§ 1395w-111. PDP regions; submission of bids; plan approval
(a)
Establishment of PDP regions; service areas
(1)
Coverage of entire PDP region
The service area for a prescription drug plan shall consist of an entire PDP region established under paragraph (2).
(2)
Establishment of PDP regions
(B)
Relation to MA regions
To the extent practicable, PDP regions shall be the same as MA regions under section
1395w–27a
(a)(2) of this title. The Secretary may establish PDP regions which are not the same as MA regions if the Secretary determines that the establishment of different regions under this part would improve access to benefits under this part.
(b)
Submission of bids, premiums, and related information
(1)
In general
A PDP sponsor shall submit to the Secretary information described in paragraph (2) with respect to each prescription drug plan it offers. Such information shall be submitted at the same time and in a similar manner to the manner in which information described in paragraph (6) of section
1395w–24
(a) of this title is submitted by an MA organization under paragraph (1) of such section.
(2)
Information described
The information described in this paragraph is information on the following:
(A)
Coverage provided
The prescription drug coverage provided under the plan, including the deductible and other cost-sharing.
(C)
Bid
Information on the bid, including an actuarial certification of—
(ii)
the portion of such bid attributable to basic prescription drug coverage and, if applicable, the portion of such bid attributable to supplemental benefits;
(E)
Level of risk assumed
(i)
In general
Whether the PDP sponsor requires a modification of risk level under clause (ii) and, if so, the extent of such modification. Any such modification shall apply with respect to all prescription drug plans offered by a PDP sponsor in a PDP region. This subparagraph shall not apply to an MA–PD plan.
(ii)
Risk levels described
A modification of risk level under this clause may consist of one or more of the following:
(I)
Increase in Federal percentage assumed in initial risk corridor
An equal percentage point increase in the percents applied under subparagraphs (B)(i), (B)(ii)(I), (C)(i), and (C)(ii)(I) of section
1395w–115
(e)(2) of this title. In no case shall the application of previous sentence prevent the application of a higher percentage under section
1395w–115
(e)(2)(B)(iii) [1] of this title.
(3)
Paperwork reduction for offering of prescription drug plans nationally or in multi-region areas
The Secretary shall establish requirements for information submission under this subsection in a manner that promotes the offering of such plans in more than one PDP region (including all regions) through the filing of consolidated information.
(c)
Actuarial valuation
(1)
Processes
For purposes of this part, the Secretary shall establish processes and methods for determining the actuarial valuation of prescription drug coverage, including—
(A)
an actuarial valuation of standard prescription drug coverage under section
1395w–102
(b) of this title;
(B)
actuarial valuations relating to alternative prescription drug coverage under section
1395w–102
(c)(1) of this title;
(2)
Accounting for drug utilization
Such processes and methods for determining actuarial valuation shall take into account the effect that providing alternative prescription drug coverage (rather than standard prescription drug coverage) has on drug utilization.
(d)
Review of information and negotiation
(1)
Review of information
The Secretary shall review the information filed under subsection (b) of this section for the purpose of conducting negotiations under paragraph (2).
(e)
Approval of proposed plans
(1)
In general
After review and negotiation under subsection (d) of this section, the Secretary shall approve or disapprove the prescription drug plan.
(2)
Requirements for approval
The Secretary may approve a prescription drug plan only if the following requirements are met:
(A)
Compliance with requirements
The plan and the PDP sponsor offering the plan comply with the requirements under this part, including the provision of qualified prescription drug coverage.
(C)
Application of FEHBP standard
(i)
In general
The Secretary determines that the portion of the bid submitted under subsection (b) of this section that is attributable to basic prescription drug coverage is supported by the actuarial bases provided under such subsection and reasonably and equitably reflects the revenue requirements (as used for purposes of section
300e–1
(8)(C) of this title) for benefits provided under that plan, less the sum (determined on a monthly per capita basis) of the actuarial value of the reinsurance payments under section
1395w–115
(b) of this title.
(ii)
Supplemental coverage
The Secretary determines that the portion of the bid submitted under subsection (b) of this section that is attributable to supplemental prescription drug coverage pursuant to section
1395w–102
(a)(2) of this title is supported by the actuarial bases provided under such subsection and reasonably and equitably reflects the revenue requirements (as used for purposes of section
300e–1
(8)(C) of this title) for such coverage under the plan.
(D)
Plan design
(i)
In general
The Secretary does not find that the design of the plan and its benefits (including any formulary and tiered formulary structure) are likely to substantially discourage enrollment by certain part D eligible individuals under the plan.
(ii)
Use of categories and classes in formularies
The Secretary may not find that the design of categories and classes within a formulary violates clause (i) if such categories and classes are consistent with guidelines (if any) for such categories and classes established by the United States Pharmacopeia.
(f)
Application of limited risk plans
(1)
Conditions for approval of limited risk plans
The Secretary may only approve a limited risk plan (as defined in paragraph (4)(A)) for a PDP region if the access requirements under section
1395w–103
(a) of this title would not be met for the region but for the approval of such a plan (or a fallback prescription drug plan under subsection (g) of this section).
(2)
Rules
The following rules shall apply with respect to the approval of a limited risk plan in a PDP region:
(3)
Acceptance of all full risk contracts
There shall be no limit on the number of full risk plans that are approved under subsection (e) of this section.
(4)
Risk-plans defined
For purposes of this subsection:
(A)
Limited risk plan
The term “limited risk plan” means a prescription drug plan that provides basic prescription drug coverage and for which the PDP sponsor includes a modification of risk level described in subparagraph (E) of subsection (b)(2) of this section in its bid submitted for the plan under such subsection. Such term does not include a fallback prescription drug plan.
(g)
Guaranteeing access to coverage
(1)
Solicitation of bids
(A)
In general
Separate from the bidding process under subsection (b) of this section, the Secretary shall provide for a process for the solicitation of bids from eligible fallback entities (as defined in paragraph (2)) for the offering in all fallback service areas (as defined in paragraph (3)) in one or more PDP regions of a fallback prescription drug plan (as defined in paragraph (4)) during the contract period specified in paragraph (5).
(B)
Acceptance of bids
(i)
In general
Except as provided in this subparagraph, the provisions of subsection (e) of this section shall apply with respect to the approval or disapproval of fallback prescription drug plans. The Secretary shall enter into contracts under this subsection with eligible fallback entities for the offering of fallback prescription drug plans so approved in fallback service areas.
(ii)
Limitation of 1 plan for all fallback service areas in a PDP region
With respect to all fallback service areas in any PDP region for a contract period, the Secretary shall approve the offering of only 1 fallback prescription drug plan.
(iii)
Competitive procedures
Competitive procedures (as defined in section
403
(5) of title
41) shall be used to enter into a contract under this subsection. The provisions of subsection (d) of section
1395kk–1 of this title shall apply to a contract under this section in the same manner as they apply to a contract under such section.
(iv)
Timing
The Secretary shall approve a fallback prescription drug plan for a PDP region in a manner so that, if there are any fallback service areas in the region for a year, the fallback prescription drug plan is offered at the same time as prescription drug plans would otherwise be offered.
(V)
[2] No national fallback plan
The Secretary shall not enter into a contract with a single fallback entity for the offering of fallback plans throughout the United States.
(2)
Eligible fallback entity
For purposes of this section, the term “eligible fallback entity” means, with respect to all fallback service areas in a PDP region for a contract period, an entity that—
(A)
meets the requirements to be a PDP sponsor (or would meet such requirements but for the fact that the entity is not a risk-bearing entity); and
(B)
does not submit a bid under subsection (b) of this section for any prescription drug plan for any PDP region for the first year of such contract period.
For purposes of subparagraph (B), an entity shall be treated as submitting a bid with respect to a prescription drug plan if the entity is acting as a subcontractor of a PDP sponsor that is offering such a plan. The previous sentence shall not apply to entities that are subcontractors of an MA organization except insofar as such organization is acting as a PDP sponsor with respect to a prescription drug plan.
(3)
Fallback service area
For purposes of this subsection, the term “fallback service area” means, for a PDP region with respect to a year, any area within such region for which the Secretary determines before the beginning of the year that the access requirements of the first sentence of section
1395w–103
(a) of this title will not be met for part D eligible individuals residing in the area for the year.
(4)
Fallback prescription drug plan
For purposes of this part, the term “fallback prescription drug plan” means a prescription drug plan that—
(5)
Payments under the contract
(A)
In general
A contract entered into under this subsection shall provide for—
(B)
Performance measures
The performance measures established by the Secretary pursuant to subparagraph (A)(ii) shall include at least measures for each of the following:
(i)
Costs
The entity contains costs to the Medicare Prescription Drug Account and to part D eligible individuals enrolled in a fallback prescription drug plan offered by the entity through mechanisms such as generic substitution and price discounts.
(ii)
Quality programs
The entity provides such enrollees with quality programs that avoid adverse drug reactions and overutilization and reduce medical errors.
(6)
Monthly beneficiary premium
Except as provided in section
1395w–113
(b) of this title (relating to late enrollment penalty) and subject to section
1395w–114 of this title (relating to low-income assistance), the monthly beneficiary premium to be charged under a fallback prescription drug plan offered in all fallback service areas in a PDP region shall be uniform and shall be equal to 25.5 percent of an amount equal to the Secretary’s estimate of the average monthly per capita actuarial cost, including administrative expenses, under the fallback prescription drug plan of providing coverage in the region, as calculated by the Chief Actuary of the Centers for Medicare & Medicaid Services. In calculating such administrative expenses, the Chief Actuary shall use a factor that is based on similar expenses of prescription drug plans that are not fallback prescription drug plans.
(7)
General contract terms and conditions
(A)
In general
Except as may be appropriate to carry out this section, the terms and conditions of contracts with eligible fallback entities offering fallback prescription drug plans under this subsection shall be the same as the terms and conditions of contracts under this part for prescription drug plans.
(h)
Annual report on use of limited risk plans and fallback plans
The Secretary shall submit to Congress an annual report that describes instances in which limited risk plans and fallback prescription drug plans were offered under subsections (f) and (g) of this section. The Secretary shall include in such report such recommendations as may be appropriate to limit the need for the provision of such plans and to maximize the assumption of financial risk under section subsection (f) of this section.
(i)
Noninterference
In order to promote competition under this part and in carrying out this part, the Secretary—
(j)
Coordination of benefits
A PDP sponsor offering a prescription drug plan shall permit State Pharmaceutical Assistance Programs and Rx plans under sections
1395w–133 and
1395w–134 of this title to coordinate benefits with the plan and, in connection with such coordination with such a Program, not to impose fees that are unrelated to the cost of coordination.
[1] See References in Text note below.
[2] So in original. Probably should be “(v)”.