§1395w–141 Medicare prescription drug discount card and transitional assistance program

Summary

The Secretary must set up a national program that approves private prescription drug discount card plans and gives short-term financial help to low-income Medicare people who join those approved plans. The cards and help had to be available within 6 months after December 8, 2003. The program stops applying to drugs dispensed after December 31, 2005, but people already enrolled by that date can get a short transition period in 2006 with no enrollment fee and with any remaining help still available. People with Medicare Part A or Part B can join if they do not already get outpatient drug help from Medicaid. Low-income help is for those with income at or below 135% of the poverty line (and a stronger help for those at or below 100%). Members may enroll in only one approved program at a time, but may change plans during a special 2004 process for 2005 or for certain moves or special cases. Sponsors may charge an annual fee of up to $30 for 2004 and 2005 only (not prorated); the government pays that fee for low-income eligible people. Low-income members get 90% of drug costs paid (95% if income ≤100% of poverty) up to $600 for 2004; for 2005 the basic amount is $600 plus any unused 2004 amount for that person, subject to the rules. Sponsors must give negotiated prices, a standard card, public price information (including at point of sale and by phone or internet), a pharmacy network that gives convenient access, and must let pharmacies tell enrollees when a cheaper generic is available. The Secretary will run outreach (including 1-800-MEDICARE), make rules (which may start on an interim basis with later public comment), inspect records, audit sponsors, and can stop approval or fine sponsors (up to $10,000) for violations. Payments for the low-income help come from a special Transitional Assistance Account inside the Medicare trust fund, and the Secretary must set up reimbursement and accounting rules. Defined terms (one line each): covered discount card drug = same as a covered Part D drug; discount card eligible individual = Medicare Part A or B beneficiary who is not covered for outpatient drugs by Medicaid; transitional assistance eligible individual = low-income eligible person with income ≤135% of poverty; special transitional assistance eligible individual = income ≤100% of poverty; endorsed discount card program/endorsed program = a discount card plan approved and contracted with the Secretary; negotiated prices = prices that reflect discounts, rebates, subsidies, and dispensing fees; prescription drug card sponsor/sponsor = a private entity (for example a PBM, pharmacy system, insurer, or Medicare Advantage organization) that runs an approved program; State = as defined for Medicaid purposes.