42 U.S.C. § 1396u–5 | Special provisions relating to medicare prescription drug benefit

(a)

Requirements relating to medicare prescription drug low-income subsidies, medicare transitional prescription drug assistance, and medicare cost-sharing

section 1396a(a)(66) of this title section 1396b(a) of this titleAs a condition of its State plan under this subchapter under and receipt of any Federal financial assistance under subject to subsection (e), a State shall do the following:

(1)

Information for transitional prescription drug assistance verification

section 1395w–141(f)(3)(B)(i) of this titleThe State shall provide the Secretary with information to carry out .

(2)

Eligibility determinations for low-income subsidies

The State shall—

(A)

section 1395w–114 of this title make determinations of eligibility for premium and cost-sharing subsidies under and in accordance with ;

(B)

inform the Secretary of such determinations in cases in which such eligibility is established; and

(C)

section 1395w–114 of this title otherwise provide the Secretary with such information as may be required to carry out part D, other than subpart 4, of subchapter XVIII (including ).

(3)

Screening for eligibility, and enrollment of, beneficiaries for medicare cost-sharing

section 1396d(p)(3) of this titleAs part of making an eligibility determination required under paragraph (2) for an individual, the State shall make a determination of the individual’s eligibility for medical assistance for any medicare cost-sharing described in and, if the individual is eligible for any such medicare cost-sharing, offer enrollment to the individual under the State plan (or under a waiver of such plan).

(4)

Consideration of data transmitted by the Social Security Administration for purposes of Medicare Savings Program

section 1320b–14(c)(3) of this titleThe State shall accept data transmitted under and act on such data in the same manner and in accordance with the same deadlines as if the data constituted an initiation of an application for benefits under the Medicare Savings Program (as defined for purposes of such section) that had been submitted directly by the applicant. The date of the individual’s application for the low income subsidy program from which the data have been derived shall constitute the date of filing of such application for benefits under the Medicare Savings Program.

(b)

Regular Federal subsidy of administrative costs

section 1396b(a) of this titleThe amounts expended by a State in carrying out subsection (a) are expenditures reimbursable under the appropriate paragraph of .

(c)

Federal assumption of medicaid prescription drug costs for dually eligible individuals

(1)

Phased-down State contribution

(A)

In general

Each of the 50 States and the District of Columbia for each month beginning with January 2006 shall provide for payment under this subsection to the Secretary of the product of—

(i)

the amount computed under paragraph (2)(A) for the State and month;

(ii)

the total number of full-benefit dual eligible individuals (as defined in paragraph (6)) for such State and month; and

(iii)

the factor for the month specified in paragraph (5).

(B)

Form and manner of payment

section 1395v of this titlePayment under subparagraph (A) shall be made in a manner specified by the Secretary that is similar to the manner in which State payments are made under an agreement entered into under , except that all such payments shall be deposited into the Medicare Prescription Drug Account in the Federal Supplementary Medical Insurance Trust Fund.

(C)

Compliance

section 1396b(d)(5) of this title section 1396b(a) of this title 1

1 See References in Text note below.

If a State fails to pay to the Secretary an amount required under subparagraph (A), interest shall accrue on such amount at the rate provided under . The amount so owed and applicable interest shall be immediately offset against amounts otherwise payable to the State under subject to subsection (e), in accordance with the Federal Claims Collection Act of 1996  and applicable regulations.

(D)

Data match

The Secretary shall perform such periodic data matches as may be necessary to identify and compute the number of full-benefit dual eligible individuals for purposes of computing the amount under subparagraph (A).

(2)

Amount

(A)

In general

The amount computed under this paragraph for a State described in paragraph (1) and for a month in a year is equal to—

(i)

¹₁₂ ⁄ of the product of—

(I)

the base year State medicaid per capita expenditures for covered part D drugs for full-benefit dual eligible individuals (as computed under paragraph (3)); and

(II)

section 1396d(b) of this title a proportion equal to 100 percent minus the Federal medical assistance percentage (as defined in ) applicable to the State for the fiscal year in which the month occurs; and

(ii)

increased for each year (beginning with 2004 up to and including the year involved) by the applicable growth factor specified in paragraph (4) for that year.

(B)

Notice

The Secretary shall notify each State described in paragraph (1) not later than October 15 before the beginning of each year (beginning with 2006) of the amount computed under subparagraph (A) for the State for that year.

(3)

Base year state medicaid per capita expenditures for covered part D drugs for full-benefit dual eligible individuals

(A)

In general

For purposes of paragraph (2)(A), the “base year State medicaid per capita expenditures for covered part D drugs for full-benefit dual eligible individuals” for a State is equal to the weighted average (as weighted under subparagraph (C)) of—

(i)

the gross per capita medicaid expenditures for prescription drugs for 2003, determined under subparagraph (B); and

(ii)

the estimated actuarial value of prescription drug benefits provided under a capitated managed care plan per full-benefit dual eligible individual for 2003, as determined using such data as the Secretary determines appropriate.

(B)

Gross per capita medicaid expenditures for prescription drugs

(i)

In general

The gross per capita medicaid expenditures for prescription drugs for 2003 under this subparagraph is equal to the expenditures, including dispensing fees, for the State under this subchapter during 2003 for covered outpatient drugs, determined per full-benefit-dual-eligible-individual for such individuals not receiving medical assistance for such drugs through a medicaid managed care plan.

(ii)

Determination

In determining the amount under clause (i), the Secretary shall—

(I)

use data from the Medicaid Statistical Information System (MSIS) and other available data;

(II)

section 1395w–102(e) of this title section 1396r–8(d)(2) of this title exclude expenditures attributable to covered outpatient prescription drugs that are not covered part D drugs (as defined in , including drugs described in subparagraph (K) of ); and

(III)

reduce such expenditures by the product of such portion and the adjustment factor (described in clause (iii)).

(iii)

Adjustment factor

The adjustment factor described in this clause for a State is equal to the ratio for the State for 2003 of—

(I)

section 1396r–8 of this title aggregate payments under agreements under ; to

(II)

the gross expenditures under this subchapter for covered outpatient drugs referred to in clause (i).

Such factor shall be determined based on information reported by the State in the medicaid financial management reports (form CMS–64) for the 4 quarters of calendar year 2003 and such other data as the Secretary may require.

(C)

Weighted average

The weighted average under subparagraph (A) shall be determined taking into account—

(i)

with respect to subparagraph (A)(i), the average number of full-benefit dual eligible individuals in 2003 who are not described in clause (ii); and

(ii)

with respect to subparagraph (A)(ii), the average number of full-benefit dual eligible individuals in such year who received in 2003 medical assistance for covered outpatient drugs through a medicaid managed care plan.

(4)

Applicable growth factor

The applicable growth factor under this paragraph for—

(A)

each of 2004, 2005, and 2006, is the average annual percent change (to that year from the previous year) of the per capita amount of prescription drug expenditures (as determined based on the most recent National Health Expenditure projections for the years involved); and

(B)

section 1395w–102(b)(6) of this title a succeeding year, is the annual percentage increase specified in for the year.

(5)

Factor

The factor under this paragraph for a month—

(A)

in 2006 is 90 percent;

(B)

in 2007 is 88⅓ percent;

(C)

in 2008 is 86⅔ percent;

(D)

in 2009 is 85 percent;

(E)

in 2010 is 83⅓ percent;

(F)

in 2011 is 81⅔ percent;

(G)

in 2012 is 80 percent;

(H)

in 2013 is 78⅓ percent;

(I)

in 2014 is 76⅔ percent; or

(J)

after December 2014, is 75 percent.

(6)

Full-benefit dual eligible individual defined

(A)

In general

For purposes of this section, the term “full-benefit dual eligible individual” means for a State for a month an individual who—

(i)

has coverage for the month for covered part D drugs under a prescription drug plan under part D of subchapter XVIII, or under an MA–PD plan under part C of such subchapter; and

(ii)

section 1396a(f) of this title is determined eligible by the State for medical assistance for full benefits under this subchapter for such month under section 1396a(a)(10)(A) or 1396a(a)(10)(C) of this title, by reason of , or under any other category of eligibility for medical assistance for full benefits under this subchapter, as determined by the Secretary.

(B)

Treatment of medically needy and other individuals required to spend down

section 1396a(a)(10)(C) of this title section 1396a(f) of this titleIn applying subparagraph (A) in the case of an individual determined to be eligible by the State for medical assistance under or by reason of , the individual shall be treated as meeting the requirement of subparagraph (A)(ii) for any month if such medical assistance is provided for in any part of the month.

(d)

Coordination of prescription drug benefits

(1)

Medicare as primary payor

section 1395w–101(a)(3)(A) of this title section 1396b(a) of this titleIn the case of a part D eligible individual (as defined in ) who is described in subsection (c)(6)(A)(ii), notwithstanding any other provision of this subchapter, medical assistance is not available under this subchapter for such drugs (or for any cost-sharing respecting such drugs), and the rules under this subchapter relating to the provision of medical assistance for such drugs shall not apply. The provision of benefits with respect to such drugs shall not be considered as the provision of care or services under the plan under this subchapter. No payment may be made under for prescribed drugs for which medical assistance is not available pursuant to this paragraph.

(2)

Coverage of certain excludable drugs

In the case of medical assistance under this subchapter with respect to a covered outpatient drug (other than a covered part D drug) furnished to an individual who is enrolled in a prescription drug plan under part D of subchapter XVIII or an MA–PD plan under part C of such subchapter, the State may elect to provide such medical assistance in the manner otherwise provided in the case of individuals who are not full-benefit dual eligible individuals or through an arrangement with such plan.

(e)

Treatment of territories

(1)

In general

In the case of a State, other than the 50 States and the District of Columbia—

(A)

the previous provisions of this section shall not apply to residents of such State; and

(B)

section 1308(f) of this title section 1308(g) of this title subject to paragraph (4), if the State establishes and submits to the Secretary a plan described in paragraph (2) (for providing medical assistance with respect to the provision of prescription drugs to part D eligible individuals), the amount otherwise determined under (as increased under ) for the State shall be increased by the amount for the fiscal period specified in paragraph (3).

(2)

Plan

The Secretary shall determine that a plan is described in this paragraph if the plan—

(A)

section 1395w–102(e) of this title provides medical assistance with respect to the provision of covered part D drugs (as defined in ) to low-income part D eligible individuals;

(B)

provides assurances that additional amounts received by the State that are attributable to the operation of this subsection shall be used only for such assistance and related administrative expenses and that no more than 10 percent of the amount specified in paragraph (3)(A) for the State for any fiscal period shall be used for such administrative expenses; and

(C)

meets such other criteria as the Secretary may establish.

(3)

Increased amount

(A)

In general

The amount specified in this paragraph for a State for a year is equal to the product of—

(i)

the aggregate amount specified in subparagraph (B); and

(ii)

the ratio (as estimated by the Secretary) of—

(I)

¹¹ the number of individuals who are entitled to benefits under part A  or enrolled under part B  and who reside in the State (as determined by the Secretary based on the most recent available data before the beginning of the year); to

(II)

the sum of such numbers for all States that submit a plan described in paragraph (2).

(B)

Aggregate amount

The aggregate amount specified in this subparagraph for—

(i)

the last 3 quarters of fiscal year 2006, is equal to $28,125,000;

(ii)

fiscal year 2007, is equal to $37,500,000; or

(iii)

section 1395w–102(b)(6) of this title a subsequent year, is equal to the aggregate amount specified in this subparagraph for the previous year increased by annual percentage increase specified in for the year involved.

(4)

Treatment of funding for certain fiscal years

section 1308(g)(2) of this titleNotwithstanding paragraph (1)(B), in the case that Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, or American Samoa establishes and submits to the Secretary a plan described in paragraph (2) with respect to any of fiscal years 2020 through 2021, the amount specified for such a year in paragraph (3) for Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, or American Samoa, as the case may be, shall be taken into account in applying, as applicable, subparagraph (A)(ii), (B)(ii), (C)(ii), (D)(ii), or (E)(ii) of for such year.

(5)

Report

The Secretary shall submit to Congress a report on the application of this subsection and may include in the report such recommendations as the Secretary deems appropriate.

Aug. 14, 1935, ch. 531 Pub. L. 108–173, title I, § 103(a)(2)(B)Dec. 8, 2003117 Stat. 2154–2158 Pub. L. 109–91, title I, § 104(c)Oct. 20, 2005119 Stat. 2093 Pub. L. 110–275, title I, § 113(b)July 15, 2008122 Stat. 2506 Pub. L. 116–94, div. N, title I, § 202(b)Dec. 20, 2019133 Stat. 3107(, title XIX, § 1935, as added and amended , (b)–(d)(1), , ; , , ; , , ; , , .)

Editorial Notes

References in Text

Pub. L. 89–508July 19, 196680 Stat. 308 Pub. L. 89–508 Pub. L. 97–258, § 5(b)Sept. 13, 198296 Stat. 877 section 101 of Title 31 Pub. L. 89–508No act with the title Federal Claims Collection Act of 1996, referred to in subsec. (c)(1)(C), has been enacted. However, , , , was known as the Federal Claims Collection Act of 1966. Sections 2, 3, and 5 of , which enacted sections 951, 952, and 954, respectively, of former Title 31, Money and Finance, were repealed by , , , the first section of which enacted Title 31, Money and Finance. For disposition of sections of former Title 31 into revised Title 31, see Table preceding . For complete classification of to the Code, see Tables.

Parts A and B, referred to in subsec. (e)(3)(A)(ii)(I), probably means parts A and B of subchapter XVIII of this chapter. This subchapter does not contain parts.

Prior Provisions

Aug. 14, 1935section 1396v of this titleA prior section 1935 of act , was renumbered section 1939 and is classified to .

Amendments

Pub. L. 116–94, § 202(b)(1)2019—Subsec. (e)(1)(B). , substituted “subject to paragraph (4), if the State” for “if the State”.

Pub. L. 116–94, § 202(b)(2)Subsec. (e)(4), (5). , (3), added par. (4) and redesignated former par. (4) as (5).

Pub. L. 110–2752008—Subsec. (a). amended heading to include reference to medicare cost-sharing and added par. (4).

Pub. L. 109–91 section 1396r–8(d)(2) of this title section 1395w–102(e) of this title2005—Subsec. (c)(3)(B)(ii)(II). inserted “, including drugs described in subparagraph (K) of ” after “”.

Pub. L. 108–173, § 103(d)(1)(A)section 1396b(a) of this title2003—Subsec. (a). , inserted “subject to subsection (e)” after “” in introductory provisions.

Pub. L. 108–173, § 103(b)Subsec. (c). , added subsec. (c).

Pub. L. 108–173, § 103(d)(1)(B)section 1396b(a)(1) of this title section 1396b(a) of this titleSubsec. (c)(1)(C). , which directed the amendment of subsec. (c)(1) by inserting “subject to subsection (e)” after “”, was executed by making the insertion after “” in subpar. (C) to reflect the probable intent of Congress.

Pub. L. 108–173, § 103(c)Subsec. (d). , added subsec. (d).

Pub. L. 108–173, § 103(d)(1)(C)Subsec. (e). , added subsec. (e).

Statutory Notes and Related Subsidiaries

Effective Date of 2008 Amendment

Pub. L. 110–275Jan. 1, 2010section 113(c) of Pub. L. 110–275 section 1320b–14 of this titleAmendment by effective , see , set out as a note under .

Effective Date of 2005 Amendment

Pub. L. 109–91Jan. 1, 2006section 104(d) of Pub. L. 109–91 section 1396b of this titleAmendment by applicable to drugs dispensed on or after , see , set out as a note under .