Pool Administrators Inc

Administration of theSenior Prescription Drug Assistance

Programfor

Maryland Health Insurance Plan

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PAI’s Role as Administrator Best Practices Employed

◦ Program Requirements◦ System Needs◦ Skills and Staffing

Lessons Learned Questions?


Process SPDAP applications◦ Accept/pend/deny◦ Outbound communications and follow-up

Submit eligible members to CMS for verification, plan membership

Receive CMS response file, update member file Calculate payments to Prescription Drug Plans

(PDP’s) Aggregate payments by PDP, transfer $ to

accounts Recertify members annually Scan and index all correspondence Call center and written communications


Consider Special Requirements of a new program:◦ People, policy, process adapt to the program, not

vice versa Consider the System Needs

◦ A custom system vs. a legacy system◦ System that can be configured, extended and

modified◦ Flexibility for data capture through the web

Consider the Skills and Staffing◦ For program changes and volume shifts

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Web-based eligibility inquiry for PDP’s Recertification and member communications Retroactive adjustments based on CMS

response file: THIS IS HARD!!!…if CMS file says member eligibility was in different PDP as of

effective date 6 months ago and member became eligible for federal low income subsidy 3 months ago…

…then back out each member-month payment for each of last 6 months, recalculate payments for 3 months of new PDP at that rate, then update member as LIS therefore not eligible as of 3 months ago then re-accumulate PDP subsidy payments, combine with others…

…until further notice…or termination according to CMS or no recertification verification, etc… WHEW!!!


Maintain both SPDAP Member and PDP eligibility for all periods of membership in terms of member-months

Accommodate ever changing member master file to store unique information required by program

Process adjustments for n months in the past Be configured for tailored communications (like

recerts or terms) and call center scripts Scan and index all documents and link to

member file on call center rep screen to show entire member story and enable once and done, outstanding customer service


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SPDAPMember

Database

CaptureApplicatio

n Form

Determine

Eligibility

EnrollApplican

t Eligible?

ProcessDenials

(Manual)

RecertifyEligibility(annual)

TerminateApplicant

s(periodic)

Y

N

EligibilityManagement

ConfirmBenefits(monthly

)

Confirmations& Terms

Denial Letters To Applications

Billing and Reconciliation

Customer Center/Customer Service

Data Collection and Management

Inquiry &Status

Changes

Service Web-Site (future)

Program

SubsidyPaymen

t

PaymentRecon-ciliation

AnnualReport

PDP Plan Payment Files

(monthly)

DiscrepancyReport

(quarterly)

CMS Report

(Annual)

MISReportin

g

Scan, Index and Retrieve Paper Documents

Board Reportin

g

Current &Historical Reporting

Activity &Volume Reports

(Monthly)

Audit Trail

General Ledger &Financial

Statements

AnnualReportin

g

Bank Reporting(monthly)

Subsidy &PaymentReports

CMS Reportin

g

EnrollmentReport

(Monthly)

Telephony System

CMS EligibilityValidation Feed

Subsidy Payment Administration,Reporting and Control System

Process and systems engineering skills to convert old system to new, design new process, assure adequate controls and manage the project

Multi-skilled and collaborative team thanks to MHIP’s participation and leadership

Flexible staffing with cross-trained team to handle changes in program needs and changes in volume

Attention to detail without getting bogged down ◦ WE DID IT IN 3 MONTHS…but we’d recommend

allowing a little more time.


It’s a project and a process, and you need a lot of different skills

Find a system that will fit the program or quality and efficiency will suffer

Support a climate of continuous participation and leadership from your client

Expect that needs will change and be ready to accommodate them

