CMS Pub. 100-11, ch. 14, § 30.10

CMS systems will compare PACE Part D enrollment transactions to information CMS

has regarding the existence of employer or union sponsored qualified prescription drug

coverage for which the beneficiary is also being claimed for the Retiree Drug Subsidy

(RDS). If there is a match indicating that the individual may have such other coverage,

the PACE Part D enrollment will be conditionally rejected by CMS systems as

incomplete. Within 10 calendar days of receipt of the Code 127 conditional rejection, the

PACE organization must contact the individual to confirm the individual’s intent to enroll

and that the individual has discussed and understands the implications of enrollment in a

Part D plan on his or her employer or union coverage. Individuals will have 30 calendar

days from the date they are contacted to respond. The PACE organization must ensure

that plan benefits are available to the individual as of the effective date of the initial

enrollment request. The organization may contact the individual in writing or by phone,

or may discuss this in person and must document this contact and retain it with the record

of the individual’s enrollment request. If the individual indicates that s/he is fully aware

of any consequence to his/her employer or union coverage brought about by enrolling in

the Part D Plan, and confirms s/he still wants to enroll, the PACE organization must

update the transaction with the appropriate “flag” (detailed instructions for this activity

are included with CMS systems guidance) and re-submit it for enrollment. The effective

date of enrollment will be based upon the individual's initial enrollment request. This

effective date may be retroactive in the event that the confirmation step occurs after the

effective date. Organizations may use the Code 62 enrollment transaction code to submit

the enrollment transaction directly to CMS, as described in the Plan Communication

Users Guide (PCUG):

• The Part D sponsor must use a number other than an enrollee’s Social

Security Number (SSN) or Healthcare Insurance Claim Number (HICN) on

enrollee identification cards. (PACE Part D Solicitation);

The Part D sponsor must provide the beneficiary’s gross covered drug spend and true out-of-pocket (TrOOP) balance to the beneficiary as of the effective date of disenrollment.

(PACE Part D Solicitation, PACE Plan Addendum – Implementation of Automated

Troop Balance Transfer Process).