42 USC 1395w-131 - Application to Medicare Advantage program and related managed care programs

U.S Code last checked for updates: May 17, 2024

§ 1395w–131.

Application to Medicare Advantage program and related managed care programs

(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) to an enrollee—

(i)

under an MSA plan; or

(ii)

under another MA plan unless such drug coverage under such other plan provides qualified prescription drug coverage and unless the requirements of this section with respect to such coverage are met.

(2)

Qualifying coverage

For purposes of paragraph (1)(A), the term “required coverage” means with respect to an MA–PD plan—

(A)

basic prescription drug coverage; or

(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

(B)

for periods after January 1, 2006, such MA plan is an MA–PD plan.

(3)

Discontinuance of MA–PD election during first year of eligibility

(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.

The information disclosed under section 1395w–22(c)(1) of this title for individuals who are enrolled in such an MA plan shall include information regarding such rules.

(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

(2)

Waiver

(3)

Treatment of MA owned and operated pharmacies

(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

(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

(B)

takes into account the average reinsurance payments made under section 1395w–115(b) of this title for populations of similar risk under MA–PD plans described in such section.

(5)

Exemption from risk corridor provisions

(6)

Exemption from negotiations

(7)

Treatment of incurred costs without regard to formulary

(e)

Application to reasonable cost reimbursement contractors

(1)

In general

(2)

Limitation on enrollment

(3)

Bids not included in determining national average monthly bid amount

(f)

Application to PACE

(1)

In general

(2)

Limitation on enrollment

(3)

Bids not included in determining standardized bid amount

(Aug. 14, 1935, ch. 531, title XVIII, § 1860D–21, as added Pub. L. 108–173, title I, § 101(a)(2), Dec. 8, 2003, 117 Stat. 2122; amended Pub. L. 117–169, title I, § 11201(e)(4), Aug. 16, 2022, 136 Stat. 1891.)

cite as: 42 USC 1395w-131