42 U.S.C. § 1395w–131 — Application to Medicare Advantage program and related managed care programs
submitted 91 years ago by Pub. L. 108-173 to r/title-42-THE-PUBLIC-HEALTH-AND-WELFARE · 1,562 words · no verdicts yet
This section sets special rules for prescription drug coverage offered through Medicare Advantage, reasonable-cost contracts, and PACE. It addresses required coverage, enrollment, plan rules, bids, reinsurance, and risk corridors.
(a) Special rules for offering qualified prescription drug coverage*.
(1) In general. Beginning January 1, 2006, an MA organization—
(A) may not offer an MA plan* described in section 1395w–21(a)(2)(A) in an area unless that plan, or another MA plan the organization offers in the same service area, includes required prescription drug* coverage; and
(B) may not offer prescription drug coverage beyond that required under parts A and B to an enrollee under (i) an MSA plan or (ii) another MA plan unless that coverage is qualified prescription drug coverage and this section’s requirements are met.
(2) Qualifying coverage. For paragraph (1)(A), “required coverage” for an MA–PD plan* means either basic prescription drug coverage* or qualified prescription drug coverage that includes supplemental coverage, as long as the plan does not charge an MA monthly supplemental beneficiary premium because a rebate under section 1395w–24(b)(1)(C) is credited against that premium.
(b) Application of default enrollment rules.
(1) Seamless continuation. Under section 1395w–21(c)(3)(A)(ii), a person* enrolled in a health benefits plan is not treated as having chosen an MA–PD plan unless the health benefits plan provides some prescription drug coverage.
(2) MA continuation. Under section 1395w–21(c)(3)(B), a person enrolled in an MA plan is not treated as having chosen an MA–PD plan unless (A), for the January 1, 2006 election, the MA plan provided prescription drug coverage on December 31, 2005, or (B), for later periods, the MA plan is an MA–PD plan.
(3) Ending an MA–PD election during the first eligibility year. When a person elects to end MA–PD enrollment, the person may enroll in a part D prescription drug plan* when the person elects original Medicare fee-for-service coverage, as provided in the second sentence of section 1395w–21(e)(4).
(4) Enrollees in MA plans without qualified coverage. If an individual is enrolled in an MA plan other than an MSA plan that does not provide qualified prescription drug coverage, and the organization stops offering that individual all MA plans without such coverage, then (i) the individual is treated as choosing original Medicare unless the individual affirmatively chooses an MA–PD plan; and (ii) that deemed disenrollment is treated as an involuntary MA-plan termination under section 1395ss(s)(3)(B)(ii). The information disclosed under section 1395w–22(c)(1) must tell these enrollees about these rules.
(c) Application of part D rules to MA prescription drug coverage. Beginning January 1, 2006, when an MA organization offers qualified prescription drug coverage—
(1) the rules in this part apply under part C to that coverage instead of the other part C rules that would otherwise apply;
(2) the Secretary* must waive those rules when they duplicate or conflict with part C rules or when needed to improve coordination with part C benefits; and
(3) the Secretary may waive section 1395w–104(b)(1)(C) for an MA–PD plan that gives non-mail-order access through pharmacies owned and operated by the MA organization if the Secretary finds the network provides comparable access.
(d) Special rules for private fee-for-service plans. Beginning January 1, 2006, these rules apply to an MA plan described in section 1395w–21(a)(2)(C) that offers qualified prescription drug coverage.
(1) Negotiated prices. Sections 1395w–102(a)(1) and (d)(1), and section 1395w–104(b)(2)(A), do not require the plan to provide negotiated prices, but apply if it does provide them.
(2) Pharmacy access and disclosure. If the plan covers drugs bought from every pharmacy without extra cost-sharing*, regardless of network participation or agreements, sections 1395w–104(b)(1)(C) and (k) do not apply.
(3) Utilization and medication management. The drug-utilization-management and medication-therapy-management requirements in section 1395w–104(c)(1)(A) and (C) do not apply.
(4) Reinsurance. The Secretary must calculate reinsurance under section 1395w–115(b) using a method that (A) estimates what would be payable if the plan were an MA–PD local plan under section 1395w–21(a)(2)(A)(i) and paragraphs (1) through (3) did not apply, and (B) considers average reinsurance payments for similarly risky populations in MA–PD plans.
(5) Risk corridors. Section 1395w–115(e) does not apply.
(6) Negotiations. Sections 1395w–111(d) and (e)(2)(C) do not apply. The rule in section 1395w–24(a)(5)(B) against reviewing, approving, or disapproving the specified amounts applies to the proposed bid and terms described in section 1395w–111(d).
(7) Costs without a formulary. The rule excluding costs for covered drugs not included, or treated as included, in a formulary under section 1395w–102(b)(4)(C)(i) does not apply to the extent the plan has no formulary.
(e) Application to reasonable-cost reimbursement contractors.
(1) Subject to paragraphs (2) and (3) and the Secretary’s rules, an organization providing benefits under a reasonable-cost reimbursement contract under section 1395mm(h) may choose to provide qualified prescription drug coverage to an eligible individual enrolled under that contract. This part and related part C rules then apply as they apply to an MA–PD local plan described in section 1395w–21(a)(2)(A)(i), and the coverage is treated as an MA–PD local plan.
(2) The organization may not enroll eligible individuals who are not enrolled under the relevant reasonable-cost contract.
(3) The organization’s bid is not used to calculate the national average monthly bid amount or low-income benchmark premium amount.
(f) Application to PACE.
(1) Subject to paragraphs (2) and (3) and the Secretary’s rules, a PACE program under section 1395eee that chooses to provide qualified prescription drug coverage to an eligible enrollee is governed by this part and related part C rules in a way similar to an MA–PD local plan under section 1395w–21(a)(2)(A)(ii). The PACE program may be treated as an MA–PD local plan.
(2) The PACE program may not enroll eligible individuals who are not enrolled in that PACE program.
(3) The organization’s bid is not used to calculate any average benchmark bid amount or low-income benchmark premium amount under this part.
An MA organization on and after January 1, 2006—
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
may not offer prescription drug coverage (other than that required under parts A and B) to an enrollee—
under an MSA plan; or
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.
For purposes of paragraph (1)(A), the term “required coverage” means with respect to an MA–PD plan*—
basic prescription drug coverage*; or
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).
In applying section 1395w–21(c)(3)(A)(ii) of this title, an individual who is enrolled in a health benefits plan shall not be considered to have been deemed to make an election into an MA–PD plan unless such health benefits plan provides any prescription drug coverage.
In 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—
for purposes of the election as of January 1, 2006, the MA plan provided as of December 31, 2005, any prescription drug coverage; or
for periods after January 1, 2006, such MA plan is an MA–PD plan.
In applying the second sentence of section 1395w–21(e)(4) of this title in the case of an individual who is electing to discontinue enrollment in an MA–PD plan, the individual shall be permitted to enroll in a prescription drug plan* under part D at the time of the election of coverage under the original medicare fee-for-service program.
In 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—
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
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.
With respect to the offering of qualified prescription drug coverage by an MA organization under this part on and after January 1, 2006—
Except as otherwise provided, the provisions of this part shall apply under part C with respect to prescription drug coverage provided under MA–PD plans in lieu of the other provisions of part C that would apply to such coverage under such plans.
The Secretary* shall waive the provisions referred to in paragraph (1) to the extent the Secretary determines that such provisions duplicate, or are in conflict with, provisions otherwise applicable to the organization or plan under part C or as may be necessary in order to improve coordination of this part with the benefits under this part.
The Secretary may waive the requirement of section 1395w–104(b)(1)(C) of this title in the case of an MA–PD plan that provides access (other than mail order) to qualified prescription drug coverage through pharmacies owned and operated by the MA organization, if the Secretary determines that the organization’s pharmacy network is sufficient to provide comparable access for enrollees under the plan.
With 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:
Subsections (a)(1) and (d)(1) of section 1395w–102 of this title and section 1395w–104(b)(2)(A) of this title shall not be construed to require the plan to provide negotiated prices (described in subsection (d)(1)(B) of such section), but shall apply to the extent the plan does so.
If the plan provides coverage for drugs purchased from all pharmacies, without charging additional cost-sharing*, and without regard to whether they are participating pharmacies in a network or have entered into contracts or agreements with pharmacies to provide drugs to enrollees covered by the plan, subsections (b)(1)(C) and (k) of section 1395w–104 of this title shall not apply to the plan.
The requirements of subparagraphs (A) and (C) of section 1395w–104(c)(1) of this title shall not apply to the plan.
The Secretary shall determine the amount of reinsurance payments under section 1395w–115(b) of this title using a methodology that—
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
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.
The provisions of section 1395w–115(e) of this title shall not apply.
Subsections (d) and (e)(2)(C) of section 1395w–111 of this title shall not apply and the provisions of section 1395w–24(a)(5)(B) of this title prohibiting the review, approval, or disapproval of amounts described in such section shall apply to the proposed bid and terms and conditions described in section 1395w–111(d) of this title.
The exclusion of costs incurred for covered part D drugs which are not included (or treated as being included) in a plan’s formulary under section 1395w–102(b)(4)(C)(i) of this title shall not apply insofar as the plan does not utilize a formulary.
Subject to paragraphs (2) and (3) and rules established by the Secretary, in the case of an organization that is providing benefits under a reasonable cost reimbursement contract under section 1395mm(h) of this title and that elects to provide qualified prescription drug coverage to a part D eligible individual* who is enrolled under such a contract, the provisions of this part (and related provisions of part C) shall apply to the provision of such coverage to such enrollee in the same manner as such provisions apply to the provision of such coverage under an MA–PD local plan described in section 1395–21(a)(2)(A)(i) of this title and coverage under such a contract that so provides qualified prescription drug coverage shall be deemed to be an MA–PD local plan.
In applying paragraph (1), the organization may not enroll part D eligible individuals who are not enrolled under the reasonable cost reimbursement contract involved.
The bid of an organization offering prescription drug coverage under this subsection shall not be taken into account in computing the national average monthly bid amount and low-income benchmark premium amount under this part.
Subject to paragraphs (2) and (3) and rules established by the Secretary, in the case of a PACE program under section 1395eee of this title that elects to provide qualified prescription drug coverage to a part D eligible individual who is enrolled under such program, the provisions of this part (and related provisions of part C) shall apply to the provision of such coverage to such enrollee in a manner that is similar to the manner in which such provisions apply to the provision of such coverage under an MA–PD local plan described in section 1395w–21(a)(2)(A)(ii) of this title and a PACE program that so provides such coverage may be deemed to be an MA–PD local plan.
In applying paragraph (1), the organization may not enroll part D eligible individuals who are not enrolled under the PACE program involved.
The bid of an organization offering prescription drug coverage under this subsection is not be taken into account in computing any average benchmark bid amount and low-income benchmark premium amount under this part.
Source credit: (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.)
- 1935Enacted · Pub. L. 108-173 · 117 Stat. 2122
- 2022Amended · Pub. L. 117-169 · 136 Stat. 1891
A history note hasn’t been published yet. The record shows enactment by Pub. L. 108-173 on 1935-08-14.
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