42 U.S. Code § 1395w–133 - State Pharmaceutical Assistance Programs
prev | next
(a) Requirements for benefit coordination
(1) In general
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) of this section) with respect to—
for part D eligible individuals enrolled under both types of plans.
(2) Coordination elements
The requirements under paragraph (1) shall include requirements relating to coordination of each of the following:
(E) Application of the protection against high out-of-pocket expenditures under section 1395w–102 (b)(4) of this title.
Such requirements shall be consistent with applicable law to safeguard the privacy of any individually identifiable beneficiary information.
(3) Use of lump sum per capita method
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.
(5) Part D plan defined
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.
(b) State Pharmaceutical Assistance Program
For purposes of this part, the term “State Pharmaceutical Assistance Program” means a State program—
(1) which provides financial assistance for the purchase or provision of supplemental prescription drug coverage or benefits on behalf of part D eligible individuals;
(2) 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
(c) Relation to other provisions
(1) Medicare as primary payor
The requirements of this section shall not change or affect the primary payor status of a part D plan.
(2) Use of a single card
(3) Other provisions
(4) Special treatment under out-of-pocket rule
(d) Facilitation of transition and coordination with State Pharmaceutical Assistance Programs
(1) Transitional grant program
The Secretary shall provide payments to State Pharmaceutical Assistance Programs with an application approved under this subsection.
(2) Use of funds
Payments under this section may be used by a Program for any of the following:
(A) Educating part D eligible individuals enrolled in the Program about the prescription drug coverage available through part D plans under this part.
(B) Providing technical assistance, phone support, and counseling for such enrollees to facilitate selection and enrollment in such plans.
(3) Allocation of funds
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.