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Pool Administrators Inc.

Pool Administrators Inc. Administration of the Senior Prescription Drug Assistance Program for Maryland Health Insurance Plan. Presentation Outline. PAI’s Role as Administrator Best Practices Employed Program Requirements System Needs Skills and Staffing Lessons Learned Questions?.

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Pool Administrators Inc.

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  1. Pool Administrators Inc. Administration of the Senior Prescription Drug Assistance Program for Maryland Health Insurance Plan Pool Administrators Inc

  2. Presentation Outline • PAI’s Role as Administrator • Best Practices Employed • Program Requirements • System Needs • Skills and Staffing • Lessons Learned • Questions? Pool Administrators Inc

  3. PAI’s Role as Administrator • 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 Pool Administrators Inc

  4. Best Practices Employed 9/6/2014 Pool Administrators Inc 4 • 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

  5. Special Program Requirements 9/6/2014 Pool Administrators Inc 5 • 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!!!

  6. System Needs 9/6/2014 Pool Administrators Inc 6 • 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

  7. SPARCS Subsidy Payment Administration, Reporting and Control System Bank Reporting (monthly) Subsidy & Payment Reports Customer Center/Customer Service Telephony System Inquiry & Status Changes Service Web-Site (future) Audit Trail General Ledger & Financial Statements Annual Reporting Capture Application Form Recertify Eligibility (annual) Eligibility Management Financial Reporting and Tracking (Existing PAI Systems) Determine Eligibility Enroll Applicant Y SPDAP Member Database Eligible? Data Collection and Management Terminate Applicants (periodic) Scan, Index and Retrieve Paper Documents N Billing and Reconciliation MIS Reporting CMS Reporting Board Reporting Process Denials (Manual) Confirm Benefits (monthly) Program Subsidy Payment Payment Recon- ciliation Annual Report CMS Eligibility Validation Feed Current & Historical Reporting Enrollment Report (Monthly) Activity & Volume Reports (Monthly) PDP Plan Payment Files (monthly) Discrepancy Report (quarterly) CMS Report (Annual) Denial Letters To Applications Confirmations & Terms Pool Administrators Inc

  8. Skills and Staffing 9/6/2014 Pool Administrators Inc 8 • 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.

  9. Lessons Learned 9/6/2014 Pool Administrators Inc 9 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

  10. Questions? Pool Administrators Inc

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