Prescription Payment Program (PPP)

Project Overview

The Prescription Payment Program (PPP) is a federal government-mandated initiative by the Centers for Medicare & Medicaid Services (CMS). It ensures that health plans provide real-time prescription cost-sharing information to beneficiaries at the point of sale. This project demonstrates the implementation of the program for a health plan, ensuring CMS compliance and seamless integration with pharmacy benefit managers (PBMs).

• https://www.cms.gov/files/document/medicare-prescription-payment-plan-final-part-one-guidance.pdf
• https://www.cms.gov/files/document/fact-sheet-medicare-prescription-payment-plan-final-part-one-guidance.pdf
• https://www.cms.gov/files/document/medicare-prescription-payment-plan-timeline.pdf
• https://www.medicare.gov/prescription-payment-plan

Project Goals

• Enable real-time prescription cost transparency.
• Integrate with CMS endpoints and PBM platform.
• Ensure HIPAA and CMS compliance for secure data exchange.
• Automate data reporting and error tracking.

Solution Architecture

As an IT Architect, I led the end-to-end solution design and implementation: Note - This is an option I would recommend to implement this program.

• Architecture: Event-driven microservices
• Cloud: AWS (Lambda, API Gateway, S3, SNS/SQS)
• API: RESTful endpoints with Swagger/OpenAPI documentation
• Infrastructure as Code (IaC): Terraform and AWS CDK
• CI/CD: GitHub Actions for automated deployment
• Security: OAuth2.0, JWT, and CMS-compliant encryption

Key Features

1. Real-Time Cost Sharing: APIs to calculate and share prescription costs instantly.
2. PBM Integration: Seamless data exchange with third-party PBMs.
3. Automated Reporting: Scheduled jobs for CMS compliance reporting.
4. Monitoring & Alerts: CloudWatch-based health checks.
5. Error Handling: Robust retry mechanisms using AWS SQS.

Architecture Diagram

![Architecture Diagram] - Work in progress

Technologies Used

• Cloud Platform: AWS (Lambda, API Gateway, S3)
• Infrastructure: Terraform, AWS CDK
• API & Data: REST, FHIR, Swagger/OpenAPI
• CI/CD: GitHub Actions, CodePipeline
• Security: OAuth2.0, JWT, Encryption
• Monitoring: CloudWatch, Grafana

Repository Structure

.
├── README.md          # Project overview and documentation
├── docs/              # Architecture diagrams and design documents
├── src/               # Sample code for APIs and automation
├── workflows/         # CI/CD pipeline configurations
├── api/               # OpenAPI specifications
├── deployment/        # Terraform and AWS CDK templates
├── tests/             # Automated test scripts
├── reports/           # Success metrics and dashboards
└── LICENSE            # Optional license for sharing

Deployment

1. Clone the repository:

   git clone https://github.com/nagakirankasi/Prescription-Payment-Program-CMS.git
   

2. Set up AWS credentials.
3. Deploy infrastructure using Terraform:

   cd deployment
   terraform init
   terraform apply
   

4. Deploy APIs and Lambda functions:

   cd src
   npm install
   npm run deploy
   

Project Outcomes

• Achieved CMS compliance by [Go-Live Date].
• Reduced prescription cost-sharing errors by 30%.
• Streamlined PBM integration with real-time tracking.
• Successfully processed 500,000+ transactions monthly.

Documentation

• Solution Architecture
• API Endpoints
• Deployment Guide
• Compliance Checklist

Lessons Learned

• Importance of end-to-end encryption for HIPAA compliance.
• Efficient API throttling for high-volume transactions.
• Automated alerting for faster issue resolution.

Contributing

Contributions are welcome! Please submit a pull request or open an issue for discussions.

Contact

For inquiries or collaboration opportunities, connect with me on via email at [nkiran.kasi@gmail.com]

License

This project is licensed under the MIT License. See LICENSE for details.

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💡 This repository demonstrates solution architecture and best practices while ensuring confidentiality. No sensitive data is included.