§1396u–5 Special Provisions Relating to Medicare Prescription Drug Benefit

Summary

States must give the federal Medicare official the data needed to run Part D low‑income help. States must decide who gets premium and cost‑sharing subsidies, tell the Secretary when someone is eligible, check whether that person qualifies for Medicaid help with Medicare cost‑sharing and offer enrollment if they do, and accept certain electronic data as if it were an application to the Medicare Savings Program. The federal government will repay states for money they spend doing these tasks. Starting January 2006, each State and the District of Columbia must pay the Secretary each month an amount that equals a monthly share of the State’s base per‑person drug spending (adjusted by 100% minus the State’s federal Medicaid matching rate and grown by yearly factors), times the number of full‑benefit dual eligible people in the State that month, times a monthly factor. The monthly factor is 90% for 2006; 88 1/3% for 2007; 86 2/3% for 2008; 85% for 2009; 83 1/3% for 2010; 81 2/3% for 2011; 80% for 2012; 78 1/3% for 2013; 76 2/3% for 2014; and 75% after December 2014. The Secretary will tell each State its yearly amount by October 15 before the year. If a State misses a payment, interest is charged at the rate in section 1396b(d)(5) and the owed amount can be taken from other federal payments. The Secretary will also do data matches to count the people who qualify. The base per‑person amount comes from 2003 Medicaid drug spending and the 2003 value of managed‑care drug benefits, using Medicaid data and excluding drugs not covered by Part D. Growth factors are the average annual change in prescription drug spending for 2004–2006 (based on National Health Expenditure projections) and the annual percent increase used in section 1395w‑102(b)(6) for later years. Definition: full‑benefit dual eligible individual — a person who has Part D drug coverage and is eligible for full Medicaid benefits for that month. For such people, Medicaid will not pay for Part D drugs or cost‑sharing; those Part D benefits are handled under Part D rules and not as Medicaid services. States may still choose how to help with drugs not covered by Part D or may work with Part D plans to provide help. For U.S. territories (like Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa) the main rules do not automatically apply. A territory can submit a plan to get extra funds if it promises to use the money only for low‑income Part D help and limit administrative costs to 10%. The extra pool is $28,125,000 for the last three quarters of fiscal 2006, $37,500,000 for fiscal 2007, and is increased in later years by the same annual percent used in section 1395w‑102(b)(6). The Secretary must report to Congress on how this subsection is applied.