§1395w–133 State Pharmaceutical Assistance Programs

Summary

The Secretary must create rules by July 1, 2005 so Part D drug plans and State Pharmaceutical Assistance Programs (SPAPs) can work together when the same person is in both. The rules must cover how they share enrollment files, process and pay claims (including electronic claims), reconcile reports, protect people from high out-of-pocket costs, and other administrative steps. The rules must include a way for a Part D plan to use fixed per-person payments from a State program for extra drug benefits. The Secretary must talk with states, drug plans, pharmacies, manufacturers, beneficiary groups, and tech experts when making the rules. Part D plan — a prescription drug plan or an MA–PD plan. State Pharmaceutical Assistance Program — a state program that helps pay for extra drug coverage for people who qualify for Part D and that helps people in any Part D plan without favoring one plan. These rules do not change that the Part D plan is the primary payer. A Part D ID card may also be used for State program benefits and can show a special symbol. Expenses paid by a State program can count toward the annual out-of-pocket limit. The Secretary will make transitional grants to approved State programs to educate and help people enroll and to improve coordination. Grants are split based on each program’s enrollment as of October 1, 2003. Congress set $62,500,000 for each of fiscal years 2005 and 2006 for these grants.