Reporting Inaccurate or Incomplete Data

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This page contains answers to Common Questions about reporting inaccurate or incomplete retiree and cost data. Review this page to learn about the different between inaccurate and incomplete data, how to disclose the correct information, and more.

How would an RDS Plan Sponsor disclose to CMS the correct, post-Reconciliation or post-final payment data, and the difference in subsidy caused by the corrected data, other than by requesting a reopening?

ANSWER: Such disclosure must include:

  • The Plan Sponsor's Name, Plan Sponsor ID, Application ID, and contact information;
  • Indication that the Plan Sponsor wishes to disclose such data and subsidy discrepancy to CMS, and is not requesting a reconsideration or reopening at this time;
  • A description of the specific facts and circumstances, including the specific reason(s) why the data submitted with the Reconciliation or final payment request was inaccurate or incomplete, and whether or not the Plan Sponsor believes the Covered Retiree List it agreed to before submitting its Reconciliation or final payment request was accurate;
  • The gross costs, cost threshold reductions, cost limit reductions, and price concession amount that the Plan Sponsor now believes is correct. (For this purpose, the data can either be broken down by Benefit Option by month, or can be submitted in the aggregate for the entire application.) These amounts should reflect what the Plan Sponsor now believes to be its accurate retiree list.

The Plan Sponsor should also disclose:

  • The amount of subsidy it received for the application;
  • The amount of subsidy the Plan Sponsor now believes is correct, based on the post-Reconciliation or post-final payment drug cost data (i.e., gross costs, cost threshold reductions, and cost limit reductions), price concession amount, and/or retiree coverage data, the Plan Sponsor now believes the subsidy should be based upon. See "How is the Retiree Drug Subsidy calculated for a given application?" for instructions on how the subsidy for an application is calculated.

A Post-Reconciliation Discrepancy Example is available for reference.

The disclosure should be sent, with a subject line of "Post-Reconciliation Subsidy Discrepancy," to CMS' RDS Center email address rds@cms.hhs.gov.

After the Plan Sponsor discloses to CMS the data and subsidy discrepancy as stated above, CMS will notify the Plan Sponsor of any further action it may or must take, if any.

Answer ID: 6000-1
Date Posted: 10/17/2014 Last Updated: 03/27/2015

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For purposes of the RDS Program, what is "inaccurate" data, as opposed to "incomplete" data?

ANSWER: For purposes of the RDS Program, inaccurate data includes situations where the Plan Sponsor over-reported or under-reported the gross costs associated with one or more specific claims for which some amount of subsidy was requested (i.e., the Plan Sponsor reported gross costs of $30 for a given claim when gross costs for that claim were $20), over-reported or under-reported the Threshold Reduction or Limit Reduction amounts for at least one month for any Benefit Option, or over-reported or under-reported rebates and other price concessions by any amount for at least one month for any Benefit Option. It also includes situations where the Plan Sponsor agreed to a Covered Retiree List that included subsidy periods for specific individuals when in fact one or more of those individuals was not a Qualifying Covered Retiree (as defined in 42 C.F.R. ยง423.882) for all or part of the CMS-approved subsidy period.

In contrast, for purposes of the RDS Program, incomplete data includes situations where the Plan Sponsor failed to report any of the gross costs associated with one or more specific paid claims. It also includes situations where the Plan Sponsor agreed to a Covered Retiree List that did not include certain individuals who are Qualifying Covered Retirees for all or part of the RDS plan year, and situations where the Plan Sponsor agreed to a Covered Retiree List that included certain individuals, but not for the entire period(s) of time for which those individuals were Qualifying Covered Retirees.

Answer ID: 6000-2
Date Posted: 10/17/2014

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What must a Plan Sponsor initially do upon discovering that it agreed to inaccurate (as opposed to incomplete) retiree data and/or reported inaccurate cost data with its Reconciliation or final payment request for an RDS application?

ANSWER: When a Plan Sponsor, after submitting its Reconciliation payment request, or its final payment request using the RDS Secure Website Reconciliation process, discovers that it agreed to inaccurate (as opposed to incomplete) retiree data and/or reported inaccurate cost data (see "RDS Program, what is "inaccurate" data, as opposed to "incomplete" data?" for examples of what constitutes inaccurate data), it must immediately determine whether the inaccurate data had the net effect of causing the Plan Sponsor to be paid too much or too little in subsidy for the application (or that the Plan Sponsor will be paid too much or too little, after CMS processes the Reconciliation or final payment request). If so, the Plan Sponsor must immediately disclose to CMS the correct gross costs, cost threshold reduction, cost limit reduction, and price concession amount in the aggregate, for the application (i.e., this post-Reconciliation or post-final payment data need not be broken down by Benefit Option, by month, for purposes of this disclosure to CMS).

The Plan Sponsor also should immediately quantify the difference in subsidy caused by the corrected data, and should immediately report, in that same disclosure, that amount to CMS (regardless of the amount). The Plan Sponsor must disclose this information either by submitting a reopening request, or by otherwise disclosing the data to CMS. For more information on disclosing the data, refer to "How would an RDS Plan Sponsor disclose to CMS the correct, post-Reconciliation or post-final payment data, and the difference in subsidy caused by the corrected data, other than by requesting a reopening?"

After the Plan Sponsor discloses to CMS the subsidy discrepancy using one of those two methods, CMS will notify the Plan Sponsor of any further action the Plan Sponsor must take, if any.

Answer ID: 6000-3
Date Posted: 10/17/2014

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What must a Plan Sponsor do upon discovering that it agreed to incomplete (as opposed to inaccurate) retiree data and/or reported incomplete cost data with its Reconciliation or final payment request for an RDS application?

ANSWER: When a Plan Sponsor, after submitting its Reconciliation payment request, or its final payment request using the RDS Secure Website Reconciliation process, discovers that it agreed to incomplete (as opposed to inaccurate) retiree data and/or reported incomplete cost data (see "For purposes of the RDS Program, what is "inaccurate" data, as opposed to "incomplete" data?" for examples of what constitutes incomplete data), and has reason to believe that the incomplete data had the net effect of causing the Plan Sponsor to be paid (or that it will be paid) too little in subsidy for the application, it is not required to quantify that difference in subsidy. It is permissible to not disclose the corrected data or the subsidy discrepancy to CMS.

The Plan Sponsor, however, may choose to quantify the difference, and attempt to acquire the difference in subsidy by requesting a reopening. See "How would an RDS Plan Sponsor request a reopening of a reconciliation or final payment determination, when it believes the determination is incorrect due to inaccurate or incomplete cost data?" for information regarding how to request such a reopening.

After requesting a reopening, CMS will notify the Plan Sponsor whether it may acquire the difference in subsidy, and if so, what further steps the Plan Sponsor must take in order to do so.

Answer ID: 6000-4
Date Posted: 10/17/2014

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