Sec. 11202. Maximum monthly cap on cost-sharing payments under prescription drug plans and MA–PD plans
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Section 1860D–2(b) of the Social Security Act ( 42 U.S.C. 1395w–102(b) ) 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, 2025, each PDP sponsor offering a prescription drug plan and each MA organization offering an MA–PD plan shall provide to any enrollee of such plan, including an enrollee who is a subsidy eligible individual (as defined in paragraph
(3)of section 1860D–14(a)), the option to elect with respect to a plan year to pay cost-sharing under the plan in monthly amounts that are capped in accordance with this subparagraph. For each month in the plan year for which an enrollee in a prescription drug plan or an MA–PD plan has made an election pursuant to clause (i), the PDP sponsor or MA organization shall determine a maximum monthly cap (as defined in clause (iv)) for such enrollee. With respect to an enrollee who has made an election pursuant to clause (i), for each month described in clause (ii), the PDP sponsor or MA organization shall bill such enrollee an amount (not to exceed the maximum monthly cap) for the out-of-pocket costs of such enrollee in such month. In this subparagraph, the term maximum monthly cap means, with respect to an enrollee— for the first month for which the enrollee has made an election pursuant to clause (i), 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 out-of-pocket 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 option to make an election pursuant to clause
(i)under this subparagraph: The Secretary shall provide information to part D eligible individuals on the option to make such election through educational materials, including through the notices provided under section 1804(a). An enrollee in a prescription drug plan or an MA–PD plan may make such an election— prior to the beginning of the plan year; or in any month during the plan year. Each PDP sponsor offering a prescription drug plan or MA organization offering an MA–PD plan— may not limit the option for an enrollee to make such an election to certain covered part D drugs; shall, prior to the plan year, notify prospective enrollees of the option to make such an election in promotional materials; shall include information on such option in enrollee educational materials; 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 may benefit from making such an election; 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 such an election by an enrollee 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 enrollee fails to pay the amount billed for a month as required under this subparagraph— the election of the enrollee pursuant to clause
(i)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); and the PDP sponsor or MA organization may preclude the enrollee from making an election pursuant to clause
(i)in a subsequent plan year. 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 subparagraph
(E)and inserting subparagraph
(E)or subparagraph
(F); and by adding at the end the following new subparagraph: In applying subparagraph (A), with respect to an enrollee who has made an election pursuant to clause
(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 option 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: The maximum monthly cap on cost-sharing payments shall apply to coverage with respect to an enrollee who has made an election pursuant to clause
(i)of subsection (b)(2)(E) under the option provided under such subsection. . The Secretary shall implement this section, including the amendments made by this section, for 2025 by program instruction or other forms of program guidance. In addition to amounts otherwise available, there are appropriated to the Centers for Medicare & Medicaid Services, out of any money in the Treasury not otherwise appropriated, $10,000,000 for fiscal year 2023, to remain available until expended, to carry out the provisions of, including the amendments made by, this section.
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- 42 USC 1395w–102(b)
- 42 USC 1395w–102(c)
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Sec. 11202
Maximum monthly cap on cost-sharing payments under prescription drug plans and MA–PD plans
Cite42 USC 1395w–102(b)
Cite42 USC 1395w–102(c)
Cites 2Cited by 0 across 0 sources