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

2. 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

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
6/4/2018

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Questions?
Pool Administrators Inc
6/4/2018