Sec. 222. Monthly out-of-pocket cost sharing maximum for enrollees who incur a significant portion of costs towards annual out-of-pocket threshold

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Section 1860D–2(b) of the Social Security Act ( 42 U.S.C. 1395w–102(b) ), as amended by section 2, is amended— in paragraph (2)— in subparagraph (A), by striking and

(D)and inserting , (D), and

(E); and by adding at the end the following new subparagraph: For plan years beginning on or after January 1, 2024, the Secretary shall, through notice and comment rulemaking, establish a process under which each PDP sponsor offering a prescription drug plan and each MA organization offering an MA–PD plan shall each plan year automatically enroll applicable enrollees in the option to have their monthly out-of-pocket cost-sharing under the plan capped and paid in monthly installments in accordance with this subparagraph (referred to in this subparagraph as the monthly out-of-pocket cost sharing maximum option ). The process established under this clause shall permit an applicable enrollee, prior to the beginning of the plan year or at any point during the plan year, to opt out of enrollment in the monthly out-of-pocket cost sharing maximum option and pay any out-of-pocket cost-sharing otherwise applicable for any covered part D drug in full at the time of the dispensing of such drug (or at the time of such opt out in the case of costs incurred during such enrollment that have not yet been billed to the enrollee). In this subparagraph, the term applicable enrollee means any enrollee in a prescription drug plan or an MA–PD plan, including an enrollee who is a subsidy eligible individual (as defined in paragraph

(3)of section 1860D–14(a)), who incurs or is likely to incur a significant percentage of costs for covered part D drugs. For purposes of subclause (I), the Secretary shall, in the rulemaking under clause (i), define the term significant percentage with respect to a percentage of the annual out-of-pocket threshold specified in paragraph (4)(B) but in no case shall the significant percentage be less than 50 percent or more than 100 percent of the annual out-of-pocket threshold. For each month in a plan year in which an applicable enrollee is enrolled in the monthly out-of-pocket cost sharing maximum option, the PDP sponsor or MA organization shall determine a monthly out-of-pocket cost sharing maximum (as defined in clause (v)) for such enrollee. With respect to an applicable enrollee who is enrolled in the monthly out-of-pocket cost sharing maximum option, for each month described in clause (iii), the PDP sponsor or MA organization shall bill such enrollee an amount (not to exceed the monthly out-of-pocket cost sharing maximum) for the out-of-pocket costs of such enrollee in such month. In this subparagraph, the term monthly out-of-pocket cost sharing maximum means, with respect to an enrollee— for the first month in which this subparagraph applies, an amount determined by calculating— the annual out-of-pocket threshold specified in paragraph (4)(B) minus the incurred costs of the enrollee as described in paragraph (4)(C); divided by the number of months remaining in the plan year; and for a subsequent month, an amount determined by calculating— the sum of any remaining out-of-pocket costs owed by the enrollee from a previous month that have not yet been billed to the enrollee and any additional costs incurred by the enrollee; divided by the number of months remaining in the plan year. The following requirements shall apply with respect to the monthly out-of-pocket cost sharing maximum option under this subparagraph: The Secretary shall provide information to part D eligible individuals on the monthly out-of-pocket cost sharing maximum option through educational materials, including through the notices provided under section 1804(a). Each PDP sponsor offering a prescription drug plan or MA organization offering an MA–PD plan— shall not limit the application of the monthly out-of-pocket cost sharing maximum option to certain covered part D drugs; shall, prior to the plan year, notify prospective enrollees of such option, including the availability of the opt out under clause (i)(II); shall include information on such option in enrollee educational materials, including the availability of the opt out under clause (i)(II); shall have in place a mechanism to notify a pharmacy during the plan year when an enrollee incurs out-of-pocket costs with respect to covered part D drugs that make it likely the enrollee is an applicable enrollee; shall provide that a pharmacy, after receiving a notification described in item

(dd)with respect to an enrollee, informs the enrollee of such notification; shall ensure that the application of this subparagraph has no effect on the amount paid to pharmacies (or the timing of such payments) with respect to covered part D drugs dispensed to the enrollee; and shall have in place a financial reconciliation process to correct inaccuracies in payments made by an enrollee under this subparagraph with respect to covered part D drugs during the plan year. If an applicable enrollee fails to pay the amount billed for a month as required under this subparagraph, the applicable enrollee's enrollment in the monthly out-of-pocket cost sharing maximum option shall be terminated and the enrollee shall pay the cost-sharing otherwise applicable for any covered part D drugs subsequently dispensed to the enrollee up to the annual out-of-pocket threshold specified in paragraph (4)(B). Nothing in this subparagraph shall be construed as prohibiting a PDP sponsor or an MA organization from billing an enrollee for an amount owed under this subparagraph. Any unsettled balances with respect to amounts owed under this subparagraph shall be treated as plan losses and the Secretary shall not be liable for any such balances outside of those assumed as losses estimated in plan bids. ; and in paragraph (4)— in subparagraph (C), by striking and subject to subparagraph

(F)and inserting and subject to subparagraphs

(F)and

(G); and by adding at the end the following new subparagraph: In applying subparagraph (A), with respect to an applicable enrollee who is enrolled in the monthly out-of-pocket cost sharing maximum option described in clause (i)(I) of paragraph (2)(E), costs shall be treated as incurred if such costs are paid by a PDP sponsor or an MA organization under the process provided under such paragraph. . Section 1860D–2(c) of the Social Security Act ( 42 U.S.C. 1395w–102(c) ) is amended by adding at the end the following new paragraph: For plan years beginning on or after January 1, 2024, the monthly out-of-pocket cost sharing maximum for applicable enrollees under the process provided under subsection (b)(2)(E) shall apply to such coverage. .

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42 USC 1395w–102(b)
42 USC 1395w–102(c)

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Sec. 222

Monthly out-of-pocket cost sharing maximum for enrollees who incur a significant portion of costs towards annual out-of-pocket threshold

Cite42 USC 1395w–102(b)

Cite42 USC 1395w–102(c)

Cites 2Cited by 0 across 0 sources