Part D—Voluntary Prescription Drug Benefit Program[453]
Subpart 1—Part D Eligible Individuals and Prescription Drug Benefits
ELIGIBILITY, ENROLLMENT, AND INFORMATION
Sec. 1860D-1. [42 U.S.C. 1395w-101] (a) Provision of Qualified Prescription Drug Coverage Through Enrollment In Plans.—
(1) In general.—Subject to the succeeding provisions of this part, each part D eligible individual (as defined in paragraph (3)(A)) is entitled to obtain qualified prescription drug coverage (described in section 1860D-2(a)) as follows:
(A) Fee-for-service enrollees may receive coverage through a prescription drug plan.—A part D eligible individual who is not enrolled in an MA plan may obtain qualified prescription drug coverage through enrollment in a prescription drug plan (as defined in section 1860D-41(a)(14)).
(B) Medicare advantage enrollees.—
(i) Enrollees in a plan providing qualified prescription drug coverage receive coverage through the plan.—A part D eligible individual who is enrolled in an MA-PD plan obtains such coverage through such plan.
(ii) Limitation on enrollment of MA plan enrollees in prescription drug plans.—Except as provided in clauses (iii) and (iv), a part D eligible individual who is enrolled in an MA plan may not enroll in a prescription drug plan under this part.
(iii) Private fee-for-service enrollees in MA plans not providing qualified prescription drug coverage permitted to enroll in a prescription drug plan.—A part D eligible individual who is enrolled in an MA private fee-for-service plan (as defined in section 1859(b)(2)) that does not provide qualified prescription drug coverage may obtain qualified prescription drug coverage through enrollment in a prescription drug plan.
(iv) Enrollees in MSA a plans permitted to enroll in a prescription drug plan.—A part D eligible individual who is enrolled in an MSA plan (as defined in section 1859(b)(3)) may obtain qualified prescription drug coverage through enrollment in a prescription drug plan.
(2) Coverage first effective January 1, 2006.—Coverage under prescription drug plans and MA-PD plans shall first be effective on January 1, 2006.
(3) Definitions.—For purposes of this part:
(A) Part D eligible individual.—The term “part D eligible individual” means an individual who is entitled to benefits under part A or enrolled under part B.
(B) MA plan.—The term “MA plan” has the meaning given such term in section 1859(b)(1).
(C) MA-PD plan.—The term “MA-PD plan” means an MA plan that provides qualified prescription drug coverage.
(b) Enrollment Process For Prescription Drug Plans.—
(1) Establishment of process.—
(A) In general.—The Secretary shall establish a process for the enrollment, disenrollment, termination, and change of enrollment of part D eligible individuals in prescription drug plans consistent with this subsection.
(B) Application of MA rules.—In establishing such process, the Secretary shall use rules similar to (and coordinated with) the rules for enrollment, disenrollment, termination, and change of enrollment with an MA-PD plan under the following provisions of section 1851:
(i) Residence requirements.—Section 1851(b)(1)(A), relating to residence requirements.
(ii) Exercise of choice.—Section 1851(c) (other than paragraph (3)(A) and paragraph (4) of such section), relating to exercise of choice.[454]
(iii) Coverage election periods.—Subject to paragraphs (2) and (3) of this subsection, section 1851(e) (other than subparagraphs (B), (C), (E), and (F) of paragraph (2) and the second sentence of paragraph (4) of such section), relating to coverage election periods, including initial periods, annual coordinated election periods, special election periods, and election periods for exceptional circumstances.[455]
(iv) Coverage periods.—Section 1851(f), relating to effectiveness of elections and changes of elections.
(v) Guaranteed issue and renewal.—Section 1851(g) (other than paragraph (2) of such section and clause (i) and the second sentence of clause (ii) of paragraph (3)(C) of such section), relating to guaranteed issue and renewal.
(vi) Marketing material and application forms.—Section 1851(h), relating to approval of marketing material and application forms. In applying clauses (ii), (iv), and (v) of this subparagraph, any reference to section 1851(e) shall be treated as a reference to such section as applied pursuant to clause (iii) of this subparagraph.
(C) Special rule.—The process established under subparagraph (A) shall include, except as provided in subparagraph (D), in the case of a part D eligible individual who is a full-benefit dual eligible individual (as defined in section 1935(c)(6)) who has failed to enroll in a prescription drug plan or an MA-PD plan, for the enrollment in a prescription drug plan that has a monthly beneficiary premium that does not exceed the premium assistance available under section 1860D-14(a)(1)(A)). If there is more than one such plan available, the Secretary shall enroll such an individual on a random basis among all such plans in the PDP region. Nothing in the previous sentence shall prevent such an individual from declining or changing such enrollment.
(D) Special rules for plans that waive de minimus premiums.—The process established under subparagraph (A) may include, in the case of a part D eligible individual who is a subsidy eligible individual (as defined in section 1860D–14(a)(3)) who has failed to enroll in a prescription drug plan or an MA–PD plan, for the enrollment in a prescription drug plan or MA–PD plan that has waived the monthly beneficiary premium for such subsidy eligible individual under section 1860D–14(a)(5). If there is more than one such plan available, the Secretary shall enroll such an individual under the preceding sentence on a random basis among all such plans in the PDP region. Nothing in the previous sentence shall prevent such an individual from declining or changing such enrollment.
(2) Initial enrollment period.—
(A) Program initiation.—In the case of an individual who is a part D eligible individual as of November 15, 2005, there shall be an initial enrollment period that shall be the same as the annual, coordinated open election period described in section 1851(e)(3)(B)(iii), as applied under paragraph (1)(B)(iii).
(B) Continuing periods.—In the case of an individual who becomes a part D eligible individual after November 15, 2005, there shall be an initial enrollment period which is the period under section 1851(e)(1), as applied under paragraph (1)(B)(iii) of this section, as if “entitled to benefits under part A or enrolled under part B” were substituted for “entitled to benefits under part A and enrolled under part B”, but in no case shall such period end before the period described in subparagraph (A).
(3) Additional special enrollment periods.—The Secretary shall establish special enrollment periods, including the following:
(A) Involuntary loss of creditable prescription drug coverage.—
(i) In general.—In the case of a part D eligible individual who involuntarily loses creditable prescription drug coverage (as defined in section 1860D-13(b)(4)).
(ii) Notice.—In establishing special enrollment periods under clause (i), the Secretary shall take into account when the part D eligible individuals are provided notice of the loss of creditable prescription drug coverage.
(iii) Failure to pay premium.—For purposes of clause (i), a loss of coverage shall be treated as voluntary if the coverage is terminated because of failure to pay a required beneficiary premium.
(iv) Reduction in coverage.—For purposes of clause (i), a reduction in coverage so that the coverage no longer meets the requirements under section 1860D-13(b)(5) (relating to actuarial equivalence) shall be treated as an involuntary loss of coverage.
(B) Errors in enrollment.—In the case described in section 1837(h) (relating to errors in enrollment), in the same manner as such section applies to part B.
(C) Exceptional circumstances.—In the case of part D eligible individuals who meet such exceptional conditions (in addition to those conditions applied under paragraph (1)(B)(iii)) as the Secretary may provide.
(D) Medicaid coverage.—In the case of an individual (as determined by the Secretary, subject to such limits as the Secretary may establish for individuals identified pursuant to section 1860D-4(c)(5)) who is a full-benefit dual eligible individual (as defined in section 1935(c)(6)).[456]
(E) Discontinuance of MA-PD election during first year of eligibility.—In the case of a part D eligible individual who discontinues enrollment in an MA-PD plan under the second sentence of section 1851(e)(4) at the time of the election of coverage under such sentence under the original medicare fee-for-service program.
(4) Information to facilitate enrollment.—
(A) In general.—Notwithstanding any other provision of law but subject to subparagraph (B), the Secretary may provide to each PDP sponsor and MA organization such identifying information about part D eligible individuals as the Secretary determines to be necessary to facilitate efficient marketing of prescription drug plans and MA-PD plans to such individuals and enrollment of such individuals in such plans.
(B) Limitation.—
(i) Provision of information.—The Secretary may provide the information under subparagraph (A) only to the extent necessary to carry out such subparagraph.
(ii) Use of information.—Such information provided by the Secretary to a PDP sponsor or an MA organization may be used by such sponsor or organization only to facilitate marketing of, and enrollment of part D eligible individuals in, prescription drug plans and MA-PD plans.
(5) Reference to enrollment procedures for MA-PD plans.—For rules applicable to enrollment, disenrollment, termination, and change of enrollment of part D eligible individuals in MA-PD plans, see section 1851.
(6) Reference to penalties for late enrollment.—Section 1860D-13(b) imposes a late enrollment penalty for part D eligible individuals who—
(A) enroll in a prescription drug plan or an MA-PD plan after the initial enrollment period described in paragraph (2); and
(B) fail to maintain continuous creditable prescription drug coverage during the period of non-enrollment.
(c) Providing information to beneficiaries.—
(1) Activities.—The Secretary shall conduct activities that are designed to broadly disseminate information to part D eligible individuals (and prospective part D eligible individuals) regarding the coverage provided under this part. Such activities shall ensure that such information is first made available at least 30 days prior to the initial enrollment period described in subsection (b)(2)(A).
(2) Requirements.—The activities described in paragraph (1) shall—
(A) be similar to the activities performed by the Secretary under section 1851(d), including dissemination (including through the toll-free telephone number 1-800-MEDICARE) of comparative information for prescription drug plans and MA-PD plans; and
(B) be coordinated with the activities performed by the Secretary under such section and under section 1804.
(3) Comparative information.—
(A) In general.—Subject to subparagraph (B), the comparative information referred to in paragraph (2)(A) shall include a comparison of the following with respect to qualified prescription drug coverage:
(i) Benefits.—The benefits provided under the plan.
(ii) Monthly beneficiary premium.—The monthly beneficiary premium under the plan.
(iii) Quality and performance.—The quality and performance under the plan.
(iv) Beneficiary cost-sharing.—The cost-sharing required of part D eligible individuals under the plan.
(v) Consumer satisfaction surveys.—The results of consumer satisfaction surveys regarding the plan conducted pursuant to section 1860D-4(d).
(B) Exception for unavailability of information.—The Secretary is not required to provide comparative information under clauses (iii) and (v) of subparagraph (A) with respect to a plan—
(i) for the first plan year in which it is offered; and
(ii) for the next plan year if it is impracticable or the information is otherwise unavailable.
(4) Information on late enrollment penalty.—The information disseminated under paragraph (1) shall include information concerning the methodology for determining the late enrollment penalty under section 1860D-13(b).
[453] See Vol. II, P.L. 108-173, §101(b), with respect to the submission of a legislative proposal; §101(c), with respect to a study on transitioning Part B prescription drug coverage; §101(d), with respect to a report on progress in implementation of prescription drug benefit; §106, with respect to the State Pharmaceutical Assistance Transition commission; and §110, with respect to a conflict of interest study.
See Vol. II, P.L. 111-148, §3313, with respect to Office of the Inspector General studies and reports on Part D Formularies’ inclusion of drugs commonly used by dula eligibles and prescription drug prices under Medicare Part D and Medicaid.
See Vol. II, P.L. 115–271, §6012, with respect to study and report to Congress on adequacy of abuse-deterrent opioid formulations prescribed to individuals with chronic pain under Part D.
[454] P.L. 114-10, §209(b)(2)(B)(ii)(I), inserted “and paragraph (4)” after “paragraph (3)(A)” , effective January 2, 2013.
[455] P.L. 114-10, §209(b)(2)(B)(ii)(II), striking “and (E)” and inserting “(E), and (F)”. , effective January 2, 2013.
[456] P.L.114-255, §704(b)(3) inserted “, subject to such limits as the Secretary may establish for individuals identified pursuant to section 1860D- 4(c)(5)” after “the Secretary”. See Vol. II, P.L. 114–198, §704(g) for effective date and implementation provisions.