View all text of Subpart 3 [§ 1395w-131 - § 1395w-134]
§ 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.)