Instructions SPAP_dis

Instructions SPAP_dis.pdf

Coordination of Benefits between Part D Plans and Other Prescription Coverage Providers

Instructions SPAP_dis

OMB: 0938-0978

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Dear State Official:
As you know, the Centers for Medicare & Medicaid Services (CMS) clarified our
non-discrimination policy in the 2008 Call Letter to explicitly permit States to adopt
reasonable coordinating criteria that will allow the SPAPs and Part D sponsors to provide
quality coordination of care and benefits in the interest of our beneficiaries. Our revised
approach allowed SPAPs with authorized representative status to enroll on behalf of their
members into plans that agree to the State-specific coordination criteria, such as offering
similar formularies, expanding pharmacy networks, and sharing historical claims data.
For calendar years 2008 and thereafter, we require SPAPs to submit information
on their programs using the attached template (or an alternative format) to CMS, which
will allow CMS to approve its coordination criteria prior to the beginning of the calendar
year. For 2009 and thereafter, we have revised the template slightly to request
information regarding the timing of States’ enrollment activities relative to their
authorized representative status (See section III. Enrollment). This will allow CMS to
anticipate beneficiary inquiries to its call centers about enrollments that occur outside of
the annual open-enrollment period. CMS is currently accepting the SPAP templates and
SPAP information for CMS review for calendar year 2009.
To reiterate our current policy, the coordinating criteria adopted by an SPAP must
serve the purpose of either easing the transition of SPAP members into the Part D benefit,
or establishing reasonable administrative requirements. CMS will carefully review an
SPAP’s proposed criteria to ensure that it serves these legitimate purposes, and are not a
pretext for steering beneficiaries towards one or more preferred plans. In addition, the
coordinating criteria may not be unduly burdensome so as to deter a significant number
of Part D plans from coordinating with the SPAP; rather, all Part D plans must have a real
opportunity to coordinate with an SPAP on an equal basis. Finally, the SPAP must
permit an SPAP member to enroll in a Part D plan that does not meet the SPAP’s
coordinating criteria, without negatively impacting the beneficiary’s SPAP benefits.

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Attached is the standardized template and instructions for calendar year 2009.
SPAPs are required to submit information regarding its program in the attached template
(or an alternative format) by August 1 in order to expedite CMS’s approval of its
coordination criteria prior to the calendar year. CMS will review the state’s template
within 30 days. We believe this process will give the states enough time to issue a request
for proposal (RFP) prior to the Part D benefit year. CMS’s review of the state’s template
will be based upon the guidance we have provided in regulation at 42 CFR 423.464,
Chapter 14 of the Medicare Prescription Drug Manual, and the 2007 SPAP Qualified
Guidelines.
States should submit their scanned and signed template to the following email
box: SPAP_Plans@cms.hhs.gov.
If you have questions regarding the instructions, please contact Christine Hinds on
(410)786-4578 or Debbie Hunter on (410)786-0625.

Sincerely,

Abby L. Block
Director
Center for Beneficiary Choices

Revised June 2008

SPAP Plan to Wrap-Around Part D
State_______________

Program Name_______________

I. Eligibility
Who is eligible for your state’s SPAP benefits? Please provide applicable poverty and
asset thresholds. If eligibility is linked to a specific disease or condition, LIS application
status, and/or Part D enrollment status, please note that as well:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
II. Financial Assistance
a) Is the SPAP adopting one of the lump sum approaches outlined in Chapter 14 of the
Medicare Prescription Drug Benefit Manual? Please check at least one box.
1. ___ Yes.
2. ___ No, a lump sum approach is not being adopted.
b) If Yes to a., please check which approach you intend to use:
1. ___ Risk-based
2. ___ Non-risk based
c) If Yes to a., attach the RFP and indicate proposed publication date for RFP.
d) If you are not adopting a lump-sum approach, please check at least one box below,
and describe the type of financial assistance to be provided with respect to wrapping
around the Part D benefit:
1. ___ Premium Assistance Only. (Provide description. For example – Providing
premium assistance limited to $30 per beneficiary, per month).________
___________________________________________________________
2. ___ Cost-sharing assistance at point-of-sale (Provide description of type of cost
sharing assistance and the limit on such cost sharing assistance. For example –
SPAP pays for cost sharing of covered Part D drugs up to $5 copay per

prescription).
____________________________________________________________
____________________________________________________________
____________________________________________________________
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3. ___ Both premium assistance and cost sharing. Provide Description.
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
III. Enrollment
a) Does your program intend to make Part D enrollment elections on behalf of your
members as their authorized representative under state law? Please check at least one
box below.
1. ___ No.
2. ___ Yes. If yes, please respond to questions b & c below.

b) What is the state’s enrollment/assignment process? Please check at least one box
below.
1. ___ Random assignment. You intend to enroll your 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.
2. ___ Non-random assignment. You intend to enroll your 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.
c) Do you intend to limit enrollment in particular plans based on established
coordination criteria? Please check at least one box below.
1. ___ No.

2. ___ Yes. Please attach a detailed description of the coordinating criteria that
the State will use, including the date that the RFP will be published.
d) Please provide the approximate dates of when the SPAP will enroll its members into
coordinating plans:
____________________________________________________________
____________________________________________________________
____________________________________________________________

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NOTE: As required by our revised policy, SPAP benefits (premiums and cost sharing
financial assistance) must apply if a beneficiary chooses to opt out into another plan
outside of those that have agreed to coordinate benefits with the state, unless the state is
limiting wrap-around benefits to beneficiaries joining certain plans in accordance with
the risk-based lump sum approach noted in section II.

IV. Assurance
1. ___ I certify that at least annually, the State will submit a revised 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.
2. ___ The above information is correct and in accordance with 42 CFR 423.464,
Chapter 14 of the Medicare Prescription Drug Manual as it applies to
SPAPs, and enrollment guidance provided in the Qualified SPAP Guidelines.
Signature:

________________________________________________________

Print Name: ________________________________________________________
Title: ______________________________________________________________
Agency:

________________________________________________________

Date Submitted: _________________ Date approved by CMS:______________
Signature of CMS Approving Official ___________________________________
Typed Name of CMS Approving Official _________________________________

Please submit your signed and scanned template to the following email box:
SPAP_Plans@cms.hhs.gov.

File Type	application/pdf
File Title	To: SPAP Workgroup
Author	CMS
File Modified	2009-02-05
File Created	2009-02-05