The Medicare Prescription Drug Improvement and Modernization Act of 2003 became effective January 1, 2006. Now Medicare offers prescription drug coverage through private insurers to senior citizens under the Medicare Part D program.


While CMS supports the efforts of state pharmaceutical assistance programs (SPAPs) to continue providing prescription coverage and payment assistance for low-income seniors and the disabled, Part D places new and challenging requirements on many SPAPs.


Prior to the implementation of Medicare Part D, SPAPs had been providing prescription coverage and payment assistance to low-income seniors. The creation of Part D, however, resulted in changes to, and concerns for, the continued operation of many SPAPs. Among the many concerns were

  1. Under-identification of LIS beneficiaries;
  2. True Out of Pocket (TrOOP) data reconciliation disagreements with CMS; and
  3. Inaccurate coordination of benefits with Pharmacy Drug Plans.

Proposed solution

Since Medicare Part D began, PCG Health has been a leader in providing financial and operational services to CMS and individual states. In the past year, PCG Health™ has worked with 45 state Medicaid offices to integrate operations with CMS, and has worked with numerous PDPs to coordinate the proper reimbursement of pharmacy claims.


PCG Health worked extensively with many SPAPS during the initial implementation of Medicare Part D. We continue to offer comprehensive management, financial, and operations improvement services ranging from an initial complimentary operations assessment to the facilitation of claims adjudication from PDPs. PCG Health can also assist with the management of TrOOP and benefits data transmission between SPAPs, their pharmacy benefit managers and corresponding PDPs.

Overview of our approach

To promote accurate claiming to the PDPs and up-to-date TrOOP data, PCG can

  • Track, merge and verify data for accurate reimbursement;
  • Reconcile claims between your SPAP and various PDPs on any outstanding issues;
  • Reconcile eligibility data and mediate concerns between your SPAP and CMS;
  • Manage SPAP Accounts Payable through standardized invoice tracking and management.

To ensure that beneficiary eligibility is accurate and LIS status is current, PCG can

  • Audit beneficiary files to identify full LIS individuals;
  • Assist in the enrollment of LIS qualified individuals;
  • Disenroll full-LIS members, if necessary.

To maximize efficiency in benefits under budgetary constraints, PCG Health™ can design a benefit structure that best meets the needs of SPAP beneficiaries while considering benefits under the Medicare Part D program.

PCG Health also offers an array of services for non-qualified SPAPs that wish to seek qualification from CMS. In addition to the above tasks, PCG Health™ can help non-qualified SPAPs:

  • Navigate the qualification process to make sure CMS requirements are met;
  • Design a comprehensive SPAP program under CMS guidelines that best meets the needs of low-income seniors who value the benefits you provide.

More Information

For more information about PCG Health's SPAP Consulting Services for Medicare Part D Coordination Services please contact us at or 1-800-210-6113.