Medicare Part D Plan Reconciliation Contract

$179 / 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

2019-10-11

Version

2019-10-11

Update Frequency

Semiannual

Temporal Coverage

2017

Spatial Coverage

United States

Source

John Snow Labs; Centers for Medicare and Medicaid Services;

Source License URL

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

NameDescriptionTypeConstraints
Contract_CodeCode of the insurance contractstring-
Contract_NameName of the insurance contractstring-
Number_of_PlansNumber of plansintegerlevel : Ratio
Reconciliation_AmountTotal net reconciliation amount of all plans in the contract in a coverage yearnumber-
LICSNet 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 Amountnumber-
ReinsuranceNet reinsurance reconciliation amount, which is calculated by subtracting the Prospective Reinsurance Subsidy Amount from the Actual Reinsurance Subsidy Amountnumber-
Risk_SharingNet risk-sharing reconciliation amountnumber-
Contract CodeContract NameNumber of PlansReconciliation AmountLICSReinsuranceRisk Sharing
E0654 IBT VOLUNTARY EMPLOYEE BENEFITS TRUST12553204.64659378.01893826.640.0
E2630 C AND O EMPLOYEES' HOSPITAL ASSOCIATION1371867.13109972.64261894.490.0
E3014 PSERS HOP PROGRAM121876292.01132900.9820743391.020.0
E4744 MODOT/MSHP MEDICAL AND LIFE INSURANCE PLAN12046043.31224657.631821385.680.0
E7316 UNION PACIFIC RAILROAD EMPLOYES HEALTH SYSTEMS11786621.0418919.691367701.310.0
H0022 BUCKEYE COMMUNITY HEALTH PLAN, INC.115335263.04-294080.4912563032.323066311.21
H0028 CHA HMO, INC.3-811632.85-564706.96155803.43-402729.32
H0062 SUPERIOR HEALTHPLAN COMMUNITY SOLUTIONS, INC.3102020.3328106.774852.29-938.66
H0104 BLUE CROSS AND BLUE SHIELD OF ALABAMA51961815.661451016.28510799.380.0
H0105 THE METHODIST OAKS2-84738.0-38927.41-20211.58-25599.01