CMS-10171 2017 SPAP Template

Attachment 2: 2017 SPAP template

Program Name and State:
Contact Information:
(SPAP Agency Official, Mailing Address, Email, and Phone):
(SPAP RxBIN/RxPCN/RxGroup ID, as applicable):

SPAP Processor Contact Information:
(SPAP Processor, Contact Name, Mailing Address, Email, and Phone):

I. Eligibility
A. Provide who is eligible for your state’s SPAP benefits (specifying income and asset
thresholds, and/or specific diseases/conditions):
B. SPAP eligibility conditioned upon LIS application?
o Yes
o No
C. SPAP eligibility conditioned upon Part D enrollment?
o Yes
o No
II. Financial Assistance/Benefits
A. Does the State use a lump sum approach (outlined in Chapter 14 of the Medicare Prescription
Drug Benefit Manual)? Please check at least one box.
o No, a lump sum approach is not being adopted.
o Yes.
B. If yes to A., please check what type of approach you intend to use and attach the request for
proposal (RFP) and indicate proposed publication date of RFP:
o Risk-based
o Non-risk based
Proposed publication date of RFP: ___________
C. If not adopting lump-sum approach, indicate type of coverage provided:
o Premium only
o Cost sharing only
o Both
D. Describe the premium assistance provided by the SPAP, including a description of the
member’s premium obligation after the SPAP benefit is applied:

E. Describe the cost sharing assistance provided by the SPAP, including a description of the
member’s cost sharing obligation after the SPAP benefit is applied:

III. Enrollment
A. Indicate if State can enroll on behalf of your members as their authorized representative
under State law.
o Yes. If yes, please respond to questions B & C below.
o No
B. Provide State’s enrollment/assignment process? Please check at least one box below.
o Random assignment. State enrolls members (spouses or members of the same
household) randomly among:
___All plans in State’s region.
___Plans at or below your region’s low-income benchmark premium amount.
o Non-random assignment. State enrolls members, using a member’s unique
characteristics such as prescription drug utilization. Please attach a detailed
description of the algorithm the State will use, including all of the steps you will use
to arrive at the plan assignment.
o Limit enrollment to particular plans based on established coordination criteria.
C. Indicate when the State intends to enroll its members into Part D plans for the upcoming
year:

Assurances
o I certify that at least annually, the State will submit a template by August 5. If the
information contained in this template changes during the year, the State will
submit a revised template for CMS approval and will update the NCPDP SPAPADAP BIN/PCN Spreadsheet to reflect any changes.
o The information contained in this template is correct and in accordance with 42
CFR 423.464, Chapter 14 of the Medicare Prescription Drug Benefit Manual as it
applies to SPAPs, and enrollment guidance provided in the Qualified SPAP
Guidelines.
o I certify that the SPAP adheres to the coordination of benefits (COB) process as
adopted by industry, has signed a data sharing agreement with CMS, and uses the
INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
This information has not been publicly disclosed and may be privileged and
confidential. It is for internal government use only and must not be disseminated,
distributed, or copied to persons not authorized to receive the information.
Unauthorized disclosure may result in prosecution to the full extent of the law.

same unique 4Rx information (RxBIN/RxPCN/RxGroup) used to process claims
secondary to Part D as what is reported on the monthly coordination of benefits
(COBC) file submitted to CMS’ contractor.
Signature of SPAP
Official:____________________________________Date:______________
Signature of CMS
Official:____________________________________Date:________________
Amy Larrick Chavez-Valdez, Director, Medicare Drug Benefit and C&D Data Group
Signature of CMS
Official:____________________________________Date:________________
Arrah Tabe-Bedward, Director, Medicare Enrollment & Appeals Group

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improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop
C4-26-05, Baltimore, Maryland 21244-1850.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
This information has not been publicly disclosed and may be privileged and
confidential. It is for internal government use only and must not be disseminated,
distributed, or copied to persons not authorized to receive the information.
Unauthorized disclosure may result in prosecution to the full extent of the law.