42 USC 1395w-133 - State Pharmaceutical Assistance Programs

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

§ 1395w–133.

State Pharmaceutical Assistance Programs

(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)) with respect to—

(A)

payment of premiums and coverage; and

(B)

payment for supplemental prescription drug benefits,

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:

(A)

Enrollment file sharing.

(B)

The processing of claims, including electronic processing.

(C)

Claims payment.

(D)

Claims reconciliation reports.

(E)

Application of the protection against high out-of-pocket expenditures under section 1395w–102(b)(4) of this title.

(F)

Other administrative processes specified by the Secretary.

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

(4)

Consultation

(5)

Part D plan defined

(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

(3)

which satisfies the requirements of subsections (a) and (c).

(c)

Relation to other provisions

(1)

Medicare as primary payor

(2)

Use of a single card

(3)

Other provisions

(4)

Special treatment under out-of-pocket rule

(5)

Construction

(d)

Facilitation of transition and coordination with State Pharmaceutical Assistance Programs

(1)

Transitional grant program

(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.

(C)

Other activities designed to promote the effective coordination of enrollment, coverage, and payment between such Program and such plans.

(3)

Allocation of funds

(4)

Application

(5)

Funding

(Aug. 14, 1935, ch. 531, title XVIII, § 1860D–23, as added Pub. L. 108–173, title I, § 101(a)(2), Dec. 8, 2003, 117 Stat. 2128.)

cite as: 42 USC 1395w-133