Part D QIC - Statement of Work

Contract No. HHSM-500-2004-00005I
Task Order No. 75FCMC25FJXXX
Attachment J-2 – Statement of Work

Medicare Part D Qualified Independent Contractor (QIC) Task Order Statement of Work
I.

Scope

The contractor shall provide adjudication services in support of the coverage determinations, reconsiderations, and appeals requirements set forth at section 1860D-4(g) and section 1860D4(h) of the Social Security Act (Act), as added by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173). The contractor shall act as an independent review entity (IRE), hereinafter referred to as the Part D Qualified Independent Contractor (QIC), responsible for conducting reconsiderations of adverse coverage determinations and adverse redeterminations. For purposes of this Task Order (TO), adverse redeterminations include a request for covered drug benefit or review of an at-risk determination made by Part D plans. Coverage determinations and redeterminations include the amount of cost sharing, if any, that the enrollee is required to pay for a drug. The Part D QIC shall conduct reconsiderations of decisions made by stand-alone prescription drug plans (PDPs), Medicare Advantage Prescription Drug Plans (MA-PDs), and cost plans that offer qualified prescription drug coverage. The contractor is also responsible for reviewing requests for review of a dismissal when a PDP or MA-PD dismisses a redetermination request. The Part D QIC’s workload shall also include conducting reconsiderations of adverse determinations related to prior creditable prescription drug coverage/imposition of a late enrollment penalty (LEP) under the Medicare Part D program. I.A.

Background

CMS has issued regulations that establish procedures for grievances, coverage determinations, redeterminations, and appeals under the Medicare Part D prescription drug benefit program. These regulations are set forth at 42 CFR Part 423, Subpart M and Subpart U. Regulations related to creditable prescription drug coverage determinations and the late enrollment penalty are set out at 42 CFR Part 423 Subpart B (see, for example, 42 CFR §423.46(c) related to LEP reconsiderations). The following sections provide an overview of the most salient features of the Part D appeals process for purposes of this Task Order (TO). I.A.1 Overview of the Part D Benefit Appeals Process
Section 1860D-4(g) of the Act requires that procedures for making coverage determinations and redeterminations for Part D drug benefits be the same as the procedures under the Medicare