42 U.S.C. § 1395w–101 — Eligibility, enrollment, and information

(a) Coverage through plan enrollment

(1) In general. Subject to the later rules in this part, every “part D eligible individual” may obtain qualified prescription drug coverage^*. This section does not define “qualified prescription drug^* coverage”; it refers to section 1395w–102(a).

(A) Fee-for-service enrollees. A part D eligible individual who is not enrolled in an MA plan may get this coverage by enrolling in a prescription drug plan^*. This section does not define “prescription drug plan”; it refers to section 1395w–151(a)(14).

(B) Medicare Advantage enrollees.

(i) An individual enrolled in an MA–PD plan gets qualified prescription drug coverage through that plan. This section does not define “MA–PD plan”; it defines it in paragraph (3)(C).

(ii) Except under clauses (iii) and (iv), an individual enrolled in an MA plan may not enroll in a prescription drug plan under this part.

(iii) An individual enrolled in an MA private fee-for-service plan that does not provide qualified prescription drug coverage may get that coverage by enrolling in a prescription drug plan. This section does not define “MA private fee-for-service plan”; it refers to section 1395w–28(b)(2).

(iv) An individual enrolled in an MSA plan may get qualified prescription drug coverage by enrolling in a prescription drug plan. This section does not define “MSA plan”; it refers to section 1395w–28(b)(3).

(2) First effective date. Coverage under prescription drug plans and MA–PD plans first takes effect on January 1, 2006.

(3) Definitions. For this part:

(A) “Part D eligible individual” means a person^* entitled to benefits under part A or enrolled under part B. It does not include a person enrolled only for coverage of immunosuppressive drugs under section 1395o(b).

(B) “MA plan” has the meaning given in section 1395w–28(b)(1).

(C) “MA–PD plan” means an MA plan that provides qualified prescription drug coverage.

(b) Enrollment process for prescription drug plans

(1) Establishing the process.

(A) The Secretary^* must establish a process for enrolling, disenrolling, terminating enrollment, and changing enrollment for part D eligible individuals in prescription drug plans. The process must follow this subsection.

(B) Applying MA rules. The Secretary must use rules similar to, and coordinated with, the MA–PD enrollment rules in section 1395w–21, as follows:

(i) Residence requirements: section 1395w–21(b)(1)(A).

(ii) Choice of plan: section 1395w–21(c), except paragraph (3)(A) and paragraph (4).

(iii) Coverage election periods: section 1395w–21(e), subject to paragraphs (2) and (3) of this subsection, except subparagraphs (B), (C), (E), and (F) of paragraph (2), and the second sentence of paragraph (4). This includes initial, annual coordinated, special, and exceptional-circumstance election periods.

(iv) Coverage periods: section 1395w–21(f), concerning when elections and changes take effect.

(v) Guaranteed issue and renewal: section 1395w–21(g), except paragraph (2), clause (i) of paragraph (3)(C), and the second sentence of clause (ii) of paragraph (3)(C).

(vi) Marketing materials and application forms: section 1395w–21(h), concerning their approval. When clauses (ii), (iv), and (v) are applied, references to section 1395w–21(e) mean that section as modified by clause (iii).

(C) Automatic enrollment rule. Except as provided in subparagraph (D), the process must enroll a full-benefit dual eligible individual who has not enrolled in a prescription drug plan or MA–PD plan in a prescription drug plan whose monthly beneficiary premium does not exceed the premium assistance available under section 1395w–114(a)(1)(A). If more than one such plan is available, the Secretary must choose randomly among all such plans in the PDP region^*. The person may decline or change the enrollment.

(D) Plans waiving small premiums. The process may enroll a subsidy eligible individual^* who has not enrolled in a prescription drug plan or MA–PD plan in a prescription drug plan or MA–PD plan that has waived that person’s monthly beneficiary premium under section 1395w–114(a)(5). If more than one such plan is available, the Secretary must choose randomly among all such plans in the PDP region. The person may decline or change the enrollment.

(2) Initial enrollment period.

(A) Program start. For an individual who was part D eligible on November 15, 2005, the initial enrollment period is the same as the annual coordinated open election period described in section 1395w–21(e)(3)(B)(iii), as that rule is applied under paragraph (1)(B)(iii).

(B) Later eligibility. For an individual who becomes part D eligible after November 15, 2005, the initial enrollment period is the period under section 1395w–21(e)(1), as applied under paragraph (1)(B)(iii), as if “entitled to benefits under part A or enrolled under part B” replaced “entitled to benefits under part A and enrolled under part B.” This period may not end before the period in subparagraph (A).

(3) Additional special enrollment periods. The Secretary must establish special enrollment periods, including these:

(A) Involuntary loss of creditable prescription drug coverage^*.

(i) They apply when a part D eligible individual involuntarily loses creditable prescription drug coverage. This section does not define that term; it refers to section 1395w–113(b)(4).

(ii) The Secretary must consider when people receive notice that the coverage was lost.

(iii) A loss is treated as voluntary if coverage ended because the person did not pay a required beneficiary premium.

(iv) A reduction in coverage that makes it fail the actuarial-equivalence requirements in section 1395w–113(b)(5) is treated as an involuntary loss.

(B) Enrollment errors. The period applies in the situation described in section 1395p(h), in the same way that section applies to part B.

(C) Exceptional circumstances. The period applies to part D eligible individuals who meet additional exceptional conditions set by the Secretary, beyond the conditions used under paragraph (1)(B)(iii).

(D) Medicaid coverage. The period applies to an individual whom the Secretary determines to qualify, subject to limits the Secretary may set for people identified under section 1395w–104(c)(5), if the individual is a full-benefit dual eligible individual.

(E) Ending an MA–PD election in the first eligibility year. The period applies to a part D eligible individual who ends MA–PD enrollment under the second sentence of section 1395w–21(e)(4) when electing coverage under the original Medicare fee-for-service program.

(4) Information that helps enrollment.

(A) Subject to subparagraph (B), and despite other law, the Secretary may give each PDP sponsor^* and MA organization identifying information about part D eligible individuals when the Secretary decides it is needed to make marketing and enrollment efficient.

(B) The Secretary may provide only information needed for that purpose. A PDP sponsor or MA organization may use it only to market prescription drug plans and MA–PD plans and enroll part D eligible individuals in them.

(5) MA–PD enrollment procedures. The rules for enrolling, disenrolling, terminating, and changing enrollment of part D eligible individuals in MA–PD plans are in section 1395w–21.

(6) Late enrollment penalty. Section 1395w–113(b) imposes a late enrollment penalty on a part D eligible individual who (A) enrolls in a prescription drug plan or MA–PD plan after the initial enrollment period in paragraph (2), and (B) does not keep continuous creditable prescription drug coverage while not enrolled.

(c) Information for beneficiaries

(1) Activities. The Secretary must conduct activities that broadly provide part D eligible individuals and prospective part D eligible individuals with information about coverage under this part. The information must first be available at least 30 days before the initial enrollment period in subsection (b)(2)(A).

(2) Requirements. These activities must (A) be similar to the Secretary’s activities under section 1395w–21(d), including comparative information about prescription drug plans and MA–PD plans provided through the toll-free number 1–800–MEDICARE, and (B) be coordinated with activities under that section and section 1395b–2.

(3) Comparative information. Subject to subparagraph (B), the information must compare, for qualified prescription drug coverage: (A)(i) the plan’s benefits; (ii) its monthly beneficiary premium; (iii) its quality and performance; (iv) the cost-sharing^* required from part D eligible individuals; and (v) consumer-satisfaction survey results obtained under section 1395w–104(d).

(B) The Secretary need not provide information about quality and performance or consumer-satisfaction surveys for a plan in its first plan year, or for the next plan year if providing the information is impracticable or the information is otherwise unavailable.

(4) Late enrollment penalty information. The information provided under paragraph (1) must explain the method for determining the late enrollment penalty under section 1395w–113(b).