Collapse to view only § 1395w-133. State Pharmaceutical Assistance Programs
- § 1395w-131. Application to Medicare Advantage program and related managed care programs
- § 1395w-132. Special rules for employer-sponsored programs
- § 1395w-133. State Pharmaceutical Assistance Programs
- § 1395w-134. Coordination requirements for plans providing prescription drug coverage
§ 1395w–131. Application to Medicare Advantage program and related managed care programs
(a) Special rules relating to offering of qualified prescription drug coverage
(1) In generalAn MA organization on and after January 1, 2006—
(A) may not offer an MA plan described in section 1395w–21(a)(2)(A) of this title in an area unless either that plan (or another MA plan offered by the organization in that same service area) includes required prescription drug coverage (as defined in paragraph (2)); and
(B) may not offer prescription drug coverage (other than that required under parts A and B) to an enrollee—
(i) under an MSA plan; or
(ii) under another MA plan unless such drug coverage under such other plan provides qualified prescription drug coverage and unless the requirements of this section with respect to such coverage are met.
(2) Qualifying coverageFor purposes of paragraph (1)(A), the term “required coverage” means with respect to an MA–PD plan—
(A) basic prescription drug coverage; or
(B) qualified prescription drug coverage that provides supplemental prescription drug coverage, so long as there is no MA monthly supplemental beneficiary premium applied under the plan (due to the application of a credit against such premium of a rebate under section 1395w–24(b)(1)(C) of this title).
(b) Application of default enrollment rules
(1) Seamless continuation
(2) MA continuationIn applying section 1395w–21(c)(3)(B) of this title, an individual who is enrolled in an MA plan shall not be considered to have been deemed to make an election into an MA–PD plan unless—
(A) for purposes of the election as of January 1, 2006, the MA plan provided as of December 31, 2005, any prescription drug coverage; or
(B) for periods after January 1, 2006, such MA plan is an MA–PD plan.
(3) Discontinuance of MA–PD election during first year of eligibility
(4) Rules regarding enrollees in MA plans not providing qualified prescription drug coverageIn the case of an individual who is enrolled in an MA plan (other than an MSA plan) that does not provide qualified prescription drug coverage, if the organization offering such coverage discontinues the offering with respect to the individual of all MA plans that do not provide such coverage—
(i) the individual is deemed to have elected the original medicare fee-for-service program option, unless the individual affirmatively elects to enroll in an MA–PD plan; and
(ii) in the case of such a deemed election, the disenrollment shall be treated as an involuntary termination of the MA plan described in subparagraph (B)(ii) of section 1395ss(s)(3) of this title for purposes of applying such section.
The information disclosed under section 1395w–22(c)(1) of this title for individuals who are enrolled in such an MA plan shall include information regarding such rules.
(c) Application of part D rules for prescription drug coverageWith respect to the offering of qualified prescription drug coverage by an MA organization under this part on and after January 1, 2006—
(1) In general
(2) Waiver
(3) Treatment of MA owned and operated pharmacies
(d) Special rules for private fee-for-service plans that offer prescription drug coverageWith respect to an MA plan described in section 1395w–21(a)(2)(C) of this title that offers qualified prescription drug coverage, on and after January 1, 2006, the following rules apply:
(1) Requirements regarding negotiated prices
(2) Modification of pharmacy access standard and disclosure requirement
(3) Drug utilization management program and medication therapy management program not required
(4) Application of reinsuranceThe Secretary shall determine the amount of reinsurance payments under section 1395w–115(b) of this title using a methodology that—
(A) bases such amount on the Secretary’s estimate of the amount of such payments that would be payable if the plan were an MA–PD plan described in section 1395w–21(a)(2)(A)(i) of this title and the previous provisions of this subsection did not apply; and
(B) takes into account the average reinsurance payments made under section 1395w–115(b) of this title for populations of similar risk under MA–PD plans described in such section.
(5) Exemption from risk corridor provisions
(6) Exemption from negotiations
(7) Treatment of incurred costs without regard to formulary
(e) Application to reasonable cost reimbursement contractors
(1) In general
(2) Limitation on enrollment
(3) Bids not included in determining national average monthly bid amount
(f) Application to PACE
(1) In general
(2) Limitation on enrollment
(3) Bids not included in determining standardized bid amount
(Aug. 14, 1935, ch. 531, title XVIII, § 1860D–21, as added Pub. L. 108–173, title I, § 101(a)(2), Dec. 8, 2003, 117 Stat. 2122; amended Pub. L. 117–169, title I, § 11201(e)(4), Aug. 16, 2022, 136 Stat. 1891.)
§ 1395w–132. Special rules for employer-sponsored programs
(a) Subsidy payment
(1) In general
(2) Qualified retiree prescription drug plan definedFor purposes of this subsection, the term “qualified retiree prescription drug plan” means employment-based retiree health coverage (as defined in subsection (c)(1)) if, with respect to a part D eligible individual who is a participant or beneficiary under such coverage, the following requirements are met:
(A) Attestation of actuarial equivalence to standard coverageThe sponsor of the plan provides the Secretary, annually or at such other time as the Secretary may require, with an attestation that the actuarial value of prescription drug coverage under the plan (as determined using the processes and methods described in section 1395w–111(c) of this title) is at least equal to the actuarial value of standard prescription drug coverage, not taking into account the value of—
(i) for years prior to 2025, any discount or coverage provided during the gap in prescription drug coverage that occurs between the initial coverage limit under section 1395w–102(b)(3) of this title during the year and the out-of-pocket threshold specified in section 1395w–102(b)(4)(B) of this title; and
(ii) for 2025 and each subsequent year, any discount provided pursuant to section 1395w–114c of this title.
(B) Audits
(C) Provision of disclosure regarding prescription drug coverage
(3) Employer and union special subsidy amounts
(A) In general
(B) Cost threshold and cost limit applicable
(i) In generalSubject to clause (ii)—(I) the cost threshold under this subparagraph is equal to $250 for plan years that end in 2006; and(II) the cost limit under this subparagraph is equal to $5,000 for plan years that end in 2006.
(ii) Indexing
(C) DefinitionsFor purposes of this paragraph:
(i) Allowable retiree costs
(ii) Gross covered retiree plan-related prescription drug costs
(iii) Coverage year
(4) Qualifying covered retiree defined
(5) Payment methods, including provision of necessary information
(6) ConstructionNothing in this subsection shall be construed as—
(A) precluding a part D eligible individual who is covered under employment-based retiree health coverage from enrolling in a prescription drug plan or in an MA–PD plan;
(B) precluding such employment-based retiree health coverage or an employer or other person from paying all or any portion of any premium required for coverage under a prescription drug plan or MA–PD plan on behalf of such an individual;
(C) preventing such employment-based retiree health coverage from providing coverage—
(i) that is better than standard prescription drug coverage to retirees who are covered under a qualified retiree prescription drug plan; or
(ii) that is supplemental to the benefits provided under a prescription drug plan or an MA–PD plan, including benefits to retirees who are not covered under a qualified retiree prescription drug plan but who are enrolled in such a prescription drug plan or MA–PD plan; or
(D) preventing employers to provide for flexibility in benefit design and pharmacy access provisions, without regard to the requirements for basic prescription drug coverage, so long as the actuarial equivalence requirement of paragraph (2)(A) is met.
(b) Application of MA waiver authorityThe provisions of section 1395w–27(i) of this title shall apply with respect to prescription drug plans in relation to employment-based retiree health coverage in a manner similar to the manner in which they apply to an MA plan in relation to employers, including authorizing the establishment of separate premium amounts for enrollees in a prescription drug plan by reason of such coverage and limitations on enrollment to part D eligible individuals enrolled under such coverage, and shall be applied in a manner to facilitate the offering of prescription drug benefits under a Program plan under section 8903c of title 5, as required under subsection (h)(2) of such section, through employment-based retiree health coverage through—
(1) a prescription drug plan; or
(2) contracts between such a Program plan and the PDP sponsor of such a prescription drug plan..1
1 So in original.
(c) DefinitionsFor purposes of this section:
(1) Employment-based retiree health coverage
(2) Sponsor
(3) Group health planThe term “group health plan” includes such a plan as defined in section 1167(1) of title 29 and also includes the following:
(A) Federal and State governmental plans
(B) Collectively bargained plans
(C) Church plans
(Aug. 14, 1935, ch. 531, title XVIII, § 1860D–22, as added Pub. L. 108–173, title I, § 101(a)(2), Dec. 8, 2003, 117 Stat. 2125; amended Pub. L. 111–152, title I, § 1101(b)(4), Mar. 30, 2010, 124 Stat. 1039; Pub. L. 117–108, title I, § 101(b)(4), Apr. 6, 2022, 136 Stat. 1137; Pub. L. 117–169, title I, § 11201(e)(5), Aug. 16, 2022, 136 Stat. 1891.)
§ 1395w–133. State Pharmaceutical Assistance Programs
(a) Requirements for benefit coordination
(1) In general
Before July 1, 2005, the Secretary shall establish consistent with this section requirements for prescription drug plans to ensure the effective coordination between a part D plan (as defined in paragraph (5)) and a State Pharmaceutical Assistance Program (as defined in subsection (b)) with respect to—
(A) payment of premiums and coverage; and
(B) payment for supplemental prescription drug benefits,
for part D eligible individuals enrolled under both types of plans.
(2) Coordination elements
The requirements under paragraph (1) shall include requirements relating to coordination of each of the following:
(A) Enrollment file sharing.
(B) The processing of claims, including electronic processing.
(C) Claims payment.
(D) Claims reconciliation reports.
(E) Application of the protection against high out-of-pocket expenditures under section 1395w–102(b)(4) of this title.
(F) Other administrative processes specified by the Secretary.
Such requirements shall be consistent with applicable law to safeguard the privacy of any individually identifiable beneficiary information.
(3) Use of lump sum per capita method
(4) Consultation
(5) Part D plan defined
(b) State Pharmaceutical Assistance Program
For purposes of this part, the term “State Pharmaceutical Assistance Program” means a State program—
(1) which provides financial assistance for the purchase or provision of supplemental prescription drug coverage or benefits on behalf of part D eligible individuals;
(2) which, in determining eligibility and the amount of assistance to part D eligible individuals under the Program, provides assistance to such individuals in all part D plans and does not discriminate based upon the part D plan in which the individual is enrolled; and
(3) which satisfies the requirements of subsections (a) and (c).
(c) Relation to other provisions
(1) Medicare as primary payor
(2) Use of a single card
(3) Other provisions
(4) Special treatment under out-of-pocket rule
(5) Construction
(d) Facilitation of transition and coordination with State Pharmaceutical Assistance Programs
(1) Transitional grant program
(2) Use of funds
Payments under this section may be used by a Program for any of the following:
(A) Educating part D eligible individuals enrolled in the Program about the prescription drug coverage available through part D plans under this part.
(B) Providing technical assistance, phone support, and counseling for such enrollees to facilitate selection and enrollment in such plans.
(C) Other activities designed to promote the effective coordination of enrollment, coverage, and payment between such Program and such plans.
(3) Allocation of funds
(4) Application
(5) Funding
(Aug. 14, 1935, ch. 531, title XVIII, § 1860D–23, as added Pub. L. 108–173, title I, § 101(a)(2), Dec. 8, 2003, 117 Stat. 2128.)
§ 1395w–134. Coordination requirements for plans providing prescription drug coverage
(a) Application of benefit coordination requirements to additional plans
(1) In general
(2) Application to treatment of certain out-of-pocket expenditures
(3) User fees
(A) In general
(B) Application
(b) Rx Plan
An Rx plan described in this subsection is any of the following:
(1) Medicaid programs
(2) Group health plans
(3) FEHBP
(4) Military coverage (including TRICARE)
(5) Other prescription drug coverage
(c) Relation to other provisions
(1) Use of cost management tools
(2) No affect 1
1 So in original. Probably should be “effect”.
on treatment of certain out-of-pocket expenditures(Aug. 14, 1935, ch. 531, title XVIII, § 1860D–24, as added Pub. L. 108–173, title I, § 101(a)(2), Dec. 8, 2003, 117 Stat. 2130.)