Medicare Part D Plan Reconciliation Contract

$79 / year

This dataset contains the results by contract of the audit of the Centers for Medicare & Medicaid Services’ Medicare Part D Prescription Drug Event (PDE) reconciliation process performed by an independent certified public accounting firm.

Complexity

On November 15, 2005, Medicare Part D, the prescription drug coverage program for senior and other eligible citizens, went into effect. Under this program, private health insurance companies and organizations (Plan sponsors) offer insurance coverage for prescription drugs in which Medicare and eligible Medicaid recipients can enroll. CMS contracted with Plan sponsors nationwide to offer the Part D benefits for qualified beneficiaries on January 1, 2006.

The audit contained in this data set, by the accounting firm KPMG, was performed “in accordance with auditing standards generally accepted in the United States of America.”

The objectives were to determine whether CMS controls over payments to Plan sponsors, PDE records, and year-end reconciliation provided reasonable assurance that:

– the inputs that drive the calculation of monthly payments are accurate and complete
– the Risk Adjustment Factor calculations by the Risk Adjustment Processing System are accurate
– monthly payments are accurately calculated and are tracked
– submitted PDE records are valid, accurate, and complete
– PDE data are complete before year-end reconciliation, and
– Direct or Indirect Remuneration (DIR) reporting is accurate and complete.

CMS has designed a layered compliance framework that uses as inputs beneficiary reported complaints, internal data analysis results, audits, and other continuous oversight activities to take compliance action against Plan sponsors when needed. In addition, monthly payments are accurately being calculated and tracked. However, (1) the bid review and audit process needs improvement to ensure that inputs to monthly payments are accurate and complete; (2) controls need to be improved to ensure that submitted PDE records are accurate and complete and PDE data are complete before year-end reconciliation; and (3) improved benchmarks and metrics are needed to ensure the completeness and accuracy of DIR before reconciliation.

Date Created

2012-02-23

Last Modified

2017-01-21

Version

2017-01-21

Update Frequency

Semiannual

Temporal Coverage

2015

Spatial Coverage

United States

Source

John Snow Labs => Centers for Medicare and Medicaid Services

Source License URL

John Snow Labs Standard License

Source License Requirements

N/A

Source Citation

N/A

Keywords

Medicare Part D, Medicare Part D Plans, Medicaid Plan D, Account Reconciliation, Agreement Template, Medicare

Other Titles

Prescription Drug Event Reconciliation, PDE, Medicare Audit, Reconciliation by Contract

Name Description Type Constraints
Contract_CodeCode of the insurance contractstring-
Contract_NameName of the insurance contractstring-
Number_of_PlansNumber of plansintegerlevel : Ratio
Reconciliation_Amount_USDTotal net reconciliation amount of all plans in the contract in a coverage yearnumberlevel : Ratio
LICS_USDNet reconciliation amount of the Low Income Cost Sharing Subsidy, which is calculated by subtracting the Prospective Low-income Cost-sharing Subsidy Amount for the Actual Low-income Subsidy Amountnumberlevel : Ratio
Reinsurance_USDNet reinsurance reconciliation amount, which is calculated by subtracting the Prospective Reinsurance Subsidy Amount from the Actual Reinsurance Subsidy Amountnumberlevel : Ratio
Risk_Sharing_USDNet risk-sharing reconciliation amountnumberlevel : Ratio
Contract_CodeContract_NameNumber_of_PlansReconciliation_Amount_USDLICS_USDReinsurance_USDRisk_Sharing_USD
H2411FALLON COMMUNITY HEALTH PLAN1
S5857PRIORITY HEALTH INSURANCE COMPANY1
H6941LIFE PACE217449.95594.98750.83104.2
S0586MVP HEALTH PLAN INC.192236.592236.5
H8029ELDERPLAN INC.1231562.974512157050.9
H5969ALOHACARE1132227.16701131034.8-5508.7
H5386SHARP HEALTH PLAN222137.81285.920851.9
H0216PACE IOWA2295759.847737.5248329.4-307.1
H0105THE METHODIST OAKS250448.9-7850.458299.3
H6188VIECARE ARMSTRONG LLC136396.27642.228754