42 U.S. Code § 1395w–131 - Application to Medicare Advantage program and related managed care programs
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(a) Special rules relating to offering of qualified prescription drug coverage
(1) In general
An MA organization on and after January 1, 2006—
(A) 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
(B) may not offer prescription drug coverage (other than that required under parts A and B of this subchapter) to an enrollee—
(2) Qualifying coverage
For purposes of paragraph (1)(A), the term “required coverage” means with respect to an MA–PD plan—
(B) 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).
(b) Application of default enrollment rules
(1) Seamless continuation
(2) MA continuation
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—
(A) for purposes of the election as of January 1, 2006, the MA plan provided as of December 31, 2005, any prescription drug coverage; or
(3) Discontinuance of MA–PD election during first year of eligibility
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.
(4) Rules regarding enrollees in MA plans not providing qualified prescription drug coverage
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—
(i) 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
(ii) 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.
(c) Application of part D rules for prescription drug coverage
With respect to the offering of qualified prescription drug coverage by an MA organization under this part on and after January 1, 2006—
(1) In general
Except as otherwise provided, the provisions of this part shall apply under part C of this subchapter with respect to prescription drug coverage provided under MA–PD plans in lieu of the other provisions of part C of this subchapter 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 of this subchapter or as may be necessary in order to improve coordination of this part with the benefits under this part.
(3) Treatment of MA owned and operated pharmacies
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.
(d) Special rules for private fee-for-service plans that offer prescription drug coverage
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:
(1) Requirements regarding negotiated prices
(2) Modification of pharmacy access standard and disclosure requirement
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) ofsection 1395w–104 of this title shall not apply to the plan.
(3) Drug utilization management program and medication therapy management program not required
(4) Application of reinsurance
The Secretary shall determine the amount of reinsurance payments under section 1395w–115 (b) of this title using a methodology that—
(A) 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
(5) Exemption from risk corridor provisions
(6) Exemption from negotiations
Subsections (d) and (e)(2)(C) ofsection 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.
(7) Treatment of incurred costs without regard to formulary
(e) Application to reasonable cost reimbursement contractors
(1) In general
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 of this subchapter) 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.
(2) Limitation on enrollment
In applying paragraph (1), the organization may not enroll part D eligible individuals who are not enrolled under the reasonable cost reimbursement contract involved.
(f) Application to PACE
(1) In general
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 of this subchapter) 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.
(2) Limitation on enrollment
In applying paragraph (1), the organization may not enroll part D eligible individuals who are not enrolled under the PACE program involved.