Planning Survey Questionnaire (PSQ)

Planning Survey Questionnaire (PSQ) Plan Sponsor: LOCAL UNION Welfare Fund Benefit Plan Plan Sponsor ID#: XXXX Application ID#: XXXXX Complete this Survey for the applicable plan type and return it to the Auditor by the requested due date. Provide detailed responses where requested. Indicate "NA" when a question is not applicable to the Plan. When necessary, expand the document or attach a separate document as necessary. Note: The answers to the questions in this survey should be relevant to the RDS plan year ending in 2008 only unless otherwise specified. PART I: GENERAL INFORMATION 1) A. Briefly describe the current organizational structure, including related parties and joint ventures, if any. B. Was the Plan Sponsor a subsidiary or substantially owned by or controlled by another organization? C. Please provide a brief summary of the ownership and management structure of the organization. D. Have there been any changes in ownership such as mergers, purchases, etc.? If Yes, describe: E. Please provide a complete list of the Plan Sponsor s related parties. Related entity means any entity that is related to the Plan Sponsor by common ownership or control and (1) performs some of the RDS Plan Sponsor's management functions under contract or delegation; or (2) furnishes services to Medicare RDS qualifying covered retirees under an oral or written agreement. Related Party Name F. During the plan year under examination, did the Plan Sponsor receive any revenue from any related parties? If yes, please list the related organization and the type of income the Plan Sponsor receives, i.e. dividend, allocation, rebates, management fees, etc. Livanta, LLC Planning Survey Template November 2010 Page 1

Organization ATTACHMENT TO BENEFIT NEWS BRIEFS 2011-15 Type of Income G. Were there multiple applications for the Plan Sponsor? If yes, please list each application number, and Plan Sponsor identification number. Application Number Sponsor ID Number 2) A. Type of organization: Commercial Non-Profit Government Union Religious B. Form of entity: Corporation If public, ticker symbol LLC Sole Proprietorship Other (Explain) 3) How did you define benefit option(s)? 4) Was each benefit option fully insured or self funded? Benefit Option: Fully Insured or Self Funded Cost Reporter: Benefit Option: Fully Insured or Self Funded Cost Reporter: Benefit Option: Fully Insured or Self Funded Cost Reporter: 5) Have there been any instances of fraudulent activities/billings discovered for the plan year under audit as applies to RDS? If yes, please provide the detailed explanation and current status of such findings. 6) Were any changes made by the Plan Sponsor on the application from the initial application up to step 12 of the reconciliation process? Changes could include, but are not limited to, change of users, benefits, vendors, etc. If yes, provide details. Livanta, LLC Planning Survey Template November 2010 Page 2

7) Are you contemplating the filing of any appeals for reconsideration/reopening? If yes, describe the nature of the anticipated appeal. PART II: POLICIES, PROCEDURES & INTERNAL CONTROLS 8) Did the Plan Sponsor maintain written policy and procedures for the following transactions? Rebates and Similar Price Concessions Private Reinsurance Payment of Drug Claims Issuance of Notice of Credible Coverage Payment Request (RDS Subsidy) Process 9) For the plan year in 2008, were there any instances where access to Plan Sponsors or CMS systems was not terminated for associates no longer employed? If yes please describe. 10) A. Describe the policies and procedures implemented to comply with the 6 year record retention requirements (CFR 423.888(d)). B. Do the contracts with vendors include language regarding record retention? PART III: CREDITABLE COVERAGE NOTICES 11) List the names and contact information of the individuals who handled the Creditable Coverage Notice Disclosures for this Plan Year. Name Title Contact Info Name Title Contact Info PART IV: RETIREE FILES 12) Describe the Plan Sponsor s (and/or vendor s) process to ensure that only qualifying covered retirees costs were submitted for the RDS program. Livanta, LLC Planning Survey Template November 2010 Page 3

13) How did the Plan Sponsor determine the qualifying covered retirees were eligible to participate in the plan? 14) How did the Plan Sponsor validate the final covered retiree list received and agreed to in step 4 of reconciliation? 15) What are the Plan Sponsor s rules for determining whether the benefit option enrollee is retired or an active employee? 16) If the Plan Sponsor s vendor was responsible for creating and/or submitting retiree files, did the Plan Sponsor submit timely data to the vendor? If no, describe any problems noted by the vendor concerning timeliness? 17) A. Describe the procedures and process the Plan Sponsor implemented to ensure timely notification to CMS of any changes to the covered retiree file. B. Describe the procedures and process the Plan Sponsor implemented to ensure the Plan Sponsor s files were timely updated. 18) Who was responsible for processing retiree response and notification files received from the RDS Center? Name Title Organization 19) What controls did the Plan Sponsor establish over retiree eligibility information that was submitted to CMS by the vendor (if applicable)? 20) Are qualified covered retirees permitted to enroll into multiple benefit options? PART V: FINAL RECONCILIATION AND SUBMISSION OF COST DATA 21) Is the RDS plan year in the application the same as the plan year for other purposes, e.g. open enrollment, measuring deductibles, and 5500 Form reporting? If no, explain. Livanta, LLC Planning Survey Template November 2010 Page 4

22) Provide the name(s) and title(s) of the individual(s) who prepared the cost data that was submitted to the RDS program for each of the benefit options. Benefit Option Individual/Title/Organization 23) Provide the name(s) and title(s) of the individual(s) who submitted the cost data to the RDS program for each of the benefit options. Benefit Option Individual/Title/Organization 24) How did the Plan Sponsor (or vendor) determine whether drug costs were eligible for the RDS subsidy? 25) How did the Plan Sponsor (or vendor) identify and account for cost adjustments (manufacturer or pharmacy discounts, chargebacks, rebates, and/or other price concessions) when preparing cost data for submission to the RDS program? 26) A. Describe the process the Plan Sponsor implemented to validate the data for final reconciliation prior to submission to CMS by the Account Representative. B. Who performs this verification? Name Title 27) What controls did the Plan Sponsor establish over cost data that the vendor submitted to the RDS program on the Plan Sponsor's behalf (if applicable)? 28) For a fully insured benefit option, what procedures have been implemented to validate the costs from the insurance carrier? 29) Who reviewed and submitted the final reconciliation/payment request on behalf of the Plan Sponsor? Name Title 30) Are any amendments or corrections to final reconciliation reports anticipated? If yes, please describe. Livanta, LLC Planning Survey Template November 2010 Page 5

PART VI: PAYMENT REQUESTS, COST, AND PRICE CONCESSION RECORDS AND SYSTEMS 31) Describe the process for archiving RDS data inclusive of describing the ability to recreate a cost report. 32) Please explain the systems used to track the Group s Prescription Drug Plan related costs and activities and what processes were automated and/or manual. Expand as necessary. 33) Describe the systems for processing cost and claims including programs and applications utilized by the Plan Sponsor and its vendors. Please indicate the types of supporting documents for each system. 34) Were the journals, ledgers, and subsidiary ledgers that apply to the RDS plan year maintained electronically or manually? Journals Electronic Manual Ledgers Electronic Manual Sub-Ledgers Electronic Manual 35) Were the journals, ledgers, and subsidiary ledgers that apply to the RDS plan year available for review? Where are these journal ledgers located? Journals Location Ledgers Location Sub-Ledgers Location If not, please explain. Identify the physical location of accounting records. 36) Were supporting documents, such as invoices, billing statements, etc. available to verify the following transactions? General ledger transactions Subsidiary ledger transactions Journal entries Allocations 37) What process did the Plan Sponsor utilize to ensure its submitted costs to CMS were only for plan related Part D drugs for qualifying covered retirees? Livanta, LLC Planning Survey Template November 2010 Page 6

38) Describe how the Plan Sponsor recorded the transactions listed below in its general ledger. (Indicate account number, the process for recording the transactions, if subsidiary ledgers were used, and who recorded the transactions.) RDS Payments received Rebates (or other concessions on drug prices received) Insurance Premiums or Claims Payments 39) Describe the process the Plan Sponsor implemented to ensure: A. The accurate reporting of the threshold and limit reduction. B. The coordination of the threshold and limit reductions for qualified covered retirees enrolled in multiple benefit options, if applicable. 40) Were the costs reported to CMS the costs the PBM paid the Pharmacy, i.e. Pass-thru, or the costs paid to the PBM (if a PBM was used), i.e. Lock-in? 41) Is supporting documentation for the following available for review and where is it maintained? Transaction Supporting Documentation Location Prescription Drug Screen Shots of Yes No Data Transaction Enrollment Data Retiree Enrollment Records Yes No Rebates, Price Manufacturer/PBM Yes No Concessions, etc. contracts and/or agreements Please explain any No responses. Cost Adjustments -- Discounts, Chargebacks, Rebates, and Other Price Concessions 42) Who negotiated rebates and similar price concessions for Plan Sponsor's plan year ending 2008? Name Title Organization Livanta, LLC Planning Survey Template November 2010 Page 7

43) Who had the record keeping responsibility for the Plan Sponsor's rebates and similar price concessions? Name Title Organization 44) A.Were any price concessions remitted to the Plan Sponsor that originated from the manufacturer and/or the pharmacy? If yes, describe how the remittance of the price concessions was made to the Plan Sponsor. B. Were any price concessions remitted to the Plan Sponsor that did not originate from the manufacturer and/or pharmacy? If yes, from whom were they received and describe how the remittance for the price concessions were made to the Plan Sponsor. 45) Did the Plan Sponsor receive any reductions to drug costs, e.g. discounts, or other payments, that did not originate from a pharmacy or manufacturer? If yes, describe the type of payment and the process for recording the payment. 46) At what intervals did the Plan Sponsor receive rebates and similar price concessions (e.g., monthly, quarterly, year end, etc.)? 47) If the Plan Sponsor received interim subsidy payments and reported estimated cost adjustments, describe how the Plan Sponsor or vendor reconciled actual cost adjustments at final reconciliation. 48) Do the contracts negotiated by the party(s) noted in #42 above document the price concession terms? If yes, describe the terms. 49) Describe the process the Plan Sponsor used to validate the accuracy of all rebates and similar price concessions received. 50) Describe the Plan Sponsor s (or its vendor s) methodology and process for allocating rebates and similar price concessions to the various Plan Sponsor prescription drug plans (if applicable), and then to the benefit options, months, and/or drugs as it was reported to RDS. Livanta, LLC Planning Survey Template November 2010 Page 8

51) Were any rebates received after final reconciliation attributable to costs that were incurred during the RDS plan year? Comments Enter any comments, questions, or points of clarification in the space below. Completed By: Name (Print): Title/Position: Date: Livanta, LLC Planning Survey Template November 2010 Page 9