Title 42 — The Public Health and WelfareRelease 119-73

§1395w–103 Access to a choice of qualified prescription drug coverage

Title 42 › Chapter CHAPTER 7— - SOCIAL SECURITY › Subchapter SUBCHAPTER XVIII— - HEALTH INSURANCE FOR AGED AND DISABLED › Part Part D— - Voluntary Prescription Drug Benefit Program › Subpart subpart 1— - part d eligible individuals and prescription drug benefits › § 1395w–103

Last updated Apr 6, 2026|Official source

Summary

The Secretary must make sure people eligible for Part D can choose from at least 2 qualifying plans where they live, and at least one must be a stand-alone prescription drug plan. If no such options exist, the person must be offered a fallback prescription drug plan. The rule does not count if a single company is the only one offering all the qualifying plans in the area. "Qualifying plan" means either a prescription drug plan, or a Medicare Advantage plan with drug coverage that gives basic drug benefits or extra drug benefits only when no extra monthly supplemental premium is charged because a rebate offsets it. The Secretary may approve limited-risk plans to help meet this rule, and if access is still missing after that, must provide a fallback plan for the area.

Full Legal Text

Title 42, §1395w–103

The Public Health and Welfare — Source: USLM XML via OLRC

(a)(1)The Secretary shall ensure that each part D eligible individual has available, consistent with paragraph (2), a choice of enrollment in at least 2 qualifying plans (as defined in paragraph (3)) in the area in which the individual resides, at least one of which is a prescription drug plan. In any such case in which such plans are not available, the part D eligible individual shall be given the opportunity to enroll in a fallback prescription drug plan.

(2)The requirement in paragraph (1) is not satisfied with respect to an area if only one entity offers all the qualifying plans in the area.

(3)For purposes of this section, the term “qualifying plan” means—

(A)a prescription drug plan; or

(B)an MA–PD plan described in section 1395w–21(a)(2)(A)(i) of this title that provides—

(i)basic prescription drug coverage; or

(ii)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)In order to ensure access pursuant to subsection (a) in an area—

(1)the Secretary may approve limited risk plans under section 1395w–111(f) of this title for the area; and

(2)only if such access is still not provided in the area after applying paragraph (1), the Secretary shall provide for the offering of a fallback prescription drug plan for that area under section 1395w–111(g) of this title.

Reference

Citations & Metadata

Citation

42 U.S.C. § 1395w–103

Title 42 — The Public Health and Welfare

Last Updated

Apr 6, 2026

Release point: 119-73