CMS Pub. 100-18, ch. 14, § 50.11

CMS does not have the authority to require data exchanges between Part D sponsors and

States except as required for COB purposes. While the MMA required Part D sponsors to

allow SPAPs and other entities providing prescription drug coverage to “coordinate” with

them, this language does not support requirements on the coordination of anything but

payment. However, CMS strongly encourages Part D sponsors to independently share

historical and ongoing data on any shared enrollees with other payers – particularly with

States – provided such disclosure is consistent with the requirements of the HIPAA Privacy

Rule. CMS encourages Part D sponsors to discuss reciprocal arrangements with State

Medicaid Plans under which Part D sponsors would provide Part D drug claims data in

exchange for both historical prescription drug claims data and ongoing medical claims

(particularly diagnoses) on the dual eligible population to assist with medication therapy

management (MTM) and other quality assurance programs. CMS also encourages sponsors

to provide this reciprocal data exchange without charging any user fees.

Part D sponsors and States may negotiate details regarding the development of a Standard

File Format for Patient Drug History and Standard Data Sharing Agreement. NCPDP, which

is the national standards organization for pharmacy claims, has adopted the Post

Adjudication Standard. Section 10 of the “Post Adjudication Standard Implementation

Guide, Version 4.2” contains the “Post Adjudication Utilization Record,” which is the

recommended standard record States and Medicare Part D sponsors could use to exchange

drug history information. In order to access NCPDP documentation and use the Post

Adjudication Utilization Record, States and/or their contractors must be members of

NCPDP.

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If the States and Medicare Part D sponsors agree to exchange enrollees’ drug history

information, then States and sponsors are new business associates. Thus, it is necessary that

the exchange of data complies with HIPAA requirements. To adhere to HIPAA

requirements, a Patient Drug History Data Sharing Agreement signed by the Medicare Part

D sponsor and the State must be in place prior to executing file transfers between these

entities.

CMS believes States have the authority under Section 1902(a)(25) of the Social Security Act

to request information to coordinate benefits they may have paid under the State Medicaid

program. CMS encourages Part D sponsors to review the statute as well as related CMS

guidance.