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

Summary

States must give the federal government the data and help needed to run Medicare drug help for low-income people and transitional drug aid. States must decide who gets premium and cost-sharing help under Medicare Part D, tell the federal government when someone is eligible, and share any other information needed to run Part D. When making those decisions, states must also check if the person qualifies for Medicaid help with Medicare cost-sharing and offer to enroll them. States must accept matching data from the Social Security Administration as if the person had applied to the Medicare Savings Program, and use that SSA date as the application date. The money states spend to do this work is reimbursable by the federal government. For people who have both Medicare drug coverage and full Medicaid benefits, Medicare is the main payer for Part D drugs and Medicaid will not pay for those drugs or their cost-sharing; a state may choose to provide some other drug coverage or work with the Part D plan instead. Starting January 2006, each State and DC must pay the federal government a monthly amount for each full-benefit dual eligible person. That amount is based on the State’s 2003 per-person Medicaid drug spending for those people, multiplied by (100% minus the State’s Federal medical assistance percentage), divided by 12, and increased by yearly growth factors. The monthly total is then multiplied by a yearly factor that phases down from 90% in 2006 to 75% after December 2014 (2006: 90%; 2007: 88 1/3%; 2008: 86 2/3%; 2009: 85%; 2010: 83 1/3%; 2011: 81 2/3%; 2012: 80%; 2013: 78 1/3%; 2014: 76 2/3%; after 2014: 75%). Payments go into the Medicare Prescription Drug Account in the Federal Supplementary Medical Insurance Trust Fund and are made in a manner like previous state payments. If a State does not pay, interest will run at the Medicaid rate and the unpaid amount (plus interest) will be taken from other federal Medicaid payments to the State. The federal government will do data matches to count eligible people and will notify each State by October 15 before each year of the computed amount. A “full-benefit dual eligible individual” is someone who has Medicare Part D drug coverage and is determined by the State to have full Medicaid benefits for that month. U.S. territories are handled differently: the main rules do not apply, but a territory that submits a plan to provide Part D drugs to low-income Part D eligible people can get extra federal money (aggregate amounts: $28,125,000 for the last three quarters of fiscal year 2006; $37,500,000 for fiscal year 2007; later years increased by the annual percent specified in law). Those territories must use the extra funds mostly for drug help and may spend no more than 10% for administration. The Secretary must report to Congress on how these rules are applied.