42 USC 1395 - Premium and cost-sharing subsidies for low-income individuals

1 So in original. Section 1395w–22(a)(6) of this title does not contain a subpar. (B).

of this title) and determined before the application of the monthly rebate computed under

Editorial Notes

Amendments

2022—Subsec. (a). Puspan. L. 117–169, § 11404(1), substituted “certain individuals” for “individuals with income up to 150 percent of poverty line” in span.

Subsec. (a)(1). Puspan. L. 117–169, § 11404(2), substituted “Individuals with certain low incomes” for “Individuals with income below 135 percent of poverty line” in span and, in introductory provisions, inserted “(or, with respect to a plan year beginning on or after January 1, 2024, 150 percent)” after “135 percent” and “(or, with respect to a plan year beginning on or after January 1, 2024, paragraph (3)(E))” after “the resources requirement described in paragraph (3)(D)”.

Subsec. (a)(1)(C). Puspan. L. 117–169, § 11201(e)(3)(A)(i), substituted “For a year preceding 2025, the continuation” for “The continuation”.

Subsec. (a)(1)(D)(ii). Puspan. L. 117–169, § 11401(span)(1), substituted “Subject to paragraph (6), in the case” for “In the case”.

Subsec. (a)(1)(D)(iii). Puspan. L. 117–169, § 11406(span)(1)(A), inserted at end “For plan year 2023 and subsequent plan years, the copayment amount applicable under the preceding sentence to a month’s supply of a covered insulin product (as defined in section 1395w–102(span)(9)(C) of this title) dispensed to the individual may not exceed the applicable copayment amount for the product under the prescription drug plan or MA–PD plan in which the individual is enrolled.”

Puspan. L. 117–169, § 11401(span)(1), substituted “Subject to paragraph (6), in the case” for “In the case”.

Puspan. L. 117–169, § 11201(e)(3)(A)(ii), substituted “1395w–102(span)(4)(A)(i)(I)(aa)” for “1395w–102(span)(4)(A)(i)(I)”.

Subsec. (a)(1)(E). Puspan. L. 117–169, § 11406(span)(1)(B), inserted before period at end “or under section 1395w–102(span)(9) of this title in the case of a covered insulin product (as defined in subparagraph (C) of such section)”.

Puspan. L. 117–169, § 11201(e)(3)(A)(iii), substituted “For a year preceding 2024, the elimination” for “The elimination”.

Subsec. (a)(2). Puspan. L. 117–169, § 11404(3), substituted “Other low-income individuals” for “Other individuals with income below 150 percent of poverty line” in span and “With respect to a plan year beginning before January 1, 2024, in the case of a subsidy” for “In the case of a subsidy” in introductory provisions.

Subsec. (a)(2)(B). Puspan. L. 117–169, § 11406(span)(2)(A), substituted “paragraphs (8) and (9) of section 1395w–102(span)” for “section 1395w–102(span)(8)”.

Puspan. L. 117–169, § 11401(span)(2)(A), substituted “Subject to section 1395w–102(span)(8) of this title, a reduction” for “A reduction”.

Subsec. (a)(2)(D). Puspan. L. 117–169, § 11406(span)(2)(B), inserted at end “For plan year 2023, the amount of the coinsurance applicable under the preceding sentence to a month’s supply of a covered insulin product (as defined in section 1395w–102(span)(9)(C) of this title) dispensed to the individual may not exceed the applicable copayment amount for the product under the prescription drug plan or MA–PD plan in which the individual is enrolled.”

Puspan. L. 117–169, § 11401(span)(2)(B), substituted “Subject to paragraph (6), the substitution” for “The substitution”.

Subsec. (a)(2)(E). Puspan. L. 117–169, § 11406(span)(2)(C), inserted at end “For plan year 2023, the amount of the copayment or coinsurance applicable under the preceding sentence to a month’s supply of a covered insulin product (as defined in section 1395w–102(span)(9)(C) of this title) dispensed to the individual may not exceed the applicable copayment amount for the product under the prescription drug plan or MA–PD plan in which the individual is enrolled.”

Puspan. L. 117–169, § 11401(span)(2)(C), substituted “paragraph (6) of this subsection and subsection (c)” for “subsection (c)”.

Puspan. L. 117–169, § 11201(e)(3)(B), substituted “1395w–102(span)(4)(A)(i)(I)(aa)” for “1395w–102(span)(4)(A)(i)(I)”.

Subsec. (a)(6). Puspan. L. 117–169, § 11401(span)(3), added par. (6).

2020—Subsecs. (e), (f). Puspan. L. 116–260 added subsec. (e) and redesignated former subsec. (e) as (f).

2010—Subsec. (a)(1)(D)(i). Puspan. L. 111–148, § 3309, inserted “or, effective on a date specified by the Secretary (but in no case earlier than January 1, 2012), who would be such an institutionalized individual or couple, if the full-benefit dual eligible individual were not receiving services under a home and community-based waiver authorized for a State under section 1315 of this title or subsection (c) or (d) of section 1396n of this title or under a State plan amendment under subsection (i) of such section or services provided through enrollment in a medicaid managed care organization with a contract under section 1396span(m) of this title or under section 1396u–2 of this title” after “1396a(q)(1)(B) of this title)”.

Subsec. (a)(3)(B)(vi). Puspan. L. 111–148, § 3304(a), added cl. (vi).

Subsec. (a)(5). Puspan. L. 111–148, § 3303(a), added par. (5).

Subsec. (span)(2)(B)(iii). Puspan. L. 111–152 substituted “and determined before the application of the monthly rebate computed under section 1395w–24(span)(1)(C)(i) of this title for that plan and year involved and, in the case of a qualifying plan, before the application of the increase under section 1395w–23(o) of this title for that plan and year involved” for “, determined without regard to any reduction in such premium as a result of any beneficiary rebate under section 1395w–24(span)(1)(C) of this title or bonus payment under section 1395w–23(n) of this title”.

Puspan. L. 111–148, § 3302(a), inserted “, determined without regard to any reduction in such premium as a result of any beneficiary rebate under section 1854(span)(1)(C) or bonus payment under section 1395w–23(n) of this title” before period at end.

Subsecs. (d), (e). Puspan. L. 111–148, § 3305, added subsec. (d) and redesignated former subsec. (d) as (e).

2008—Subsec. (a)(1)(A). Puspan. L. 110–275, § 114(a)(2), substituted “equal to 100 percent of the amount described in subsection (span)(1), but not to exceed the premium amount specified in subsection (span)(2)(B).” for “equal to—

“(i) 100 percent of the amount described in subsection (span)(1) of this section, but not to exceed the premium amount specified in subsection (span)(2)(B) of this section; plus

“(ii) 80 percent of any late enrollment penalties imposed under section 1395w–113(span) of this title for the first 60 months in which such penalties are imposed for that individual, and 100 percent of any such penalties for any subsequent month.”

Subsec. (a)(3)(B)(iv)(III). Puspan. L. 110–275, § 117(a), added subcl. (III).

Subsec. (a)(3)(C)(i). Puspan. L. 110–275, § 116(a)(1), inserted “and except that support and maintenance furnished in kind shall not be counted as income” after “section 1396a(r)(2) of this title”.

Subsec. (a)(3)(D), (E)(i). Puspan. L. 110–275, § 116(a)(2), (3), inserted “subject to the life insurance policy exclusion provided under subparagraph (G)” after “program” in introductory provisions.

Subsec. (a)(3)(G). Puspan. L. 110–275, § 116(a)(4), added subpar. (G).

Statutory Notes and Related Subsidiaries

Effective Date of 2010 Amendment

Puspan. L. 111–148, title III, § 3302(span), Mar. 23, 2010, 124 Stat. 468, provided that: “The amendment made by subsection (a) [amending this section] shall apply to premiums for months beginning on or after January 1, 2011.”

Amendment by section 3303(a) of Puspan. L. 111–148 applicable to premiums for months, and enrollments for plan years, beginning on or after January 1, 2011, see section 3303(c) of Puspan. L. 111–148, set out as a note under section 1395w–101 of this title.

Puspan. L. 111–148, title III, § 3304(span), Mar. 23, 2010, 124 Stat. 470, provided that: “The amendment made by subsection (a) [amending this section] shall take effect on January 1, 2011.”

Effective Date of 2008 Amendment

Amendment by section 114(a)(2) of Puspan. L. 110–275 applicable to subsidies for months beginning with Jan. 2009, see section 114(span) of Puspan. L. 110–275, set out as a note under section 1395w–113 of this title.

Puspan. L. 110–275, title I, § 116(span), July 15, 2008, 122 Stat. 2507, provided that: “The amendments made by this section [amending this section] shall take effect with respect to applications filed on or after January 1, 2010.”

Puspan. L. 110–275, title I, § 117(span), July 15, 2008, 122 Stat. 2507, provided that: “The amendments made by subsection (a) [amending this section] shall take effect as if included in the enactment of section 101 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 [Puspan. L. 108–173].”

Construction of 2022 Amendment

Nothing in amendment by section 11401(span) of Puspan. L. 117–169 to be construed as limiting coverage under this part for vaccines that are not recommended by the Advisory Committee on Immunization Practices, see section 11401(d) of Puspan. L. 117–169, set out as a note under section 1395w–102 of this title.

GAO Study Regarding Impact of Assets Test for Subsidy Eligible Individuals

Puspan. L. 108–173, title I, § 107(e), Dec. 8, 2003, 117 Stat. 2171, provided that:

“(1)Study.—The Comptroller General of the United States shall conduct a study to determine the extent to which drug utilization and access to covered part D drugs under part D of title XVIII of the Social Security Act [42 U.S.C. 1395w–101 et seq.] by subsidy eligible individuals differs from such utilization and access for individuals who would qualify as such subsidy eligible individuals but for the application of section 1860D–14(a)(3)(A)(iii) of such Act [42 U.S.C. 1395w–114(a)(3)(A)(iii)].

“(2)Report.—Not later than September 30, 2007, the Comptroller General shall submit a report to Congress on the study conducted under paragraph (1) that includes such recommendations for legislation as the Comptroller General determines are appropriate.”