Reconciliation Agreement

User Roles:

AR

Signature of Plan Sponsor Authorized Representative

In order to receive subsidy payments, Plan Sponsor agrees to comply with all of the terms and conditions of the Plan Sponsor Agreement that was signed by the Authorized Representative of the Plan Sponsor and submitted with the application. Plan Sponsor will promptly notify CMS of any changes to the information submitted in its Plan Sponsor Agreement.

Obtaining Federal Funds: Plan Sponsor acknowledges that the information furnished in its retiree drug subsidy Reconciliation Payment Request is being provided to obtain Federal funds. Plan Sponsor certifies that it requires all subcontractors, including plan administrators, to acknowledge that information provided in connection with the subcontract is used for purposes of obtaining Federal funds. Plan Sponsor acknowledges that payment of a subsidy is conditioned on the submission of accurate information. Plan Sponsor agrees that it will not knowingly present or cause to be presented a false or fraudulent claim. Plan Sponsor acknowledges that any overpayment made to the Plan Sponsor under the RDS program may be recouped by CMS/RDS Contractor as described in applicable provisions of the Department of Health and Human Services overpayment regulations at 45 C.F.R. 30 Subpart B. Plan Sponsor agrees that once it becomes aware that an overpayment has occurred, it will promptly take action to repay the overpayment to the RDS Center within 30 days of the discovery of the overpayment. Plan Sponsor authorizes CMS to initiate payment and other adjustments, including offsets and requests for payment, in accordance with the provisions of 42 C.F.R. 423 Subpart R and applicable provisions of 45 C.F.R. 30 Subpart B to the account at the financial institution (hereinafter the "Depository") indicated under the Electronic Funds Transfer (EFT) section of the Plan Sponsor Application. Plan Sponsor agrees to promptly notify CMS of any changes in its Depository information and submit an updated EFT Authorization.

I, the undersigned Authorized Representative, on behalf of the Plan Sponsor, declare that I have examined this Reconciliation Payment Request and certify that the information contained in this Reconciliation Payment Request is true, accurate and complete to the best of my knowledge and belief; that the Plan Sponsor agrees to comply with all RDS program requirements (including 42 C.F.R. 423 Subpart R and applicable provisions of 45 C.F.R. 30 Subpart B) and other applicable laws and regulations. I understand that, because payment of a subsidy will be made from Federal funds, any false statements, documents, or concealment of a material fact is subject to prosecution under any applicable Federal and/or State law.