The process for filing ongoing and/or reopening Retiree Drug Subsidy applications is incredibly complex for both Plan Sponsors participating in the program and the brokers/consultants that assist them. Below are some Broker FAQs to assist them with understanding and navigating the RDS program. Visitors can also find printer-friendly information on the RDS program on our Documents page.
One of the biggest challenges Plan Sponsors face with the RDS program is coordinating between the Centers for Medicare and Medicaid Services (CMS), multiple vendors, and data sources to compile the necessary information to receive subsidy payments. In summary, the CMS requires Plan Sponsors and their vendor(s) must do the following to compile the requisite information:
While these requirements are simple enough in theory, more often than not, each piece is completed by different parties. This means that when the time comes to compile this information, miscommunications and oversights can only be expected. This confusion is only compounded by sometimes conflicting and generally complicated rules and restrictions for each item, which are set by the CMS.
It May Be Difficult to get all the Necessary Data from Vendors for Past Years
This can be particularly challenging when the Plan Sponsor has terminated the relationship with one or more of the vendors or if the vendors have gone through one or more acquisitions.
PDA works closely with more than eighty (80) vendors around the country. PDA will submit the initial data requests to the different vendors in order to receive all necessary data elements to complete the RDS review. PDA also makes it easier on these vendors by accepting data in any format that they may have readily available, reducing the likelihood that the vendor will have system issues. In the event that a vendor is unable or unwilling to provide the necessary data, PDA will work with the client to obtain the data.
The RDS Center May Deny the Reopening
In the event that the appeal is denied, PDA is committed to warehousing all of the Plan Sponsor’s data, in an auditable format, so that it is readily available in case of a CMS audit. Unfortunately, Medicare decisions on RDS appeals are final and cannot be appealed.
Once the Recalculations for are done, the Plan Sponsor may be in an Over Payment Situation
This may result in the Plan Sponsor having to reimburse the CMS some of the previously collected subsidy net of PDA’s improvements.
While this is unlikely, PDA will submit a cost report prior to the Plan Sponsor filing an appeal. It is the choice of the Plan Sponsor whether or not they would like to pursue the appeal. Alternatively, the Plan Sponsor can notify CMS that it believes there is some degree of overpayment or the Plan Sponsor may simply do nothing. If either of those options is selected, PDA remains committed to warehousing all of the Plan Sponsor’s data, in an auditable format, so that it is readily available in case of a CMS audit.