Pool Administrators Inc. Administration of the Senior Prescription Drug Assistance Program for Maryland Health Insurance Plan Pool Administrators Inc 6/4/2018

Presentation Outline PAI’s Role as Administrator Best Practices Employed Program Requirements System Needs Skills and Staffing Lessons Learned Questions? Pool Administrators Inc 6/4/2018

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 6/4/2018

Best Practices Employed 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 6/4/2018 Pool Administrators Inc 4

Special Program Requirements 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!!! 6/4/2018 Pool Administrators Inc 5

Pool Administrators Inc System Needs 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 6/4/2018 Pool Administrators Inc 6

Customer Center/Customer Service SPARCS Subsidy Payment Administration, Reporting and Control System Bank Reporting (monthly) Subsidy & Payment Reports Customer Center/Customer Service Telephony System Capture Application Form Determine Eligibility Enroll Applicant Eligible? Process Denials (Manual) Recertify (annual) Terminate Applicants (periodic) Y N Management Confirm Benefits (monthly) Confirmations & Terms Denial Letters To Applications Inquiry & Status Changes Service Web-Site (future) Financial Reporting and Tracking (Existing PAI Systems) Audit Trail General Ledger & Financial Statements Annual Reporting SPDAP Member Database Data Collection and Management Scan, Index and Retrieve Paper Documents Billing and Reconciliation MIS Reporting CMS Reporting Board Reporting Program Subsidy Payment Payment Recon- ciliation Annual Report CMS Eligibility Validation Feed PDP Plan Payment Files (monthly) Discrepancy Report (quarterly) CMS Report (Annual) Current & Historical Reporting Enrollment Report (Monthly) Activity & Volume Reports (Monthly) 6/4/2018 Pool Administrators Inc

Pool Administrators Inc Skills and Staffing 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. Nks 6/4/2018 Pool Administrators Inc 8

Pool Administrators Inc Lessons Learned 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 6/4/2018 Pool Administrators Inc 9

Questions? Pool Administrators Inc 6/4/2018