House Bill. New Section 1860D-1 would specify that PDP sponsors and MA or EFFS organizations providing qualified prescription drug coverage could not deny, limit, or condition the coverage or provision of benefits or increase the premium based on any health-related status factor in the case of persons who maintained continuous prescription drug coverage since the date they first qualified to elect drug coverage under Part D. Individuals who did not maintain continuous coverage could be subject to an adjusted premium or a pre-existing condition exclusion in a manner reflecting the additional actuarial risk involved. Such risk would be established through an appropriate actuarial opinion. The Administrator would provide a mechanism for assisting sponsors and entities in identifying eligible individuals who had, or had not, maintained continuous coverage. The provision would specify that an individual would be considered to have had continuous prescription drug coverage if the individual established that he or she had coverage under one of the following (and coverage in one plan occurred no more than 63 days after termination of coverage in another plan): 1) qualified prescription drug coverage under a PDP or MA Rx or EFFS Rx plan; 2) Medicaid prescription drug coverage; 3) prescription drug coverage under a group health plan, but only if benefits were at least equivalent to benefits under a qualified PDP; 4) prescription drug coverage under a Medigap plan, but only if the policy was in effect on January 1, 2006, and only if the benefits were at least equivalent to benefits under a qualified PDP; 5) state pharmaceutical assistance program, but only if benefits were at least equivalent to benefits under a qualified PDP; and 6) veterans coverage for prescription drugs, but only if benefits were at least equivalent to benefits under a qualified PDP. Individuals could apply to the Administrator to waive the requirement that such coverage be at least equivalent to benefits under a qualified prescription drug plan. They could make such application if they could establish that they were not adequately informed that the coverage did not provide such level of coverage. New Section 1860D-6 would specify that the bid and premium for a PDP could not vary among individuals enrolled in the plan in the same service area, provided they were not subject to late enrollment penalties. A PDP sponsor would permit each enrollee to have their premiums withheld from their Social Security checks...
House Bill. The New Section 1860D-7 would provide income-related subsidies for low-income individuals. Low-income persons would receive a premium subsidy (based on the value of standard coverage). Individuals with incomes below 135% of poverty would have a subsidy equal to 100% of the value of standard drug coverage provided under the plan. For individuals between 135% and 150% of poverty, there would be a sliding scale premium subsidy ranging from 100% of such value at 135% of poverty to 0% of such value at 150% of poverty. For those with incomes under 135% of poverty, beneficiary cost-sharing for spending up to the initial coverage limit would be reduced to an amount not to exceed $2 for a multiple source or generic drug and $5 for a non-preferred drug. Sponsors and entities could not charge individuals receiving cost-sharing subsidies more than $5 per prescription. (Beginning in 2007, these amounts would be increased by the percentage increase in per capita beneficiary drug costs.) Sponsors and entities could reduce to zero the cost-sharing otherwise applicable for generic drugs. In 2006, persons eligible for low-income subsidies would have to have resources at or below three times the level applicable for the Supplemental Security Income program (i.e. $6,000 for an individual and $9,000 for a couple). Beginning in 2007, these amounts would be increased by the annual percentage increase in the consumer price index. The determination of whether an individual was a subsidy eligible individual, and the amount of the subsidy, would be made by the State Medicaid program or the Social Security Administration. Such funds as necessary would be appropriated to the Social Security Administration. Individuals not in the 50 states or the District of Columbia could not be subsidy eligible individuals but could be eligible for financial assistance with drug costs under new Section 1935(e) added by Section 103. The premium subsidy amount would be defined as the benchmark premium amount for the qualified prescription drug coverage that the beneficiary selects whether offered by a PDP plan or an MA Rx or EFFS Rx plan in the area. The benchmark premium amount for a plan means the premium amount for enrollment under the plan (without regard to any subsidies or late enrollment penalties) for standard coverage (or alternative coverage if the actuarial value was equivalent). If a plan provided alternative coverage with a higher actuarial value than that for standard coverage, the benchm...
House Bill. The provision would require the Secretary to establish a program to: 1) endorse prescription drug discount card programs meeting certain requirements; 2) provide for prescription drug accounts; and 3) make available information on such programs to beneficiaries. The Secretary would begin operation of the endorsement program within 90 days of enactment. The account part of the program would begin no later than September 2004. The Secretary would provide for an appropriate transition and termination of the program on January 1, 2006. The program would be voluntary. Eligible beneficiaries would be defined as persons eligible under Part A or enrolled in Part B, but not enrolled in an MA plan offering qualified prescription drug coverage. The Secretary would establish a process through which an Part D eligible individual could make an election to enroll under the new Section 1807 with an endorsed program. The beneficiary would have to enroll for a year in order to receive the benefits for the year. An individual would, in general have only one opportunity for enrollment. This would occur during an initial, general enrollment period as soon as possible after enactment, and annually thereafter. The annual open enrollment periods would be coordinated with those for MA. An individual who enrolled in the new Section 1807, subsequently enrolled in an MA plan with drug coverage, and then discontinued such MA enrollment would be permitted to reenroll under Section 1807. In general, eligible beneficiaries would not be permitted to enroll after their initial enrollment period (as defined under Part B). The Secretary would establish an open enrollment period for current beneficiaries. The Secretary would establish a process through which an Part D eligible individual, enrolled under the new Section 1807, would select an eligible entity to provide access to negotiated prices. The entity would be one, which had been awarded a contract and served the state in which the beneficiary resided. Eligible entities would be pharmaceutical benefit management companies, wholesale and retail pharmacy delivery systems, insurers, MA organizations, other entities, or any combination of these. The enrollment process, established by the Secretary, would use rules similar to those established for MA. Individuals could not select more than one entity at a time and, except for unusual circumstances (including changing residential setting, such as nursing home placement.) change the selection o...
House Bill. The reporting deadline for ACRs and other information would permanently move to July 1 of each year. The annual coordinated election period would be permanently changed to November 15 through December 31. The announcement of payment rates, including rates for EFFS plans, would be permanently moved to no later than the second Monday in May. In addition to the information dissemination required under current law, the Secretary would be required to provide beneficiaries with a list of plans that are or would be available in an area, to the extent the information was available at the time the materials were prepared for mailing. Senate Bill Each MA organization would be required to submit information by the second Monday in September, including: 1) notice of intent and information on the service area of the plan; 2) the plan type for each plan; 3) specific information for coordinated care and PFFS plans; 4) enrollment capacity; 5) the expected mix of enrollees, by health status; and 6) other information specified by the Secretary. Medicare beneficiaries would retain their ability to make and change elections to a Medicare+Choice plan through 2005. The current law limitation on changing elections that begins in 2005, would be delayed until 2006. Further, the annual coordinated election period for 2003 through 2006 would begin on November 15 and end on December 31. Beginning in 2007, the annual coordinated election period would be during the month of November. In addition to the information dissemination required under current law, the Secretary would be required to provide: 1) the MA monthly basic beneficiary premium; 2) the monthly beneficiary premium for any enhanced medical benefits; 3) the MA monthly beneficiary obligation for qualified prescription drug coverage; 4) the catastrophic coverage amount (including the maximum limitation on out-of-pocket expenses) and unified deductible for the plan; 5) the outpatient prescription drug coverage benefits; 6) any beneficiary cost-sharing, including information on the unified deductible; 7) comparative information relating to prescription drug coverage; 8) if applicable, any reduction in the Medicare Part B premium; 9) whether the MA monthly premium for enhanced benefits was optional or mandatory; and 10) quality and performance indicators for prescription drug coverage, including a comparison with FFS Medicare. Additionally, the Secretary would conduct a special information campaign to inform MA eligible beneficia...
House Bill. The provision would prohibit, effective January 1, 2006, the issuance of new Medigap policies with prescription drug coverage. The prohibition would not apply to policies replacing another policy with drug coverage. Beneficiaries could keep their existing policies. Further, it would not apply to policies meeting new standards, as outlined below. The provision would guarantee issuance of a substitute Medigap policy for persons, enrolling in Part D, who at the time of such enrollment were enrolled in and terminated enrollment in a Medigap policy H, I, or J. The guaranteed enrollment would be for any of the Plans A through Plan G. The guarantee would apply for enrollments occurring in the new Medigap plan within 63 days of termination of enrollment in a Medigap drug Plan H, I, or J. The insurer could not impose an exclusion based on a pre-existing condition for such individuals. Further, the insurer would be prohibited from discriminating in the pricing of such policy on the basis of the individual’s health status, claims experience, receipt of health care or medical condition. The provision would provide for the development by the NAIC of two new standardized Medigap plans and would outline the standards for these policies. The first new policy would have the following benefits (notwithstanding other provisions of law relating to core benefits): 1) coverage of 50% of the cost-sharing otherwise applicable (except coverage of 100% cost-sharing applicable for preventive benefits); 2) no coverage of the Part B deductible; 3) coverage of all hospital coinsurance for long stays (as in current core package); and 4) a limitation on annual out-of-pocket costs of $4,000 in 2006 (increased in future years by an appropriate inflation adjustment as specified by the Secretary). The second new policy would have the same benefit structure as the first new policy, except that: 1) coverage would be provided for 75%, rather than 50%, of cost-sharing otherwise applicable; and 2) the limitation on out-of-pocket costs would be $2,000, rather than $4,000. Both policies could provide for coverage of Part D cost-sharing; however, neither policy could cover the Part D deductible. Senate Bill Effective January 1, 2006, Medigap drug policies could not be sold, issued or renewed for Part D enrollees. Persons who had such policies could obtain Medigap coverage without drug benefits. Beneficiaries who sought to enroll during the Part D open enrollment period established for current benefi...
House Bill. The provision would permit the Secretary of the Treasury, upon written request from the Secretary of the Department of Health and Human Services (HHS) to disclose to officers and employees of HHS specific information with respect to a specified taxpayer for a specific tax year. The information that could be disclosed is taxpayer identity information and the adjusted gross income for the taxpayer or, if less, the income threshold limit specified under the new Part D ($200,000 in 2006). A specified taxpayer would be either: 1) an individual who had adjusted gross income for the year in question in excess of the income threshold specified in the new Part D ($60,000); or 2) an individual who elected to use more recent income information as permitted under Part D. Individuals filing joint returns would each be treated separately with each person considered to have an adjusted gross income equal to one-half of the total. Return information disclosed, could be used by officers and employees of HHS only for administering the prescription drug benefit. They could disclose the annual out-of-pocket threshold applicable to an individual to the entity offering the individual prescription drug coverage. The sponsor could use such information only for the purposes of administering the benefit. Senate Bill No provision.
House Bill. Section 200. Title II would establish the Medicare Enhanced Fee-for-Service (EFFS) program, under which Medicare beneficiaries would be provided access to a range of regional EFFS plans that could include preferred provider networks, beginning in 2006. It would establish the Medicare Advantage (MA) program, upon enactment, to replace the M+C program, which would continue to offer coordinated care and other plans on a county-wide basis as under current law. It would also use competitive bidding, beginning in 2010, in the same style as the Federal Employees Health Benefits program (FEHBP) for certain EFFS plans and MA plans, to promote greater efficiency and responsiveness to Medicare beneficiaries. Senate Bill Title II would establish the Medicare Advantage (MA) program, which would replace the M+C program, beginning in 2006. The MA program would continue to offer coordinated care and other plans on a county-wide basis as under current law. It would also establish regional PPOs, to be offered in regions. Beginning in 2008, it would establish a limited competition program, in areas designated as “highly competitive,”
House Bill. Section 212(a). For 2004, a 4th payment mechanism would be added and plans would receive the highest of the four payment calculations (the floor, blend, minimum percentage increase, or the new amount). The new payment amount would be 100% of fee-for-service (FFS) costs. The FFS payment would be based on the adjusted average per capita cost for the year, for an MA payment area, for services covered under Parts A and B for beneficiaries entitled to benefits under Part A, enrolled in Part B and not enrolled in an MA plan. This payment would be adjusted to remove payments for direct medical education costs and to include the additional payments that would have been made if Medicare beneficiaries entitled to benefits from facilities of the Department of Veteran Affairs (VA) and the Department of Defense (DOD) had not used those services (VA/DOD adjustment). Section 212(b). In 2004, no adjustment would be made for budget neutrality, which would fund the blend for that year.
House Bill. The House bill provides for a revised system of accounting for Federal credit programs that requires the appropriation of budget authority equal to the cost to the government, which is the estimated net present value of the cash flows associated with federal direct loan and loan guarantee programs. The revised accounting would also apply to any modifications in the costs of outstanding direct loans or loan guarantees. An exception from the requirement for an appropriation is provided for existing entitlement credit programs and the credit activities of the Commodity Credit Corporation. The credit program cost estimates will not include administrative expenses, but these expenses will be displayed in the program account as a separate subaccount on a cash basis. All of the residual cash flows associated with direct loan and loan guarantee programs not included in the cost to the government estimate would be non-budgetary and treated as means of financing. The House bill gives the Director of the Office of Management and Budget (OMB) the authority to make credit cost estimates for the Executive Branch. The OMB Director could also delegate such authority to any Federal agency through written guidelines. The Director of the OMB would have access to necessary data from the Federal agencies and has a mandate to work with the Congressional Budget Office to improve cost estimates through an annual review process. The House bill authorizes the President to establish the necessary non-budgetary accounts and the Secretary of the Treasury to borrow from, receive from, lend to, or pay to such amounts as may be appropriate to these non-budgetary accounts. These transactions will be subject to the Antideficiency Act. The House bill also authorizes the funds necessary to implement this change in credit accounting. The House bill makes credit reform effective starting in fiscal year 1992 and provides that direct loans and loan guarantees made before this date shall be reflected in the budget on a cash basis. The House also provides permanent indefinite authority to liquidate the loan obligations and guarantee commitments made prior to October 1, 1991. The House bill also calls for a study by the OMB and the CBO concerning whether the accounting for Federal deposit insurance programs should be made on a cash basis, on the same basis as loan guarantees, or on some other basis. Finally, the House bill would no longer require the inclusion of credit authority amounts in budget ...
House Bill. The House bill establishes new sequestration reporting requirements and presidential sequestration orders to implement the discretionary spending sequester (enforcing the discretionary spending categories), the pay-as-you-go sequester (enforcing the deficit-neutrality of mandatory spending and receipt legislation), and the deficit sequester (enforcing the deficit targets). The bill establishes the following timetable for sequestration reports and orders: On or before Action to be completed First Monday in February Lock in the Office of Management and Budget estimating assumptions. August 15 Initial snapshot. August 20 Sequester preview. Latest possible date before October 15 Final snapshot. October 15 Pay-as-you-go and deficit sequester reports; Presidential order. Within 15 days after end of Discretionary sequester reports; Presidential On or before Action to be completed session order. 30 days later GAO compliance report. On August 20, both the Congressional Budget Office and the Office of Management and Budget Directors issue sequester preview reports to the President and Congress for the pay-as-you-go and deficit sequesters for the fiscal year. For the pay-as-you-go sequester preview, the reports must set forth the change in the deficit for the fiscal year caused by the enactment of direct spending and receipts legislation, identify each law included in the estimate, and calculate the appropriate sequester percentage. For the deficit sequester, the reports must estimate the baseline deficit for the fiscal year, any deficit excess, the deficit margin, any deficit excess remaining after the pay-as-you-go sequester has been made, and calculate the specified reductions required to eliminate any remaining deficit excess. On October 15, the Office of Management and Budget and Congressional Budget Office Directors issue revised pay-as- you-go and deficit sequester reports updated to reflect laws enacted through the final snapshot date and containing all the information required in the sequester preview reports. If the revised Office of Management and Budget report indicates that any pay-as-you-go and deficit sequester is required, the President shall issue an order on the same date implementing the sequester without change. Within 15 days after the end of the session, the Congressional Budget Office and Office of Management and Budget Directors issue discretionary spending sequestration reports to the President and Congress. In general, the reports shall expl...
