§1395w–133 State Pharmaceutical Assistance Programs

Summary

By July 1, 2005, the Secretary must make rules so Medicare Part D plans and State Pharmaceutical Assistance Programs work together on things like who pays premiums and who covers extra drug benefits. The rules must cover sharing enrollment files, handling claims (including electronic claims), paying claims, doing payment-reconciliation reports, applying protections so people do not face very high out‑of‑pocket drug costs, and other administrative steps. The rules must also include a way for a Part D plan to use money from a State program to pay for extra drug benefits for people enrolled in that program. The Secretary must talk with states, plan sponsors, pharmacists, drug manufacturers, employers, consumer groups, data experts, and others when making the rules. Part D plan = prescription drug plans and MA–PD plans. State Pharmaceutical Assistance Program = a State program that helps Part D eligible people pay for supplemental drug coverage, gives help to enrollees in any Part D plan without favoring one plan, and follows the rules above. These rules do not change which payer is the main payer. A Part D ID card may also be used for State program benefits and may show a special mark. State program payments can count toward a person’s annual out‑of‑pocket limit. The Secretary will pay State programs that submit and get an approved application. Those payments can be used for education, phone and technical help, counseling, and other activities to improve coordination. Funds for each fiscal year will be split among approved programs based on how many people were enrolled in each program on October 1, 2003. No payments are allowed without an approved application. $62,500,000 is appropriated for each of fiscal years 2005 and 2006 from Treasury funds not otherwise appropriated. States are not required to coordinate with or pay for any Part D plan.