42 CFR 423.329 - Determination of payments.
(a)Subsidy payments -
(1)Direct subsidy. CMS makes a direct subsidy payment for each Part D eligible beneficiary enrolled in a Part D plan for a month equal to the amount of the plan's approved standardized bid, adjusted for health status (as determined under § 423.329(b)(1)), and reduced by the base beneficiary premium for the plan (as determined under § 423.286(c) and adjusted in § 423.286(d)(1)). The direct subsidy payment may be increased by the excess amount of a negative premium as described in § 423.286(d)(1), if applicable.
(b)Health status risk adjustment -
(1)Establishment of risk factors. CMS establishes an appropriate methodology for adjusting the standardized bid amount to take into account variation in costs for basic prescription drug coverage among Part D plans based on the differences in actuarial risk of different enrollees being served. Any risk adjustment is designed in a manner so as to be budget neutral in the aggregate to the risk of the Part D eligible individuals who enroll in Part D plans.
(2)Considerations. In establishing the methodology under paragraph (b)(1) of this section, CMS takes into account the similar methodologies used under § 422.308(c) of this chapter to adjust payments to MA organizations for benefits under the original Medicare fee-for-service program option.
(3)Data collection. In order to carry out this paragraph, CMS requires -
(i) PDP sponsors to submit data regarding drug claims that can be linked at the individual level to Part A and Part B data in a form and manner similar to the process provided under § 422.310 of this chapter and other information as CMS determines necessary; and
(ii) MA organizations that offer MA-PD plans to submit data regarding drug claims that can be linked at the individual level to other data that the organizations are required to submit to CMS in a form and manner similar to the process provided under § 422.310 of this chapter and other information as CMS determines necessary.
(4)Publication. At the time of publication of risk adjustment factors under § 422.312(a)(1)(ii) of this chapter, CMS publishes the risk adjusters established under this paragraph of this section for the upcoming calendar year.
(c)Reinsurance payment amount -
(1)General rule. The reinsurance payment amount for a Part D eligible individual enrolled in a Part D plan for a coverage year is an amount equal to 80 percent of the allowable reinsurance costs attributable to that portion of gross covered prescription drug costs incurred in the coverage year after the individual has incurred true out-of-pocket costs that exceed the annual out-of-pocket threshold specified in § 423.104(d)(5)(iii).
(i) Payments during the coverage year. CMS establishes a payment method by which payments of amounts under this section are made on a monthly basis during a year based on either estimated or incurred allowable reinsurance costs.
(3)Special rules for private fee-for-service Plans offering prescription drug coverage. CMS determines the amount of reinsurance payments for private fee-for-service plans as defined by § 422.4(a)(3) of this chapter offering qualified prescription drug coverage using a methodology that -
(d)Low-income cost sharing subsidy payment amount -
(1)General rule. The low-income cost-sharing subsidy payment amount on behalf of a low-income subsidy eligible individual enrolled in a Part D plan for a coverage year is the difference between the cost sharing for a non-low-income subsidy eligible beneficiary under the Part D plan and the statutory cost sharing for a low-income subsidy eligible beneficiary.
(i)Interim payments. CMS establishes a payment method by which interim payments of amounts under this section are made during a year based on the low-income cost-sharing assumptions submitted with plan bids under § 423.265(d)(2)(iv) of this part and negotiated and approved under § 423.272 of this part, or by an alternative method that CMS determines.
- 42 CFR 423.346 — Reopening.
- 42 CFR 423.352 — CMS-identified Overpayments Associated With Payment Data Submitted by Part D Sponsors.
- 42 CFR 423.293 — Collection of Monthly Beneficiary Premium.
- 42 CFR 423.120 — Access to Covered Part D Drugs.
- 42 CFR 423.360 — Reporting and Returning of Overpayments.
- 42 CFR 423.505 — Contract Provisions.
- 42 CFR 423.286 — Rules Regarding Premiums.
- 42 CFR 423.308 — Definitions and Terminology.
- 42 CFR 423.2420 — Calculation of Medical Loss Ratio.
- 42 CFR 423.272 — Review and Negotiation of Bid and Approval of Plans Submitted by Potential Part D Sponsors.
- 42 CFR 422.2420 — Calculation of the Medical Loss Ratio.
- 42 CFR 423.315 — General Payment Provisions.
- 42 CFR 423.265 — Submission of Bids and Related Information.
- 42 CFR 423.343 — Retroactive Adjustments and Reconciliations.
- 42 CFR 423.336 — Risk-Sharing Arrangements.
- 42 CFR 423.329 — Determination of Payments.