PLAN SPONSOR AGREEMENT – New 8/22/2007
Note: This page contains the Plan Sponsor Agreement made between CMS and the RDS Plan Sponsor. This document is for reference and can only be completed on the RDS Secure Web Site.
The Authorized Representative of the Plan Sponsor MUST read each clause, agree to all of the conditions by completing the Check to Approve box, and answer the security questions provided.
- Compliance: In order to receive subsidy payment(s), Sponsor agrees to comply with all of the terms and conditions for obtaining the retiree drug subsidy and as outlined in 42 C.F.R. 423.880 et. seq., (Subpart R) and in other guidance issued by CMS, including the conditions for submission of cost data for obtaining payment and the record retention requirements.
- Notice of Creditable Coverage: Sponsor certifies that it has provided or will provide prior to the beginning of the plan year, creditable coverage notices in accordance with 42 C.F.R. 423.56 to Part D eligible individuals covered under the Sponsor's plan.
- Written Agreement: Sponsor certifies that it will execute a written agreement with its health insurance issuer or group health plan regarding disclosure of information to CMS, and the issuer or plan agrees to disclose to CMS, on behalf of the Sponsor, the information necessary for the Sponsor to comply with the requirements of the RDS Program. This written agreement must be executed prior to the Sponsor's plan year start date.
- Use of Records: Sponsor understands and agrees that officers, employees and contractors of the Department of Health and Human Services, including the Office of Inspector General (OIG), may use information collected under the RDS Program only for the purposes of, and to the extent necessary in, carrying out their responsibilities under 42 C.F.R. 423 Subpart R including, but not limited to, determination of payments and payment-related oversight and program integrity activities, or as otherwise required by law. This restriction does not limit OIG authority to conduct audits and evaluations under 42 C.F.R. 423 Subpart R or other authority.
- Obtaining Federal Funds: Sponsor acknowledges that the information furnished in its retiree drug subsidy application is being provided to obtain Federal funds. 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. Sponsor acknowledges that payment of a subsidy is conditioned on the submission of accurate information. Sponsor agrees that it will not knowingly present or cause to be presented a false or fraudulent claim. Sponsor acknowledges that any overpayment made to the Sponsor under the RDS program may be recouped by CMS/RDS Contractor. Sponsor will promptly notify CMS of any changes to the information submitted in its Plan Sponsor Agreement.
- Data Security: Sponsor agrees to establish and implement proper safeguards against unauthorized use and disclosure of the data exchanged under this RDS Application. Sponsor recognizes that the use and disclosure of protected health information is governed by the Health Insurance Portability and Accountability Act (HIPAA) and accompanying regulations. Plan Sponsor certifies that its retiree group health plan(s) has established and implemented appropriate safeguards in compliance with 45 C.F.R. Parts 160, 162 and 164 (HIPAA administrative simplification, privacy and security rule) in order to prevent unauthorized disclosure of such information or data. Sponsor also agrees that if it participates in the administration of the plan(s), then it has also established and implemented the same safeguards in compliance with the above HIPAA citations. Any and all Sponsor personnel interacting with this data shall be advised of (1) the confidential nature of the information; (2) safeguards required to protect the information, and (3) the administrative, civil and criminal penalties for noncompliance contained in applicable Federal laws.
- Depository Information: Sponsor hereby authorizes CMS to initiate payment, credit entries and other adjustments, including offsets and requests for payment, in accordance with the provisions of 42 C.F.R. 423 Subpart R to the account at the financial institution (hereinafter the "Depository") indicated under the Electronic Funds Transfer (EFT) section of the Plan Sponsor Application. When Sponsor know of, and agrees to, an overpayment it must pay that amount back to CMS. Sponsor agrees to promptly notify CMS of any changes in its Depository information and submit an update EFT Authorization.
- Change of Ownership: The Sponsor shall provide written notice to CMS/RDS Contractor at least 60 days prior to a change in ownership. When a change of ownership results in a transfer of the liability for prescription drug costs, this Plan Sponsor Agreement is automatically assigned to the new owner, who shall be subject to the terms and conditions of this Plan Sponsor Agreement.
I, the undersigned Authorized Representative of Sponsor, declare that I have examined this Application and Plan Sponsor Agreement. My signature legally and financially binds the Sponsor to the laws, regulations, and other guidance applicable to the RDS program (including 42 C.F.R. 423 Subpart R) and all other applicable laws and regulations. I certify that the information contained in this Application and Plan Sponsor Agreement is true, accurate and complete to the best of my knowledge and belief, and I authorize CMS/RDS Contractor to verify this information. 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. If I become aware that information in this application is not (or is no longer) true, accurate and complete, I agree to notify CMS/RDS Contractor promptly of this fact.
