CMS Pub. 100-11, ch. 14, § 30.2

As provided in the MMA, beneficiaries are legally obligated to report information about

other prescription drug coverage or reimbursement for prescription drug costs that the

beneficiaries have or expect to receive; any material misrepresentation of such

information by a beneficiary may constitute grounds for termination of coverage from a

Part D plan. PACE Part D sponsors must, therefore, regularly survey their participants

regarding any other prescription drug coverage they may have and report that information

to the Coordination of Benefits contractor so that it can be validated, captured, and

maintained for Coordination of Benefit purposes. Anytime a PACE organization receives

information concerning a change, this information should be sent electronically to the

Coordination of Benefits contractor within 30 days of receipt.

Except as noted, the Coordination of Benefits survey should be performed within 30 days

of the date the PACE organization processes a participant’s enrollment and annually

thereafter. If a participant indicates on his or her enrollment form that there is no other

prescription drug coverage, no PACE organization follow-up is required until the annual

survey is performed. However, if the enrollee indicates on the enrollment form that he or

she in fact has other prescription drug coverage or does not provide any response to those

questions, the sponsor must perform the 30-day survey.

The survey should collect from the participant the same information on other payers that

Part D sponsors must submit electronically to the Coordination of Benefits contractor.

PACE Part D sponsors have the flexibility to design their survey process according to

their own needs. PACE Part D sponsors may conduct their survey by telephone, mail,

email if available, or in-person. The survey should not require that the participant provide

his or her Social Security Number; instead, PACE Part D sponsors should use other

identifiers, such as the Member ID. Also, in addition to providing a self-addressed return

envelope for mail surveys, sponsors should include, on the survey form itself, the mailing

address to be used for completed surveys in case the envelope is lost or damaged.

A non-response to the survey regarding other prescription drug coverage cannot be

interpreted as a negative answer since effective coordination of benefits with other

prescription drug coverage requires that sponsors be aware of any other prescription drug

coverage a beneficiary may have. Therefore, PACE Part D sponsors are required to

follow up with participants who fail to respond. Follow-up with non-responding

participants may be conducted by telephone, mail, email if available, or in person. After

unsuccessful attempts to gain a response using one mode, PACE Part D sponsors may

find a change to another mode is more productive. Also, if the participant has had drug

claims, PACE Part D sponsors may contact the pharmacy to determine if Coordination of

Benefits information was captured while the participant was in the pharmacy. PACE Part

D sponsors are expected to make a minimum of three attempts to follow up with non-responding participants. At least one of the follow-up efforts must involve the use of a

different method of contact. For example, if the initial survey was mailed, at least one of

the follow-up attempts must be other than a mailed survey, i.e., must be conducted by

telephone, email if available, or in-person.

PACE Part D sponsors also are responsible for sending electronic updates about their

participant’s other sources of prescription drug coverage to the Coordination of Benefits

contractor. Since supplemental payer information is essential for Coordination of

Benefits, PACE Part D sponsors should submit this information to the Coordination of

Benefits contractor at least monthly.

For more information, refer

to: http://www.cms.gov/PrescriptionDrugCovContra/Downloads/Chapter14.pdf.