42 U.S.C. § 1395w–133 — State Pharmaceutical Assistance Programs
submitted 91 years ago by Pub. L. 108-173 to r/title-42-THE-PUBLIC-HEALTH-AND-WELFARE · 756 words · no verdicts yet
This section requires coordination between part D plans and qualifying State Pharmaceutical Assistance Programs. It sets coordination, privacy, funding, consultation, and transition-grant rules.
(a) Requirements for benefit coordination.
(1) Before July 1, 2005, the Secretary* must establish requirements consistent with this section for a part D plan to coordinate effectively with a State* Pharmaceutical Assistance Program regarding (A) payment of premiums and coverage and (B) payment for supplemental prescription drug* benefits, for eligible individuals enrolled in both types of plans. A “part D plan” means either a prescription drug plan* or an MA–PD plan*, as stated in paragraph (5).
(2) The requirements must address coordination of (A) enrollment-file sharing; (B) claim processing, including electronic processing; (C) claim payment; (D) claim-reconciliation reports; (E) the protection against high out-of-pocket expenses under section 1395w–102(b)(4); and (F) other administrative processes the Secretary specifies. They must follow applicable privacy laws protecting individually identifiable beneficiary information.
(3) The requirements must include a method for a part D plan to apply specified per-person* funding from a State Pharmaceutical Assistance Program to supplemental drug benefits for enrolled individuals.
(4) The Secretary must consult with the listed State programs, MA organizations, States, pharmaceutical benefit managers, employers, eligible individuals’ representatives, data-processing experts, pharmacists, drug manufacturers, and other experts.
(5) “Part D plan” means a prescription drug plan or an MA–PD plan.
(b) State Pharmaceutical Assistance Program. For this part, it means a state program that (1) gives financial help to buy or provide supplemental prescription drug coverage or benefits for eligible individuals; (2) when deciding eligibility and the amount of help, helps those individuals in all part D plans and does not discriminate based on the plan chosen; and (3) meets subsections (a) and (c).
(c) Relation to other provisions.
(1) Medicare remains the primary payer; this section does not change that status.
(2) A card issued under section 1395w–104(b)(2)(A) for a part D plan may also be used for State-program benefits and may show a symbol indicating that connection.
(3) Section 1395w–134(c) applies to requirements under this section.
(4) When section 1395w–102(b)(4)(C)(ii) is applied, expenses under a State Pharmaceutical Assistance Program may count toward the annual out-of-pocket threshold.
(5) Nothing here requires a State Pharmaceutical Assistance Program to coordinate with, or give financial help concerning, any part D plan.
(d) Transition and coordination grants.
(1) The Secretary must pay State Pharmaceutical Assistance Programs whose applications under this subsection are approved.
(2) A program may use the payments to (A) educate enrolled eligible individuals about part D coverage; (B) provide technical help, phone support, and counseling to help them choose and enroll in part D plans; and (C) carry out other activities that promote effective coordination of enrollment, coverage, and payment.
(3) Of the amount appropriated for a fiscal year, the Secretary must allocate payments among approved programs in proportion to each program’s enrollment on October 1, 2003.
(4) No payment may be made without an application submitted and approved at the time, in the form, and in the manner the Secretary specifies.
(5) For fiscal years 2005 and 2006, $62,500,000 is appropriated from Treasury funds not otherwise appropriated to carry out this subsection.
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—
payment of premiums and coverage; and
payment for supplemental prescription drug benefits,
for part D eligible individuals enrolled under both types of plans.
The requirements under paragraph (1) shall include requirements relating to coordination of each of the following:
Enrollment file sharing.
The processing of claims, including electronic processing.
Claims payment.
Claims reconciliation reports.
Application of the protection against high out-of-pocket expenditures under section 1395w–102(b)(4) of this title.
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.
Such requirements shall include a method for the application by a part D plan of specified funding amounts from a State Pharmaceutical Assistance Program for enrolled individuals for supplemental prescription drug benefits.
In establishing requirements under this subsection, the Secretary shall consult with State Pharmaceutical Assistance Programs, MA organizations, States, pharmaceutical benefit managers, employers, representatives of part D eligible individuals, the data processing experts, pharmacists, pharmaceutical manufacturers, and other experts.
For purposes of this section and section 1395w–134 of this title, the term “part D plan” means a prescription drug plan* and an MA–PD plan*.
For purposes of this part, the term “State Pharmaceutical Assistance Program” means a State program—
which provides financial assistance for the purchase or provision of supplemental prescription drug coverage or benefits on behalf of part D eligible individuals;
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
which satisfies the requirements of subsections (a) and (c).
The requirements of this section shall not change or affect the primary payor status of a part D plan.
A card that is issued under section 1395w–104(b)(2)(A) of this title for use under a part D plan may also be used in connection with coverage of benefits provided under a State Pharmaceutical Assistance Program and, in such case, may contain an emblem or symbol indicating such connection.
The provisions of section 1395w–134(c) of this title shall apply to the requirements under this section.
In applying section 1395w–102(b)(4)(C)(ii) of this title, expenses incurred under a State Pharmaceutical Assistance Program may be counted toward the annual out-of-pocket threshold.
Nothing in this section shall be construed as requiring a State Pharmaceutical Assistance Program to coordinate or provide financial assistance with respect to any part D plan.
The Secretary shall provide payments to State Pharmaceutical Assistance Programs with an application approved under this subsection.
Payments under this section may be used by a Program for any of the following:
Educating part D eligible individuals enrolled in the Program about the prescription drug coverage available through part D plans under this part.
Providing technical assistance, phone support, and counseling for such enrollees to facilitate selection and enrollment in such plans.
Other activities designed to promote the effective coordination of enrollment, coverage, and payment between such Program and such plans.
Of the amount appropriated to carry out this subsection for a fiscal year, the Secretary shall allocate payments among Programs that have applications approved under paragraph (4) for such fiscal year in proportion to the number of enrollees enrolled in each such Program as of October 1, 2003.
No payments may be made under this subsection except pursuant to an application that is submitted and approved in a time, manner, and form specified by the Secretary.
Out of any funds in the Treasury not otherwise appropriated, there are appropriated for each of fiscal years 2005 and 2006, $62,500,000 to carry out this subsection.
Source credit: (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.)
- 1935Enacted · Pub. L. 108-173 · 117 Stat. 2128
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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