CMS Responsibilities Clause Samples

CMS Responsibilities. 1.1 Nondiscrimination 1.1.1 The CM shall comply with Applicable Law regarding equal employment opportunity, including ORC Section 1.1.1.1 As required under ORC Section 153.59, the CM agrees to both of the following: .1 “in the hiring of employees for the performance of work under the contract or any subcontract, no contractor, subcontractor, or any person acting on a contractor’s or subcontractor’s behalf, by reason of race, creed, sex, disability or military status as defined in section 4112.01 of the Revised Code, or color, shall discriminate against any citizen of the state in the employment of labor or workers who is qualified and available to perform the work to which the employment relates;” and .2 “no contractor, subcontractor, or any person on a contractor’s or subcontractor’s behalf, in any manner, shall discriminate against or intimidate any employee hired for the performance of work under the contract on account of race, creed, sex, disability or military status as defined in section 4112.01 of the Revised Code, or color.” 1.1.1.2 The CM shall cooperate fully with the State’s Equal Opportunity Coordinator (“EOC”), with any other official or agency of the state or federal government that seeks to eliminate unlawful employment discrimination, and with all other state and federal efforts to assure equal employment practices under the Contract. 1.1.1.3 In the event the CM fails to comply with these nondiscrimination clauses, the Contracting Authority shall deduct from the amount payable to the CM a forfeiture of the statutory penalty pursuant to ORC 153.60 for each person who is discriminated against or intimidated in violation of this Section 1.1.1. 1.1.1.4 The Contract may be terminated or suspended in whole or in part by the Contracting Authority and all money to become due hereunder may be forfeited in the event of a subsequent violation of this Section 1.1.1.

CMS Responsibilities. ‌ (a) CMS shall administer the Part D Manufacturer Discount Program, including the determination of the amount of the Applicable Discount for an Applicable Drug of the Manufacturer pursuant to section 1860D-14C(c)(1)(A) of the Act. (b) CMS shall establish procedures pursuant to section 1860D-14C(c)(1)(B) of the Act that require Part D Sponsors to pay Applicable Discounts on behalf of the Manufacturer for Applicable Drugs dispensed by a pharmacy, mail order service, or other dispenser within the Applicable Number of Calendar Days beginning January 1, 2025. (c) CMS shall establish procedures pursuant to section 1860D-14C(c)(1)(C) of the Act to ensure that the Applicable Discount for an Applicable Drug is applied before any coverage or financial assistance under other health benefit plans or programs that provide coverage or financial assistance for the purchase or provision of prescription drug coverage on behalf of Applicable Beneficiaries. (d) CMS shall provide a reasonable dispute resolution mechanism to resolve disagreements between manufacturers, Part D Sponsors, and CMS. (e) CMS shall monitor compliance by the Manufacturer with the terms of this Agreement, sections 1860D-14C and 1860D-43 of the Act, and any applicable regulations and guidance related to the Part D Manufacturer Discount Program pursuant to section 1860D- 14C(c)(2) of the Act. CMS shall monitor compliance by Part D Sponsors and the TPA with their respective obligations in connection with the Part D Manufacturer Discount Program. (f) CMS shall use PDE information reported by Part D Sponsors for monitoring and tracking the Applicable Discounts for Applicable Drugs paid by Part D Sponsors and reimbursed by the Manufacturer for Applicable Drugs, and for implementing internal control measures designed to ensure the accuracy and appropriateness of Applicable Discount payments provided by Part D Sponsors. (g) CMS shall, or shall ensure that its TPA shall, do each of the following:‌ (1) Receive and transmit information, including Medicare Part D Discount Information, among CMS, the Manufacturer, Part D Sponsors and other individuals or entities CMS determines appropriate; (2) Provide adequate and timely information to the Manufacturer as necessary for the Manufacturer to fulfill its obligations under this Agreement; (3) Calculate the invoice quarterly based upon PDEs reported to CMS by Part D Sponsors on a flow basis, which invoices may include PDEs with Dates of Dispensing from prior quarters, a...

CMS Responsibilities. 1. CMS will identify paid claims eligible for reimbursement under the Colorado Reinsurance Program (eligible claims) for services provided on or between January 1, 2022 to December 31, 2026. CMS will identify such claims from data submitted to “EDGE Servers” maintained by issuers offering coverage in the State of Colorado. CMS will identify such claims based on the parameters for the Colorado Reinsurance Program as described in the state’s section 1332 waiver extension application approved on August 13, 2021, and as confirmed by the DOI as described under paragraph V.B.1

CMS Responsibilities. Pursuant to section 1196 of the Act and any applicable guidance and regulations implementing those provisions: (a) CMS shall engage with an MTF Data Module Contractor and MTF Payment Module Contractor to establish the MTF to facilitate the exchange of data and payment. (b) CMS shall provide technical instructions and ensure that user inquiries from the Manufacturer are addressed regarding the MTF DM and MTF PM. (c) CMS shall provide a complaint mechanism through the MTF DM to address concerns raised by the Manufacturer regarding MFP availability and any issues with the MTF, if good faith efforts to address issues with dispensing entities directly are not successful. (d) CMS shall provide a dispute mechanism within the MTF DM to address technical challenges or issues with a technical aspect of the MTF DM or MTF PM system or process. (e) CMS shall provide a Ledger System as described in section I(d) of this Agreement. (f) In accordance with section 1196 of the Act, CMS shall monitor compliance by the Manufacturer with the terms of this Agreement, any applicable guidance and regulations, and the Negotiation Program Agreement(s). Part of CMS’ monitoring efforts include the audit process established in section V of this Agreement. (g) In its sole discretion, CMS may use information related to this Agreement, including, without limitation, information about and generated by the Manufacturer, and, to promote compliance with the statutes, regulations and written directives of Medicare, Medicaid and all other Federal health care programs (as defined in 42 U.S.C. § 1320a-7b(f)) (“Federal health care program”), CMS may disclose such information to law enforcement and regulatory authorities.

CMS Responsibilities. 1. CMS will develop and maintain the Hub to support activities described in this Agreement. 2. CMS will develop the appropriate form and manner of submission of data to and from the Hub. 3. CMS will develop procedures and conditions through and under which an AE may request information via the Hub from available data sources, which include but are not limited to CMS, the Internal Revenue Service (IRS), Social Security Administration (SSA), Department of Homeland Security (DHS), Department of Veterans Affairs (VA), Department of Defense (DOD), Peace Corps, Office Personnel Management (OPM), and commercial databases of income and employment, to support an Eligibility Determination. 4. CMS will develop procedures through which an AE can request information via the Hub to support identity proofing for an Applicant or Application Filer prior to the release of matching data under this Agreement. 5. CMS will not use the Hub to transmit data to an authorized AE to support an Eligibility Determination, unless specifically authorized in Section VI of this Agreement.

CMS Responsibilities. 1. Submission of Data (from an Administering Entity) a. Prior to submitting a request to IRS, CMS must validate the social security number (SSN) of each Applicant, Medicaid/CHIP Beneficiary, Enrollee, or Relevant Taxpayer with the Social Security Administration (SSA) or through documentation of SSN provided by the Applicant, Medicaid/CHIP Beneficiary, Enrollee, or Relevant Taxpayer. Unvalidated SSNs will not be included in the request to IRS. b. To submit a request for Household Income and Family Size to the IRS through the Hub, an Administering Entity must include the Relevant Taxpayer’s name, SSN, and the taxpayer relationship (primary, spouse, or dependent) to any Applicant, Enrollee, or Medicaid/CHIP Beneficiaries listed on an application. c. As part of the initial application for Insurance Affordability Programs, the Administering Entity will give Applicants, Enrollees and/or Medicaid/CHIP Beneficiaries the option to obtain Return Information as part of the annual Redetermination and Renewal processes, for a period not to exceed 5 years based on a single authorization. Such option will be provided on the single-streamlined application for Eligibility Determinations. Applicants, Enrollees and Medicaid/CHIP Beneficiaries may also discontinue, change, or renew their authorization. Current Medicaid/CHIP Beneficiaries renewing coverage will be provided the option to obtain Return Information as part of the renewal Eligibility Determination. CMS must ensure Administering Entities maintain records that properly account for the option elected by each Applicant, Enrollee or Medicaid/CHIP Beneficiary, and will not obtain Return Information for use in annual Redeterminations for years in which the Applicant, Enrollee or Medicaid/CHIP Beneficiary did not authorize use of Return Information. d. For each Enrollee or Medicaid/CHIP Beneficiary, at the time of their annual or periodic eligibility Redetermination or Renewal, the Relevant Taxpayer’s name, SSN, and the taxpayer relationship to any Applicants, Enrollees, or Medicaid/CHIP Beneficiaries on the application (primary, spouse, or dependent) must be submitted to IRS through the Hub. e. Each Administering Entity must be uniquely identified when requesting Return Information so that authorization to receive Return Information is validated by IRS prior to disclosure to CMS. Administering Entities are authorized to receive Return Information via the Hub pursuant to this matching Agreement and through separately exec...

CMS Responsibilities. 1. CMS will identify paid claims eligible for reimbursement under the PA-RE program (eligible claims) for services provided on or between January 1, 2021 to December 31, 2025. CMS will identify such claims from data submitted to “EDGE Servers” maintained by issuers offering coverage in the Commonwealth of Pennsylvania. CMS will identify such claims based on the parameters for the Commonwealth of PA-RE Program as described in the state’s section 1332 waiver application approved on July 24, 2020, and as confirmed by PID as described under paragraph V.B.1 below. 2. CMS will calculate the total reinsurance payment due to an issuer on account of each eligible claim CMS identifies. CMS will provide PID a monthly report detailing the reinsurance payments on a cumulative basis to date owed to specific issuers under the PA-RE Program criteria by the 30th of the month. 3. CMS will perform development, implementation, maintenance, operations, and customer support work for the state for the activities outlined in section V.A. 4. The parties acknowledge and agree that CMS is not performing services under this Agreement in its capacity as a HIPAA covered entity. PID further acknowledges that no data or information CMS evaluates under this Agreement will constitute protected health information as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) or will otherwise constitute information protected by any Commonwealth of Pennsylvania law that would require CMS to comply with privacy and information security requirements or standards that are more onerous or stringent than the standards with which CMS complies as described in section XIII of this Agreement.

CMS Responsibilities. CMS will use the FCC-submitted electronic file(s) to conduct a data match in Medicaid and Children’s Health Insurance Program (CHIP) Business Information Solution (MACBIS) against Medicaid enrollment records maintained in the Transformed Medicaid Statistical Information System (T-MSIS) SOR, and return either a positive CMS match of enrollees, or a no-match-found response to FCC.

CMS Responsibilities. CMS— (1) Sends the bill to the group payer upon authorization from the enrollee; (2) Notifies both the payer and the enrollee if the payer fails to make timely payments; and (3) Refunds excess premiums in ac- cordance with § 408.88.