42 U.S. Code § 1395w–151 - Definitions; treatment of references to provisions in part C

(a) Definitions

For purposes of this part:

(1) Basic prescription drug coverage

The term “basic prescription drug coverage” is defined in section 1395w–102(a)(3) of this title.

(2) Covered part D drug

The term “covered part D drug” is defined in section 1395w–102(e) of this title.

(3) Creditable prescription drug coverage

The term “creditable prescription drug coverage” has the meaning given such term in section 1395w–113(b)(4) of this title.

(4) Part D eligible individual

The term “part D eligible individual” has the meaning given such term in section 1395w–101(a)(3)(A) of this title.[1]

(5) Fallback prescription drug plan

The term “fallback prescription drug plan” has the meaning given such term in section 1395w–111(g)(4) of this title.

(6) Initial coverage limit

The term “initial coverage limit” means such limit as established under section 1395w–102(b)(3) of this title for a year before 2025, or, in the case of coverage that is not standard prescription drug coverage, the comparable limit (if any) established under the coverage for such year.

(7) Insurance risk

The term “insurance risk” means, with respect to a participating pharmacy, risk of the type commonly assumed only by insurers licensed by a State and does not include payment variations designed to reflect performance-based measures of activities within the control of the pharmacy, such as formulary compliance and generic drug substitution.

(8) MA plan

The term “MA plan” has the meaning given such term in section 1395w–101(a)(3)(B) of this title.¹

(9) MA–PD plan

The term “MA–PD plan” has the meaning given such term in section 1395w–101(a)(3)(C) of this title.¹

(10) Medicare Prescription Drug Account

The term “Medicare Prescription Drug Account” means the Account created under section 1395w–116(a) of this title.

(11) PDP approved bid

The term “PDP approved bid” has the meaning given such term in section 1395w–113(a)(6) of this title.

(12) PDP region

The term “PDP region” means such a region as provided under section 1395w–111(a)(2) of this title.

(13) PDP sponsor

The term “PDP sponsor” means a nongovernmental entity that is certified under this part as meeting the requirements and standards of this part for such a sponsor.

(14) Prescription drug plan

The term “prescription drug plan” means prescription drug coverage that is offered—

(A) under a policy, contract, or plan that has been approved under section 1395w–111(e) of this title; and

(B) by a PDP sponsor pursuant to, and in accordance with, a contract between the Secretary and the sponsor under section 1395w–112(b) of this title.

(15) Qualified prescription drug coverage

The term “qualified prescription drug coverage” is defined in section 1395w–102(a)(1) of this title.

(16) Standard prescription drug coverage

The term “standard prescription drug coverage” is defined in section 1395w–102(b) of this title.

(17) State Pharmaceutical Assistance Program

The term “State Pharmaceutical Assistance Program” has the meaning given such term in section 1395w–133(b) of this title.

(18) Subsidy eligible individual

The term “subsidy eligible individual” has the meaning given such term in section 1395w–114(a)(3)(A) of this title.

(b) Application of part C provisions under this part

For purposes of applying provisions of part C under this part with respect to a prescription drug plan and a PDP sponsor, unless otherwise provided in this part such provisions shall be applied as if—

(1) any reference to an MA plan included a reference to a prescription drug plan;

(2) any reference to an MA organization or a provider-sponsored organization included a reference to a PDP sponsor;

(3) any reference to a contract under section 1395w–27 of this title included a reference to a contract under section 1395w–112(b) of this title;

(4) any reference to part C included a reference to this part; and

(5) any reference to an election period under section 1395w–21 of this title were a reference to an enrollment period under section 1395w–101 of this title.

(Aug. 14, 1935, ch. 531, title XVIII, § 1860D–41, as added Pub. L. 108–173, title I, § 101(a)(2), Dec. 8, 2003, 117 Stat. 2148; amended Pub. L. 117–169, title I, § 11201(e)(6), Aug. 16, 2022, 136 Stat. 1892.)

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[1]  See References in Text note below.

Editorial Notes

References in Text

Section 1395w–101(a)(3) of this title, referred to in subsec. (a)(4), (8), (9), was in the original “section 1860D–1(a)(4)”, and was translated as meaning section 1860D–1(a)(3) of act Aug. 14, 1935, which is classified to section 1395w–101(a)(3) of this title, to reflect the probable intent of Congress, because section 1395w–101(a) of this title does not contain a par. (4) and par. (3) defines terms for purposes of this part.

Amendments

2022—Subsec. (a)(6). Pub. L. 117–169 inserted “for a year before 2025” after “1395w–102(b)(3) of this title” and “for such year” before period at end.