CMS-10170 Retiree Drug Subsidy Payment

An asterisk (*) identifies a required field.

OMB Approval # 0

PART I.
A. Plan Sponsor Account Registration
1) *Organization’s Name (Must correspond with the information associated with the Federal Employer Tax Identification Number (EIN)):
2) *Type of Organization: Government Union Religious Commercial Non-profit
3) *Organization’s Employer Identification Number (EIN):
4) *Organization’s Telephone Number: ext.
5) *Organization’s Address (must be the address associated with the EIN provided above):
* Street Line 1
	Street Line 2
	*City *State/US Territory *Zip Code
6) Organization’s Website: http://
B. Authorized Representative Invitation
*E-mail Address: *First Name 3)Middle Initial (optional): 4)*Last Name
C. Authorized Representative Information
*Check box to agree that the Account Manager listed is associated with this plans sponsor *Read and accept the User Agreement and Privacy Policy (located in Part I Section G of this document) *First Name: Middle Initial: *Last Name: *Job Title: *Date of Birth(Month/Day/Year): 6) *Social Security Number: 7) *Telephone Number: ext

8) * Address:

* Street Line 1 Street Line 2

*City *State/US Territory *Zip Code

9) *Login

*Login ID:

*Password:

*Re-enter password:

*Security Question 1

*Answer 1

*Security Question 2

*Answer 2

D. Account Manager Information

1. *Read and accept the User Agreement and Privacy Policy (located in Part I Section G of this document)

2. *First Name: Middle Initial: *Last Name:

3. *Job Title:

4. *Date of Birth (Month/Day/Year): 5) *Social Security Number:

6. *E-mail Address:

7. *Re-enter Email Address:

8. *Telephone Number:

9. *Address:

*Street Line 1

Street Line 2

*City *State/US Territory *Zip Code

6. *Login

*Login ID:

*Password:

*Re-enter password:

*Security Question 1

*Answer 1

*Security Question 2

*Answer 2

E. Designee Invitation

1. *E-mail Address:

2. *First Name: 3)*Last Name:

4)*Pass Phrase: 5)*Re-Enter Pass Phrase:

6)* Please choose the actions that the designee can perform for this application

F. Designee Information

1. *Enter the Pass-phrase:

2. *Read and accept the User Agreement and Privacy Policy (located in Part I Section G of this document)

3. *First Name: Middle Initial: *Last Name: 4) *Job Title:

5) *Date of Birth (Month/Day/Year): 6) Social Security Number:

7. Telephone Number: ext.

8. *Address:

*Street Line 1

Street Line 2

*City *State/US Territory *Zip Code

7. *Login

*Login ID:

*Password:

*Re-enter password:

*Security Question 1

*Answer 1

*Security Question 2

*Answer 2

G. User Agreement and Privacy Policy

THE FOLLOWING DESCRIBES THE TERMS AND CONDITIONS ON WHICH THE CENTERS FOR MEDICARE &

MEDICAID SERVICES (CMS) OFFERS YOU ACCESS TO CMS’ RDS CENTER’S SECURE WEB SITE.

You must read and accept the terms and conditions contained in this User Agreement expressly set out below and incorporated by reference before you may access the RDS Secure Web Site.

CMS’ RDS Center may amend this User Agreement at any time. Except as stated below, all amended terms shall automatically be effective 30 days after they are initially posted on the Site. This User Agreement is effective immediately.

1. Purpose of the RDS Secure Web Site

CMS has recently published the final regulations for Title I and Title II of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). Title I and its implementing regulations at 42 C.F.R §423 Subpart R contain the provisions governing the Retiree Drug Subsidy (RDS) option designed to assist employers, unions, and other Plan Sponsors that continue to provide high quality prescription drug coverage to their retirees.

The RDS Secure Web Site provides Plan Sponsors with the resources required to become a participant in the RDS Program, including specific instructions and assistance during the application period and afterward.

2. Privacy Policy

The U.S. Department of Health and Human Services (HHS) of which the RDS Secure Web Site is a part, has a clear privacy policy. When you access the RDS Secure Web Site, we collect the minimum amount of information about you necessary to process your application for the RDS Program and to manage your account.

Information Automatically Collected and Stored

When you browse through any web site, certain personal information about you can be collected. We automatically collect and temporarily store the following information about your visit:

• the name of the domain you use to access the Internet (for example, aol.com, if you are using an America Online account, or stanford.edu, if you are connecting from Stanford University's domain)

• the date and time of your visit

• the pages you visited

• the address of the web site you came from when you came to visit

This information is used for statistical purposes only and to help us make this site more useful to visitors. Unless it is specifically stated otherwise, no additional information will be collected about you.

Information Collected to Process Applications and Manage Accounts Through the RDS Secure Web Site When you apply for the RDS Program through the RDS Secure Web Site, we will collect personal information

necessary to validate participants, and to process and manage the application. The authority to collect this information is granted by §1860D-22 of the Social Security Act and CMS’ RDS implementing regulations at 42 C.F.R. §423

Subpart R, as well as the Debt Collection Improvement Act of 1996 at 31 U.S.C. §7701(c) and the Federal Privacy Act at 5 U.S.C. §552a. This may include your name, address, telephone and fax numbers, e-mail address, social security number, drivers license photocopy, Federal Employer Identification Number (FEIN), banking information or other payment information. Provision of this information is mandatory for participation in the RDS Program. CMS’ RDS Center may also collect a password and password hint for each participant accessing the RDS Secure Web Site. We use this information to verify participants' identities in order to prevent unauthorized access to secure RDS Secure Web Site accounts.

CMS’ RDS Center staff has role-based access to this information, and use only the information minimally necessary to accomplish their jobs.

The personal information you provide is encrypted and sent to us using a secure method, in order to assure that your personal information is securely and safely transmitted. However, no one can give an absolute assurance that information intended to be maintained as private, whether transmitted via the Internet or otherwise, cannot be accessed inappropriately or unlawfully by third parties. We have taken and will continue to take reasonable steps to ensure the secure and safe transmission of your personal information.

Personally Provided Information

If you are not involved with the submission or management of an RDS Program application on the RDS Secure Web Site, you do not have to give us personal information. If you choose to provide us with additional information about yourself through e-mail, forms, surveys, etc., we will maintain the information as long as needed to respond to your question or to fulfill the stated purpose of the communication.

Disclosure

HHS and CMS do not disclose, give, sell or transfer any personal information about its visitors, unless required for law enforcement or statute.

Intrusion Detection

The RDS Web Sites are maintained by the U.S. Government. It is protected by various provisions of Title 18, U.S. Code. Violations of Title 18 are subject to criminal prosecution in Federal court.

For site security purposes and to ensure that this service remains available to all participants, we employ software programs to monitor traffic to identify unauthorized attempts to upload or change information, or otherwise cause damage. In the event of authorized law enforcement investigations, and pursuant to any required legal process, information from these sources may be used to help identify an individual.

3. Systems of Records

Information originally collected in traditional paper systems can be submitted electronically, i.e., electronic commerce transactions and information updates about eligibility benefits. Electronically submitted information is maintained and destroyed pursuant to the Federal Records Act and in some cases may be subject to the Privacy Act. If information that you submit is to be used in a Privacy Act system of records, there will be a Privacy Act Notice provided.

4. Links

References from RDS web sites to any non-governmental entity, product, service or information do not imply endorsement or recommendation by CMS, HHS or any other HHS agency or employees.

We are not responsible for the contents of any "off-site" web pages referenced from this server. We do not endorse ANY specific products or services provided by public or private organizations. In addition, we do not necessarily endorse the views expressed by such sites, nor do we warrant the validity of any site's information or its fitness for any particular purpose.

4. Pop-up Advertisements

When visiting RDS web sites, your web browser may produce pop-up advertisements. These advertisements were most likely produced by other web sites you visited or by third party software installed on your computer. CMS does not endorse or recommend products or services for which you may view a pop-up advertisement on your computer screen while visiting our site.

4. Outdated Information

Many HHS/CMS documents are time sensitive. Department policies change over time. Information in older documents may be outdated. You also may wish to review our Privacy Policy in section 2.

4. Accessibility

This page provides information for those visitors who use assistive or other devices to access the content on the RDS web sites. Please see Contact Us at if you have general questions and comments or have difficulty finding something on this site.

Synopsis of Section 508 Accessibility Requirements

The Centers for Medicare & Medicaid Services (CMS’) Retiree Drug Subsidy (RDS) Program is committed to making all RDS Web Sites accessible to the widest possible audience, including individuals with disabilities. In keeping with its mission, the RDS Center complies with the regulations of Section 508 of the Rehabilitation Act and the Department of Health & Human Services (HHS) Section 508 Implementation Policy. The information contained within the RDS Web Sites are intended to be accessible through screen readers and other accessibility tools. If alternative means of access to any information contained on RDS Web Sites are needed, or interpreting any information proves difficult, please contact the RDS Help Line. Call (877) RDS-HELP or (877) 737-4357. TTY for hearing impaired: (877) RDS-TTY0, or (877) 737-8890. E-mail [email protected]. In an e-mail, please indicate the nature of the accessibility problem including the accessibility tool and web browser used, the web page address that is causing difficulty, contact name, e- mail address, and phone number. Please do not include any Protected Health Information (PHI), as defined in the Health Insurance Portability and Accountability Act (HIPAA), in the e-mail.

4. Freedom of Information Act (FOIA)

The RDS Web Sites are a service of the U.S. Department of Health and Human Services. Any Freedom of Information Act (FOIA) requests concerning the RDS Web Sites should be submitted in accordance with the Department's FOIA guidelines. Information on making FOIA requests is available at the Freedom of Information Group page. You also may

wish to review our Privacy Policy in Section 2.

H. Multi-Factor Authentication (MFA)

1. Text-Enabled Device (optional)

Text-enabled Device Number : Verification Code :

2. Scan QR Code or manually enter the Secret Key from Google Authenticator

3. Google Authenticator Token

PART II.

A. Plan Information

1) *Plan Name: 2) *Plan Year - Start Date: End Date:

B. Benefit Option(s) Provided Under This Plan

1. *Benefit Option Name:

2. *Unique Benefit Option Identifier:

3. *Benefit Option Type: Self-Funded Fully-Insured

4. Retiree Submission Method:

RDS Secure Website to RDS Center

Voluntary Data Sharing Agreement (VDSA) through CMS’ Coordination of Benefits (COB)

Contractor

Vendor Connect:Direct to RDS Center Connect:Direct

Plan Sponsor Connect:Direct to RDS Center Connect:Direct

5. * Vendor ID or VDSA Plan Number or MIR Reporter ID (not required for RDS Secure Website to RDS Center):

C. Actuary Invitation

1)*First Name: 2)*Last Name:

3. * Actuary AAA Membership Number:

4. *E-mail Address:

D. Actuary Information

1. * Actuary AAA Membership Number:

2. *Read and accept the User Agreement and Privacy Policy (located in Part I Section G of this document)

3. *First Name: Middle Initial (optional): *Last Name:

4. *Social Security Number: 5) *Date of Birth(Month/Day/Year):

6. Job Title:

7. *Phone Number:

8. *Address:

*Street 1

Street 2

*City *State/US Territory *Zip Code

6. *Login

*Login ID:

*Password:

*Re-enter password:

*Security Question 1

*Answer 1

*Security Question 2

*Answer 2

PART III.

A. Benefit Option Combination Question

1. *In calculating the actuarial Net Value of the benefit option(s) listed in this Plan Sponsor Application (Please select one of the following:

1. Each Benefit Option individually meets the Net Value test as set forth at 42 C.F.R.§423.884(d)

2. Two or more Benefit Options have been combined in order to meet the Net Value test as set forth at 42 C.F.R. 423.§884(d), and each option not so combined individually meets the Net Value test as set forth in 42 C.F.R. §884

Note: Based on the answer to the above question the actuary will be presented with the corresponding Actuarial Attestation agreement. (B (i) or B (ii)).

B (i). *Actuarial Attestation for the Gross and Net Value Tests if no Benefit options are combined

I hereby attest to the following:

I am a qualified actuary and a member of the American Academy of Actuaries. I am familiar with the requirements for, and am qualified to prepare, a Retiree Drug Subsidy (RDS) Actuarial Attestation.

The actuarial Gross Value of each of the Benefit Option(s) listed in this Plan Sponsor Application is at least equal to the actuarial Gross Value of the defined standard prescription drug coverage under Medicare Part D for the Medicare Part D eligible individuals who are participants and beneficiaries of the Plan Sponsor’s plan for the subject plan year.

I have determined that each of the Benefit Option(s) listed in this Plan Sponsor Application meet the Gross Value Test requirements of 42 C.F.R. §423 884(d), including the relevant actuarial guidelines issued by CMS, and the data and assumptions used in the development of this attestation are reasonable and are based on generally accepted actuarial principles, including the appropriate actuarial standards of practice.

Each Benefit Option individually meets the Net Value test as set forth at 42 C.F.R. §423.884(d).

The actuarial Net Value of the Benefit Option(s) listed in this Plan Sponsor Application is at least equal to the actuarial Net Value of the defined standard prescription drug coverage under Medicare Part D for the Medicare Part D eligible individuals who are participants and beneficiaries of the Plan Sponsor’s Plan for the subject plan year.

The Net Value of the Plan Sponsor’s prescription drug coverage was determined using a methodology consistent with the requirements set forth at 42 C.F.R. §423.884(d)(5) and all relevant actuarial guidelines issued by CMS, and the data and assumptions used in the development of this attestation are reasonable and are based on generally accepted actuarial principles, including the appropriate actuarial standards of practice.

I understand and acknowledge that the information being provided in this attestation is being used to obtain Federal funds.

I agree to maintain and make available reports, working documents and other records as required under 42 C.F.R. 423.§888(d). This includes information about data and/or assumptions I may have relied upon.

I certify that this attestation is true and accurate to the best of my knowledge and belief.

Electronic Signature

B(ii). * Actuarial Attestation for the Gross and Net Value Tests if benefit options are combined

I hereby attest to the following:

I am a qualified actuary and a member of the American Academy of Actuaries. I am familiar with the requirements for, and am qualified to prepare, a Retiree Drug Subsidy (RDS) actuarial attestation.

The actuarial Gross Value of each of the Benefit Option(s) listed in this Plan Sponsor Application is at least equal to the actuarial Gross Value of the defined standard prescription drug coverage under Medicare Part D for the Medicare Part D eligible individuals who are participants and beneficiaries of the Plan Sponsor’s plan for the subject plan year.

I have determined that each of the Benefit Option(s) listed in this Plan Sponsor Application meet the Gross Value Test requirements of 42 C.F.R. §423 884(d), including the relevant actuarial guidelines issued by CMS, and the data and assumptions used in the development of this attestation are reasonable and are based on generally accepted actuarial principles, including the appropriate actuarial standards of practice.

Two or more Benefit Options have been combined in order to meet the Net Value test as set forth at 42 C.F.R. 423.§884(d), and each option not so combined individually meets the Net Value test as set forth in 42 C.F.R. §884(d)

The actuarial Net Value of the Benefit Option(s) listed in this Plan Sponsor Application is at least equal to the actuarial Net Value of the defined standard prescription drug coverage under Medicare Part D for the Medicare Part D eligible individuals who are participants and beneficiaries of the Plan Sponsor’s Plan for the subject plan year.

The Net Value of the Plan Sponsor’s prescription drug coverage was determined using a methodology consistent with the requirements set forth at 42 C.F.R. §423.884(d)(5) and all relevant actuarial guidelines issued by CMS, and the data and assumptions used in the development of this attestation are reasonable and are based on generally accepted actuarial principles, including the appropriate actuarial standards of practice.

I understand and acknowledge that the information being provided in this attestation is being used to obtain Federal funds.

I agree to maintain and make available reports, working documents and other records as required under 42 C.F.R. 423.§888(d). This includes information about data and/or assumptions I may have relied upon.

I certify that this attestation is true and accurate to the best of my knowledge and belief.

Electronic Signature

PART IV.

1) *Bank Name:

1) *Bank Address:

*Street 1

Street 2

*City *State/US Territory *Zip Code

3. *Account Number:

4. *Re-enter Account Number:

3. * Organization Name Associated with Account:

3. *Account type: Checking Account Savings Account

3. *Bank Routing Number:

3. *Re-enter Bank Routing Number:

3. *Bank Contact *First Name Middle Initial: *Last Name:

4. E-mail address:

5. Re-enter Email address:

6. * Telephone Number: ext.

PART VI.

First name

Last name

Middle initial (optional)

Social Security Number (SSN)

Medicare beneficiary identifier (HICN or MBI) Date of Birth

Gender

Relationship to the Retiree (self, spouse, dependent) Transaction Type (add, update, delete)

First name Last name

Middle initial (optional)

Social Security Number (SSN)

Medicare beneficiary identifier (HICN or MBI) Date of Birth

Gender

Relationship to the Retiree (self, spouse, dependent) Transaction Type (add, update, delete)

PART VII
1.	Compliance. In order to receive subsidy payment(s), Plan Sponsor agrees to comply with all of the terms and conditions of 42 C.F.R. §423Subpart R and in other guidance issued by CMS, including, but not limited to, the conditions for submission of data for obtaining payment and the record retention requirements.
2.	Notice of Creditable Coverage: Plan Sponsor certifies that it has provided or will provide prior to the beginning of the plan year referenced in this Plan Sponsor application, creditable coverage notices in accordance with 42 C.F.R. §423.56 to Part D eligible individuals covered under the Plan Sponsor’s plan.
3.	Written Agreement: Plan Sponsor certifies that, prior to the first day of the plan year specified in this Plan Sponsor application, it has executed a written agreement with its health insurance issuer or group health plan regarding disclosure of information to CMS, and the issuer or plan agrees to disclose to CMS, on behalf of the Plan Sponsor, the information necessary for the Plan Sponsor to comply with the requirements of the RDS Program.
4.	Use of Records: Plan Sponsor understands and agrees that officers, employees and contractors of the Department of Health and Human Services, including the Office of Inspector General (OIG), may use information collected under the RDS Program only for the purposes of, and to the extent necessary in, carrying out their responsibilities under 42 C.F.R. §423 Subpart R including, but not limited to, determination of payments and payment-related oversight and program integrity activities, or as otherwise required by law. This restriction does not limit OIG authority to conduct audits and evaluations necessary for purposes of 42 C.F.R. §423 Subpart R or other authority. Sponsors further acknowledge that CMS will release Retiree Drug Subsidy payment data in accordance with 423.884(c).
5.	Obtaining Federal Funds: Plan Sponsor acknowledges that the information furnished in its Plan Sponsor application is being provided to obtain Federal funds. Plan Sponsor certifies that it requires all subcontractors, including plan administrators, to acknowledge that information provided in connection with the subcontract is used for purposes of obtaining Federal funds. Plan Sponsor acknowledges that payment of a subsidy is conditioned on the submission of accurate information. Plan Sponsor agrees that it will not knowingly present or cause to be presented a false or fraudulent claim. Plan Sponsor acknowledges that any overpayment made to the Plan Sponsor under the RDS program, or any debt that arises from such overpayment, may be recovered by CMS. Plan Sponsor will promptly update any changes to the information submitted in its Plan Sponsor application. If Plan Sponsor becomes aware that information in this application is not (or is no longer) true, accurate and complete, Plan Sponsor agrees to notify CMS promptly of this fact.
6.	Data Security: Plan Sponsor agrees to establish and implement proper safeguards against unauthorized use and disclosure of the data exchanged under this Plan Sponsor application. Plan Sponsor recognizes that the use and disclosure of protected health information (PHI) is governed by the Health Insurance Portability and Accountability Act (HIPAA) and accompanying regulations. Plan Sponsor certifies that its retiree group health plan(s) has established and implemented appropriate safeguards in compliance with 45 C.F.R. Parts 160, 162 and 164 (HIPAA administrative simplification, privacy and security rule) in order to prevent unauthorized disclosure of such information or data. Sponsor also agrees that if it participates in the administration of the plan(s), then it has also established and implemented the same safeguards in compliance with the above HIPAA citations. Any and all Plan Sponsor personnel interacting with PHI shall be advised of (1) the confidential nature of the information; (2) safeguards required to protect the information, and (3) the administrative, civil and criminal penalties for noncompliance contained in applicable Federal laws.
7.	Depository Information: Plan Sponsor hereby authorizes CMS to initiate payment, credit entries and other adjustments, including offsets and requests for payment, in accordance with the provisions of 42 C.F.R. §423 Subpart R and applicable provisions of 45 CFR Part 30, to the account at the financial institution (hereinafter the “Depository”) indicated under the Electronic Funds Transfer (EFT) section of the Plan Sponsor application. Plan Sponsor agrees to immediately pay back any overpayment or debt upon notification from CMS of the overpayment or debt. Plan Sponsor agrees to promptly update any changes in its Depository information.

8.

Change of Ownership: The Plan Sponsor shall provide written notice to CMS at least 60 days prior to a change in ownership, as defined in 42 CFR §423.892(a). When a change of ownership results in a transfer of the liability for prescription drug costs, this Plan Sponsor Agreement is automatically assigned to the new owner, who shall be subject to the terms and conditions of this Plan Sponsor Agreement.

CMS Form # 10170

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 0938-0957. This information collection is used to determine the eligibility of plan sponsors to participate in the Retiree Drug Subsidy program and allows for Plan Sponsors who offer prescription drug coverage to their qualified covered retirees to receive a 28% subsidy for allowable drug costs. The time required to complete this information collection is estimated to average less than 151 hours per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is required under §1860D-22 of the Social Security Act (Act), added by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and implementing regulations at 42 CFR part 423 subpart R and that laws, regulations, and guidance associated with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, and the Privacy Act of 1974 will apply to any information collected by CMS for purposes of this. 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.