§1395w–131 Application to Medicare Advantage Program and Related Managed Care Programs

Summary

Medicare Advantage organizations must, starting January 1, 2006, offer prescription drug coverage in certain plans. They cannot sell one kind of plan in an area unless that plan or another plan they sell there includes the required drug coverage. They also may not sell separate drug coverage in MSA (medical savings account) plans, and other plans can only offer drug coverage if it is “qualified” and meets the rules. “Required coverage” means either basic drug coverage or qualified supplemental drug coverage that does not charge a monthly supplemental beneficiary premium because a rebate was applied. People are not automatically treated as having picked a Medicare Advantage prescription drug (MA–PD) plan unless their current plan gives any drug coverage. For the January 1, 2006 switch rule, an MA plan had to have offered drug coverage on December 31, 2005. If someone leaves an MA–PD plan to go back to original Medicare, they may sign up for a Part D drug plan at the switch. If an organization stops offering MA plans without qualified drug coverage, affected enrollees are treated as moving to original Medicare unless they choose an MA–PD plan, and that move counts as an involuntary plan ending in certain program rules. When an MA organization offers qualified drug coverage, most Part C rules apply to that drug coverage, but the Secretary can waive parts that are duplicative or conflict. The Secretary can also allow an MA–PD plan that uses its own pharmacies to meet access rules if the network is good enough. Special types of MA plans, reasonable cost contracts, and PACE programs that offer qualified drug coverage can be treated like local MA–PD plans for these rules, but only for their own enrollees, and their bids are not counted in the national averages or benchmark calculations.