Additional requirements

Official source

The following requirements shall apply with respect to the option to make an election pursuant to clause (i) under this subparagraph:

(I) Secretarial responsibilities

(I)Secretarial responsibilities#

The Secretary shall provide information to part D eligible individuals on the option to make such election through educational materials, including through the notices provided under section 1395b–2(a) of this title .

(II)Timing of election#

An enrollee in a prescription drug plan or an MA–PD plan may make such an election—

(aa) prior to the beginning of the plan year; or

(bb) in any month during the plan year.

(II)(aa)#

prior to the beginning of the plan year; or

(II)(bb)#

in any month during the plan year.

(III)PDP sponsor and MA organization responsibilities#

Each PDP sponsor offering a prescription drug plan or MA organization offering an MA–PD plan—

(aa) may not limit the option for an enrollee to make such an election to certain covered part D drugs;

(bb) shall, prior to the plan year, notify prospective enrollees of the option to make such an election in promotional materials;

(cc) shall include information on such option in enrollee educational materials;

(dd) shall have in place a mechanism to notify a pharmacy during the plan year when an enrollee incurs out-of-pocket costs with respect to covered part D drugs that make it likely the enrollee may benefit from making such an election;

(ee) shall provide that a pharmacy, after receiving a notification described in item (dd) with respect to an enrollee, informs the enrollee of such notification;

(ff) shall ensure that such an election by an enrollee has no effect on the amount paid to pharmacies (or the timing of such payments) with respect to covered part D drugs dispensed to the enrollee; and

(gg) shall have in place a financial reconciliation process to correct inaccuracies in payments made by an enrollee under this subparagraph with respect to covered part D drugs during the plan year.

(III)(aa)#

may not limit the option for an enrollee to make such an election to certain covered part D drugs;

(III)(bb)#

shall, prior to the plan year, notify prospective enrollees of the option to make such an election in promotional materials;

(IV)Failure to pay amount billed#

If an enrollee fails to pay the amount billed for a month as required under this subparagraph—

(aa) the election of the enrollee pursuant to clause (i) shall be terminated and the enrollee shall pay the cost-sharing otherwise applicable for any covered part D drugs subsequently dispensed to the enrollee up to the annual out-of-pocket threshold specified in paragraph (4)(B); and

(bb) the PDP sponsor or MA organization may preclude the enrollee from making an election pursuant to clause (i) in a subsequent plan year.

(IV)(aa)#

the election of the enrollee pursuant to clause (i) shall be terminated and the enrollee shall pay the cost-sharing otherwise applicable for any covered part D drugs subsequently dispensed to the enrollee up to the annual out-of-pocket threshold specified in paragraph (4)(B); and

(IV)(bb)#

the PDP sponsor or MA organization may preclude the enrollee from making an election pursuant to clause (i) in a subsequent plan year.

(V)Clarification regarding past due amounts#

Nothing in this subparagraph shall be construed as prohibiting a PDP sponsor or an MA organization from billing an enrollee for an amount owed under this subparagraph.

(VI)Treatment of unsettled balances#

Any unsettled balances with respect to amounts owed under this subparagraph shall be treated as plan losses and the Secretary shall not be liable for any such balances outside of those assumed as losses estimated in plan bids.

(III)PDP sponsor and MA organization responsibilities#

Each PDP sponsor offering a prescription drug plan or MA organization offering an MA–PD plan—

(aa) may not limit the option for an enrollee to make such an election to certain covered part D drugs;

(bb) shall, prior to the plan year, notify prospective enrollees of the option to make such an election in promotional materials;

(cc) shall include information on such option in enrollee educational materials;

(ee) shall provide that a pharmacy, after receiving a notification described in item (dd) with respect to an enrollee, informs the enrollee of such notification;

(gg) shall have in place a financial reconciliation process to correct inaccuracies in payments made by an enrollee under this subparagraph with respect to covered part D drugs during the plan year.

(III)(aa)#

may not limit the option for an enrollee to make such an election to certain covered part D drugs;

(III)(bb)#

shall, prior to the plan year, notify prospective enrollees of the option to make such an election in promotional materials;

(IV)Failure to pay amount billed#

If an enrollee fails to pay the amount billed for a month as required under this subparagraph—

(bb) the PDP sponsor or MA organization may preclude the enrollee from making an election pursuant to clause (i) in a subsequent plan year.

(IV)(aa)#

(IV)(bb)#

the PDP sponsor or MA organization may preclude the enrollee from making an election pursuant to clause (i) in a subsequent plan year.

Additional requirements

(I)Secretarial responsibilities#

(II)Timing of election#

(II)(aa)#

(II)(bb)#

(III)PDP sponsor and MA organization responsibilities#

(III)(aa)#

(III)(bb)#

(IV)Failure to pay amount billed#

(IV)(aa)#

(IV)(bb)#

(V)Clarification regarding past due amounts#

(VI)Treatment of unsettled balances#

Additional requirements

(I)Secretarial responsibilities#

(II)Timing of election#

(II)(aa)#

(II)(bb)#

(III)PDP sponsor and MA organization responsibilities#

(III)(aa)#

(III)(bb)#

(IV)Failure to pay amount billed#

(IV)(aa)#

(IV)(bb)#

(V)Clarification regarding past due amounts#

(VI)Treatment of unsettled balances#

(III)(cc)#

(III)(dd)#

(III)(ee)#

(III)(ff)#

(III)(gg)#