US Code

Public Law 119-73 (01/23/2026)

42 U.S.C. § 1395w–131

Application to Medicare Advantage program and related managed care programs

(a)

Special rules relating to offering of qualified prescription drug coverage

(1)

In general

An MA organization on and after —
(A)
section 1395w–21(a)(2)(A) of this title may not offer an MA plan described in in an area unless either that plan (or another MA plan offered by the organization in that same service area) includes required prescription drug coverage (as defined in paragraph (2)); and
(B)
may not offer prescription drug coverage (other than that required under parts A and B) to an enrollee—
(i)
under an MSA plan; or
(ii)
under another MA plan unless such drug coverage under such other plan provides qualified prescription drug coverage and unless the requirements of this section with respect to such coverage are met.
(2)

Qualifying coverage

For purposes of paragraph (1)(A), the term “required coverage” means with respect to an MA–PD plan—
(A)
basic prescription drug coverage; or
(B)
section 1395w–24(b)(1)(C) of this title qualified prescription drug coverage that provides supplemental prescription drug coverage, so long as there is no MA monthly supplemental beneficiary premium applied under the plan (due to the application of a credit against such premium of a rebate under ).
(b)

Application of default enrollment rules

(1)

Seamless continuation

section 1395w–21(c)(3)(A)(ii) of this titleIn applying , an individual who is enrolled in a health benefits plan shall not be considered to have been deemed to make an election into an MA–PD plan unless such health benefits plan provides any prescription drug coverage.

(2)

MA continuation

section 1395w–21(c)(3)(B) of this titleIn applying , an individual who is enrolled in an MA plan shall not be considered to have been deemed to make an election into an MA–PD plan unless—
(A)
for purposes of the election as of , the MA plan provided as of , any prescription drug coverage; or
(B)
for periods after , such MA plan is an MA–PD plan.
(3)

Discontinuance of MA–PD election during first year of eligibility

section 1395w–21(e)(4) of this titleIn applying the second sentence of in the case of an individual who is electing to discontinue enrollment in an MA–PD plan, the individual shall be permitted to enroll in a prescription drug plan under part D at the time of the election of coverage under the original medicare fee-for-service program.

(4)

Rules regarding enrollees in MA plans not providing qualified prescription drug coverage

In the case of an individual who is enrolled in an MA plan (other than an MSA plan) that does not provide qualified prescription drug coverage, if the organization offering such coverage discontinues the offering with respect to the individual of all MA plans that do not provide such coverage—
(i)
the individual is deemed to have elected the original medicare fee-for-service program option, unless the individual affirmatively elects to enroll in an MA–PD plan; and
(ii)
section 1395ss(s)(3) of this title in the case of such a deemed election, the disenrollment shall be treated as an involuntary termination of the MA plan described in subparagraph (B)(ii) of for purposes of applying such section.
section 1395w–22(c)(1) of this titleThe information disclosed under for individuals who are enrolled in such an MA plan shall include information regarding such rules.
(c)

Application of part D rules for prescription drug coverage

With respect to the offering of qualified prescription drug coverage by an MA organization under this part on and after —
(1)

In general

Except as otherwise provided, the provisions of this part shall apply under part C with respect to prescription drug coverage provided under MA–PD plans in lieu of the other provisions of part C that would apply to such coverage under such plans.

(2)

Waiver

The Secretary shall waive the provisions referred to in paragraph (1) to the extent the Secretary determines that such provisions duplicate, or are in conflict with, provisions otherwise applicable to the organization or plan under part C or as may be necessary in order to improve coordination of this part with the benefits under this part.

(3)

Treatment of MA owned and operated pharmacies

section 1395w–104(b)(1)(C) of this titleThe Secretary may waive the requirement of in the case of an MA–PD plan that provides access (other than mail order) to qualified prescription drug coverage through pharmacies owned and operated by the MA organization, if the Secretary determines that the organization’s pharmacy network is sufficient to provide comparable access for enrollees under the plan.

(d)

Special rules for private fee-for-service plans that offer prescription drug coverage

section 1395w–21(a)(2)(C) of this titleWith respect to an MA plan described in that offers qualified prescription drug coverage, on and after , the following rules apply:
(1)

Requirements regarding negotiated prices

section 1395w–102 of this titlesection 1395w–104(b)(2)(A) of this titleSubsections (a)(1) and (d)(1) of and shall not be construed to require the plan to provide negotiated prices (described in subsection (d)(1)(B) of such section), but shall apply to the extent the plan does so.

(2)

Modification of pharmacy access standard and disclosure requirement

section 1395w–104 of this titleIf the plan provides coverage for drugs purchased from all pharmacies, without charging additional cost-sharing, and without regard to whether they are participating pharmacies in a network or have entered into contracts or agreements with pharmacies to provide drugs to enrollees covered by the plan, subsections (b)(1)(C) and (k) of shall not apply to the plan.

(3)

Drug utilization management program and medication therapy management program not required

section 1395w–104(c)(1) of this titleThe requirements of subparagraphs (A) and (C) of shall not apply to the plan.

(4)

Application of reinsurance

section 1395w–115(b) of this titleThe Secretary shall determine the amount of reinsurance payments under using a methodology that—
(A)
section 1395w–21(a)(2)(A)(i) of this title bases such amount on the Secretary’s estimate of the amount of such payments that would be payable if the plan were an MA–PD plan described in and the previous provisions of this subsection did not apply; and
(B)
section 1395w–115(b) of this title takes into account the average reinsurance payments made under for populations of similar risk under MA–PD plans described in such section.
(5)

Exemption from risk corridor provisions

section 1395w–115(e) of this titleThe provisions of shall not apply.

(6)

Exemption from negotiations

section 1395w–111 of this titlesection 1395w–24(a)(5)(B) of this titlesection 1395w–111(d) of this titleSubsections (d) and (e)(2)(C) of shall not apply and the provisions of prohibiting the review, approval, or disapproval of amounts described in such section shall apply to the proposed bid and terms and conditions described in .

(7)

Treatment of incurred costs without regard to formulary

section 1395w–102(b)(4)(C)(i) of this titleThe exclusion of costs incurred for covered part D drugs which are not included (or treated as being included) in a plan’s formulary under shall not apply insofar as the plan does not utilize a formulary.

(e)

Application to reasonable cost reimbursement contractors

(1)

In general

section 1395mm(h) of this titlesection 1395–21(a)(2)(A)(i) of this titleSubject to paragraphs (2) and (3) and rules established by the Secretary, in the case of an organization that is providing benefits under a reasonable cost reimbursement contract under and that elects to provide qualified prescription drug coverage to a part D eligible individual who is enrolled under such a contract, the provisions of this part (and related provisions of part C) shall apply to the provision of such coverage to such enrollee in the same manner as such provisions apply to the provision of such coverage under an MA–PD local plan described in and coverage under such a contract that so provides qualified prescription drug coverage shall be deemed to be an MA–PD local plan.

(2)

Limitation on enrollment

In applying paragraph (1), the organization may not enroll part D eligible individuals who are not enrolled under the reasonable cost reimbursement contract involved.

(3)

Bids not included in determining national average monthly bid amount

The bid of an organization offering prescription drug coverage under this subsection shall not be taken into account in computing the national average monthly bid amount and low-income benchmark premium amount under this part.

(f)

Application to PACE

(1)

In general

section 1395eee of this titlesection 1395w–21(a)(2)(A)(ii) of this titleSubject to paragraphs (2) and (3) and rules established by the Secretary, in the case of a PACE program under that elects to provide qualified prescription drug coverage to a part D eligible individual who is enrolled under such program, the provisions of this part (and related provisions of part C) shall apply to the provision of such coverage to such enrollee in a manner that is similar to the manner in which such provisions apply to the provision of such coverage under an MA–PD local plan described in and a PACE program that so provides such coverage may be deemed to be an MA–PD local plan.

(2)

Limitation on enrollment

In applying paragraph (1), the organization may not enroll part D eligible individuals who are not enrolled under the PACE program involved.

(3)

Bids not included in determining standardized bid amount

The bid of an organization offering prescription drug coverage under this subsection is not be taken into account in computing any average benchmark bid amount and low-income benchmark premium amount under this part.

Aug. 14, 1935, ch. 531Pub. L. 108–173, title I, § 101(a)(2)117 Stat. 2122Pub. L. 117–169, title I, § 11201(e)(4)136 Stat. 1891(, title XVIII, § 1860D–21, as added , , ; amended , , .)

Editorial Notes

Amendments

Pub. L. 117–1692022—Subsec. (d)(7). substituted “section 1395w–102(b)(4)(C)(i)” for “section 1395w–102(b)(4)(B)(i)”.