US · guidance
CMS Pub. 100-18, ch. 14, § 50.7.1
Lump Sum Per Capita Approach
States that elect to adopt a lump sum per capita approach must issue a request for quote
(RFQ) inviting all Part D sponsors in the region to submit a quote (note – the quote is for the
increment above basic benefits) and must work with all sponsors that respond. As part of
the State’s RFQ and contract, any Part D sponsor that submits a quote would be required to
accept the lump sum per capita payments made by the State under its chosen approach.
Part D sponsors that do not opt to participate in this market are not required to submit
quotes. However, if a sponsor is not participating in the State’s lump sum approach, the
State should still explain that beneficiaries may enroll in that sponsor’s plan, but the
beneficiaries will get only basic coverage – without the SPAP additional defined benefit
– if they do so. Also, States are not obligated to provide wrap-around benefits to any
beneficiaries choosing to enroll in non-participating Part D plans, or to promote these Part D
plans, but a State electing to do so may provide wrap-around coverage on behalf of SPAP
beneficiaries choosing to enroll non-participating Part D plans. In fact, if the SPAP also
elects to pay the premium for all basic benefits, this approach does not permit the SPAP to
exclude payment of premium for any Part D sponsors not participating in the lump sum
approach.
36
The regulation at § 423.464(a) requires that Part D sponsors must coordinate with SPAPs
and other entities providing other prescription drug coverage. This includes scenarios when
the SPAP or other payer is adopting a lump sum per capita approach when supplementing
Part D benefits in accordance with § 423.464(a)(2). Therefore, CMS requires all Part D
sponsors to have the capacity to participate in non- risk based arrangements, if offered by
the State, SPAPs or other payers so that their enrollees can receive coordinated, wrap-around
coverage at the point-of-sale. If a sponsor is out of compliance with this regulatory
requirement, CMS will not disqualify a state program from its qualified SPAP status. CMS
will not view SPAPs as discriminating, in violation of section 1860D-23(b)(2) of the Act,
due to a Part D sponsor’s failure to adhere to this COB requirement.
History
(Rev. 17, Issued: 08 -23-13, Effective Date: 06-07-10, Imple mentation Date : 01-01-11)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-09-17
- Edition
- iom-2026-09-17
- Content hash
4589c76520e3b304cc6b8606f69052a622bf56cb83252b776099140acb3db44d
The link goes to the issuing authority’s own document — the one we read to produce this record. Where a source publishes whole titles rather than sections, your browser may need a moment to jump to the provision.
Unofficial copy of government-published law, reproduced from official sources with full provenance. Not an official publication; verify against official sources before relying on it in a filing. Records in the 'guidance' corpus, and only that corpus, are sub-regulatory (interpretive guidelines, survey procedures) and are not binding law. Validity bounds follow each jurisdiction's declared temporalBasis.