§1395w–133 State Pharmaceutical Assistance Programs

Summary

Before July 1, 2005, the Secretary must write rules so Part D plans and State Pharmaceutical Assistance Programs (SPAPs) work together on premiums, coverage, and payment for extra drug benefits. The rules must cover things like sharing enrollment files, electronic claims processing and payment, claims reconciliation, applying the out-of-pocket protection under section 1395w–102(b)(4), and other needed administrative steps. Plans must have a way to apply specified SPAP funds for enrolled people. The Secretary must get input from States, plans, pharmacists, drug makers, data experts, beneficiaries’ reps, and others. Part D plan = a prescription drug plan or an MA–PD plan. SPAP = a State program that helps pay for supplemental drug coverage for Part D–eligible people, helps those people in every Part D plan without favoring one, and meets the rules here. These rules do not change which payer is primary. A Part D plan card can be used with an SPAP and may show a symbol showing the link. SPAP spending can count toward the yearly out-of-pocket limit. States are not forced to coordinate or pay for any Part D plan. The Secretary will pay SPAPs that submit approved applications. Those payments may be used for education, phone help, counseling, technical assistance, and other coordination activities. Payments for a fiscal year are split among approved SPAPs based on enrollment as of October 1, 2003. No payments without an approved application. $62,500,000 is appropriated from Treasury for each of fiscal years 2005 and 2006.