O. Of the number reported in element L, the number that were fully favorable.
P. Of the number reported in element L, the number that were partially favorable.
Q. Of the number reported in element L, the number that were adverse.
R. The total number of requests for coverage determinations that were withdrawn in
the reporting time period above.
S. The total number of requests for coverage determinations that were dismissed in
the reporting time period above.
2. Redeterminations
Data elements to be entered into the HPMS at the Contract level:
A. The total number of redeterminations made in the reporting time period above.
B. Of the number reported in element A, the number processed timely.
C. Of the number reported in element A, the number that were fully favorable.
D. Of the number reported in element A, the number that were partially favorable.
E. Of the number reported in element A, the number that were adverse.
F. The total number of requests for redeterminations that were withdrawn in the
reporting time period above.
G. The total number of requests for redeterminations that were dismissed in the
reporting time period above.
3. Reopenings
Data elements to be uploaded in a data file at the Contract level:
A. The total number of reopened (revised) decisions, for any reason, in the time period
above.

14

B. For each case that was reopened, the following information will be uploaded in a
data file:
1. Contract Number;
2. Plan ID;
3. Case ID;
4. Date of original disposition;
5. Original disposition (Fully Favorable; Partially Favorable or Adverse);
6. Case level (Coverage Determination or Redetermination);
7. Date case was reopened;
8. Reason(s) for reopening (Clerical Error, New and Material Evidence, Fraud or
Similar Fault, or Other)
9. Date of reopening disposition (revised decision);
10. Reopening disposition (Fully Favorable; Partially Favorable, Adverse, or
Pending).

15

Section VI. Employer/Union-Sponsored Group Health Plan Sponsors
NOTE: This reporting requirement applies only to individual PDPs and “800
series” PDPs offered to employers. MA-PD plans already report these data as
part of the Part C reporting requirements and are therefore exempt from this Part
D reporting section.
CMS has statutory authority to waive or modify requirements that hinder the
design of, the offering of, or the enrollment in, employer/union sponsored PDPs,
as set forth in section 1860D-22(b) of the Social Security Act. Under the abovereferenced statutory authority, PDPs are permitted to utilize these waivers to
contract with employer and union group Sponsors to facilitate the enrollment of
their Medicare-eligible retirees into PDPs. (Please note that in addition to these
“indirect contract” arrangements, CMS also has separate statutory authority to
directly contract with employers and union group plan Sponsors to offer a
prescription drug benefits to their retirees). When exercising our discretion to
grant these statutory waivers or modifications to PDPs offering these plans,
these waivers and/or modifications are conditioned upon the PDP meeting a set
of conditions and complying with certain requirements, which may include these
kinds of reporting requirements.
The information requested is necessary for CMS to fulfill its affirmative oversight
obligation to ensure PDPs and the employer groups that contract with the PDPs
are properly utilizing these waivers and modifications and that CMS’ statutory
waiver authority is being implemented in accordance with the requirements of
section 1860D-22(b) of the Act.
The Tax Identification Number (TIN) is the standard unique employer
identifier. The Medicare program uses the TIN to identify employers and
businesses in other areas of the program. For example, insurers are required to
report TIN information in order to comply with the mandatory Medicare
Secondary Payer insurer reporting requirements of Section 111 of the Medicare,
Medicaid, and SCHIP Extensions Act of 2007 (Public Law 110-173). Thus, some
of these same entities (such as employer/union Sponsors) affected by our
reporting requirements will similarly be required by law to collect and report TIN
information to CMS for Medicare secondary payment purposes.
Collection of TINs from the employer/union Sponsors as outlined above may be a
challenge for PDP Sponsors. Employer/union Sponsors unable or unwilling to
provide TINs or other required information should be notified by PDP Sponsors
that they will be unable to utilize the waivers available to employer/union group
health plans and should work with them to explore other Medicare options for
their retirees.

16

Reporting timeline:
Reporting Period

YTD
January 1 – December 31

Data due to CMS/HPMS

First Monday of February

Data file to be uploaded through the HPMS at the Plan (PBP) level:
A. Employer Legal Name.
B. Employer DBA Name.
C. Employer Federal Tax ID.
D. Employer Address.
E. Type of Group Sponsor (employer, union, trustees of a fund).
F. Organization Type (state government, local government, publicly traded
organization, privately held corporation, non-profit, church group, other).
G. Type of Contract (insured, ASO, other).
H. Is this a calendar year plan? (Y (yes) or N (no)).
I. If element H is no, provide non-calendar year start date.
J. Current/Anticipated enrollment.

17

Section VII. Sponsor Oversight of Agents
NOTE: Employer/union group plans are exempt from this reporting section.
Sponsors are required to comply with State requests for information about the
performance of licensed agents or brokers as part of a state investigation into
agents’ conduct. However, CMS needs to monitor agent complaints to determine
if Sponsors are investigating complaints and imposing disciplinary actions as
well as reporting poor conduct to the state. Therefore, Sponsors must continue
to monitor the conduct of their agents.
Complaints include both complaints from the Complaint Tracking Module (CTM)
and other complaints or grievances made directly to the Sponsor. Complaints
may result in various disciplinary actions, ranging from verbal warning to
termination of employment or contract.
Reporting timeline:
Reporting Period

YTD
January 1 - December 31

Data due to CMS/HPMS

First Monday of February

Data elements to be uploaded in two data files at the Contract level:
1. Agent/Broker:
For each agent that earned compensation (including commission and salary) in
the reporting period (initial enrollments and renewal payments received),
indicate:
A.
B.
C.
D.
E.
F.

G.
H.
I.
J.
K.

Contract Number.
Agent/Broker Type (Captive, Employed, Independent).
Agent/Broker Last Name.
Agent/Broker First Name.
Agent/Broker Middle Initial.
Agent/Broker State Licensed. For agents licensed in multiple states,
complete a row for each state in which the agent is licensed if they also
earned compensation in that state.
Agent/Broker National Producer Number (NPN).
Sponsor Assigned Agent/Broker Identification Number.
Agent/Broker Current License Effective/Renewal Date (if applicable).
Agent/Broker Appointment Date (if applicable). This date should be the
most recent date the agent becomes affiliated with the Sponsor.
Agent/Broker Training Completion Date for the previous contract year
products.
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L. Agent/Broker Testing Completion Date for the previous contract year
products.
M. In aggregate, the number of Agent/Broker complaints for the reporting
period. If multiple lines are needed for an agent (licensed in more than
one state) only fill out this data element for the first line. For example, if
an agent has four complaints and is licensed in Florida and Georgia, all
four complaints should be listed under the Florida line.
N. In aggregate, the number of Agent/Broker disciplinary actions taken in the
reporting period (related to Marketing). Examples of disciplinary actions
include: retraining, verbal or written warnings, suspension, termination,
etc. If multiple lines are needed for an agent (licensed in more than one
state) only fill out this data element for the first line. For example, if an
agent has received two disciplinary actions and is licensed in Florida and
Georgia, both actions should be listed under the Florida line.
O. Agent/Broker Termination Date (if applicable).
P. Termination for Cause? (Y(yes) or N (no)).
Q. Third-party Marketing Organization (TMO)/Field Marketing Organization
Name (FMO), if applicable.
R. The number of new enrollments in the reporting period. If more than one
line is filled out because of agent being licensed in multiple states, please
put enrollments in by state.
2. New Enrollments:
For all new enrollments (initial or renewal) during the reporting period for which
an Agent/Broker is associated, indicate:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.

M.
N.
O.
P.

Contract Number.
Plan Beneficiary Package (PBP) Number.
Beneficiary Last Name.
Beneficiary First Name.
Beneficiary Middle Initial.
Beneficiary HICN or RRB Number.
Agent/Broker Last Name.
Agent/Broker First Name.
Agent/Broker Middle Initial.
Agent/Broker National Producer Number (NPN).
Sponsor Assigned Agent/Broker Identification Number.
Enrollment Mechanism. (Sponsor/Sponsor Representative Online; CMS
Online Enrollment Center; Sponsor Call Center; 1-800-MEDICARE; Paper
Application; Auto-Assigned/Facilitated; Other).
Enrollment Application Date.
Enrollment Effective Date.
The number of Agent/Broker complaints filed by the beneficiary in the
reporting period.
Of the number reported in O, the number of Marketing related complaints.
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