Coordination of Benefits Part D
Since 1999, the Coordination of Benefits (COB) contract has consolidated Medicare benefit coordination activities from various Medicare contractors to a single point of contact. These activities have consisted of the identification of Medicare Secondary Payer (MSP) situations, where Medicare has mistakenly paid primary for health services of beneficiaries whose non-Medicare coverage was the appropriate primary payer, and claims crossover to supplemental insurers.
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and subsequent regulations require unprecedented coordination between the CMS, State programs, insurers, employers, and all other payers of prescription drug coverage to ensure that the benefits provided to Part D beneficiaries by all parties are maximized and the integrity of the Medicare program is assured. The CMS and the COB contractor have worked to anticipate and accommodate all of the coordination needs of the Part D benefit. These include the expansion of the MSP rules to the Part D benefit (found in § 1860D-2(a) (4) of the MMA); providing the True Out of Pocket (TrOOP) Facilitation Contractor and Part D Plans with the secondary non-Medicare prescription drug coverage that it must have to facilitate payer determinations and the accurate calculation of the TrOOP expenses of beneficiaries; and allowing employers to easily participate in the Retire Drug Subsidy (RDS) program.
The CMS has leveraged existing relationships with the private health insurance and the employer communities to meet the MMA benefit coordination needs. The existing MSP Voluntary Data Sharing Agreement (VDSA) and crossover Coordination of Benefits Agreement (COBA) data exchange processes have been revised to include prescription drug coverage. To make participation in the RDS program as easy possible, employers with VDSAs will also be able to use that process to submit their retiree prescription drug coverage population. This supports the CMS mission of a single point of contact for entities coordinating with Medicare. The CMS has also developed data exchanges for entities that have not coordinated benefits with Medicare before, including Pharmaceutical Benefit Managers (PBMs), State Pharmaceutical Assistance Programs (SPAPs), and other prescription drug payers. The CMS has worked with these new partners to educate them about coordination needs, to inform the CMS about how the prescription drug benefit world works today, and to develop data exchanges that allow all parties to efficiently serve our mutual customer, the beneficiary.
If you are unable to find the information you need, contact us using our toll-free lines: 1-800-999-1118 or TTY/TDD: 1-800-318-8782 for the hearing and speech impaired. A representative will be available to assist you Monday through Friday, from 8:00 a.m. to 8:00 p.m., Eastern Time, except holidays.
- DSA User Guide Supplemental, January 14, 2013 [PDF, 360KB]
- ADAP Specific DSA, March 19, 2013 [PDF, 288KB]
- ADAP Specific DSA User Guide - October 1, 2012 [PDF, 324KB]
- SPAP DSA - March 19, 2013 [PDF, 243KB]
- SPAP DSA User Guide - October1, 2012 [PDF, 373KB]
- PAP DSA - March 19, 2013 [PDF, 253KB]
- PAP User Guide - October 1, 2012 [PDF, 361KB]
- PAP Implementation Questionnaire, May 18, 2012 [PDF, 128KB]
- SPAP Implementation Questionnaire, May 12, 2012 [PDF, 119KB]
- Part D Data Exchanges Powerpoint Presentation (PDF 53 KB) [PDF, 166KB]
- ADAP Implementation Questionnaire, May 11, 2012 [PDF, 118KB]
- Page last Modified: 01/24/2013 11:50 AM
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