Common use of House Bill Clause in Contracts

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 benchmark amount would bear the same ratio to the total premium as the actuarial value of standard coverage was to the actuarial value of alternative coverage. The Administrator would provide a process whereby the Administrator would notify the PDP sponsor or MA Rx or EFFS Rx entity that an individual was eligible for a subsidy and the amount of the subsidy. The sponsor or entity would reduce the premiums or cost-sharing otherwise imposed by the amount of the subsidy. The Administrator would periodically, and on a timely basis, reimburse the sponsor or entity for the amount of the reductions. Part D benefits would be primary to any coverage available under Medicaid. The Administrator would be required to develop and implement a plan for the coordination of Part D benefits and Medicaid benefits. Particular attention would be given to coordination of payments and preventing fraud and abuse. The Administrator would be required to involve the Secretary, the States, the data processing industry, pharmacists, pharmaceutical manufacturers, and other experts in the development and administration of the plan. Senate Bill Medicaid beneficiaries eligible for medical and drug benefits under their state Medicaid program (including the medically needy) would continue to receive drug benefits through Medicaid. Persons meeting the definition of QMB, SLMB, or QI-1, and not eligible for Medicaid medical and drug benefits, as well as other persons below 160% of the federal poverty level, would receive their drug benefits through Part D. They would receive assistance for the Part D premium and cost-sharing charges. QMBs, SLMBs and QI-1s would have a 100% premium subsidy for premiums provided the plan premium was at or below the national weighted average premium (or the lowest premium in the area if none was below the national weighted average). The benefit package for the QMB population would be defined as having a zero deductible, cost-sharing of 2.5% for costs below the initial coverage limit; 5.0% cost-sharing for costs above the initial coverage limit and below the annual catastrophic limit, and 2.5% cost- sharing for costs above the catastrophic limit. The benefit package for the SLMB and QI-1 population would be defined as having a zero deductible, 5.0% cost-sharing for costs below the initial coverage limit; 10.0% cost-sharing for costs above the initial coverage limit and below the annual catastrophic limit, and 2.5% cost-sharing for costs above the catastrophic limit. Plans could waive or reduce cost-sharing otherwise applicable. Persons with incomes below 160% of poverty, not otherwise eligible for low-income benefits would have a sliding scale premium subsidy ranging from 100% of the premium at 135% of poverty to 0% at 160% of poverty with no additional premium costs provided the plan premium was at or below the national weighted average premium (or the lowest premium in the area if none was below the national weighted average). The benefit package for this population would be defined as having a $50 deductible in 2006 (indexed in subsequent years by the annual percentage increase in average per capita Medicare drug expenditures), 10.0% cost-sharing for costs below the initial coverage limit; 20.0% cost-sharing for costs above the initial coverage limit and below the annual catastrophic limit, and 10.0% cost-sharing for costs above the catastrophic limit. Plans could waive or reduce cost-sharing otherwise applicable. QMBs, SLMBs and QI-1s and other Part D enrollees with incomes below 160% of poverty could enroll in MedicareAdvantage and receive their low-income assistance through such plans. Beginning November 1, 2005, eligibility for low-income individuals would be determined by states. The Administrator would implement a process to notify the eligible entity or MedicareAdvantage plan that the individual was eligible for a cost-sharing subsidy and the amount of the subsidy. The entity would reduce the applicable cost-sharing and submit information to the Administrator on the amount of the reduction. The Administrator would periodically and on a timely basis reimburse the entity or organization for the amount of the reductions. Beginning January 1, 2009, to the extent a state had not already eliminated application of an asset test, it would be required to permit individuals to make a self-declaration that assets did not exceed $10,000 for an individual or $20,000 for a couple. In subsequent years, these amounts would be increased by the increase in the consumer price index. The Secretary would develop a model declaration form. Conference Agreement New Section 1860D-14 of the conference agreement provides premium and cost-sharing subsidies for low-income subsidy-eligible individuals. There are groups of subsidy eligible individuals. The first group is composed of persons who: 1) are enrolled in a prescription drug plan or MA-PD plan; 2) have incomes below 135% of poverty; and 3) have resources in 2006 below $6,000 for an individual and $9,000 for a couple (increased in future years by the percentage increase in the CPI), or 4) who is a full benefit dual eligible, regardless whether that person meets other eligibility standards. The second group of subsidy eligible individuals are persons meeting the same requirements, except that the income level is 150% of poverty and an alternative resources standard may be used; this alternative standard in 2006 is $10,000 for an individual and $20,000 for a couple (increased in future years by the percentage increase in the CPI.) Individuals with incomes below 135% of poverty, and resources meeting the requirement for the first group, would have a premium subsidy equal to 100% of the low-income benchmark premium amount, but in no case higher than the actual premium amount for basic coverage under the plan. The low-income benchmark premium amount for a region equals either: 1) the weighted average of the basic premiums, if all prescription drug plans are offered by the same PDP sponsor; or 2) the weighted average of premiums for prescription drug plans and MA-PD plans, if plans in the region are offered by more than one PDP sponsor. Other low-income subsidy eligible persons will have a sliding scale premium subsidy ranging from 100% of such value at 135% of poverty to 0% of such value at 150% of poverty. Persons below 135% of poverty would have a premium subsidy for any late enrollment penalty equal to 80 percent for the first 60 months and 100 percent thereafter. Beneficiaries in both groups are entitled to cost-sharing subsidies. Individuals with incomes below 135% of poverty, and resources meeting the requirement for the first group will have no deductible, cost-sharing for all costs up to the out-of-pocket threshold of $2 for a generic drug or preferred multiple source and $5 for brand name or non-preferred drug. Institutionalized dual eligibles will have no cost sharing. Full benefit dual eligibles with incomes under 100 percent of poverty will have cost sharing up to the out-of-pocket threshold of up to $1 for a generic drug or preferred multiple source and $3 for a brand name or nonpreferred drug. Other low-income subsidy eligible persons will have a $50 deductible, 15 percent cost-sharing for all costs up to the out-of-pocket limit, and cost-sharing for costs above the out-of-pocket threshold of $2 for a generic drug or preferred multiple source and $5 for brand name or non-preferred drug. The deductible and cost-sharing amounts are increased each year beginning in 2007 by the annual percentage increase in per capita beneficiary expenditures for Part D covered drugs except for $1 and $3 cost-sharing, which will increase by the percentage increase in CPI. Eligibility determinations are to be made under the state Medicaid plan for the state or by the Commissioner of Social Security. Conferees believe that more beneficiaries will enroll in the new Part D benefit if given the option to apply at the Social Security office as well as the welfare office. Low-income subsidy applications, information, and application assistance shall be available to beneficiaries in all Social Security offices and State Medicaid offices. It is the intent of the conferees that while enrollment at the SSA offices is important, both Medicaid programs and the Social Security Administration should engage in outreach activities to encourage eligible individuals to apply for subsidies under this section. The determinations shall remain effective for a period determined by the Secretary, not to exceed one year. Redeterminations or appeals are to be made in the same manner as such redeterminations and appeals are made by state Medicaid plans or the Commissioner for the supplemental security income program, whichever is appropriate. Full dual eligible persons are to be treated as subsidy eligible persons; the Secretary may provide that other Medicaid beneficiaries be treated as subsidy eligible. Otherwise, income is to be determined in the same manner as determinations are made for the QMB program; however, Section 1902(r)(2) which permits the use of less restive methodologies does not apply for determining whether an individual is a low-income subsidy eligible individual. However, Section 1902(r)(2) continues to apply to all state Medicaid eligibility determinations. The Secretary is to develop a model simplified application form and process for determining and verifying eligibility. The Commissioner may only require submission of statements from financial institutions for an application for low-income subsidies to be considered complete. No other documentary evidence may be required with the submission of the application. The Secretary is permitted to verify information submitted on the application. The Secretary will provide a process whereby the Secretary will notify the PDP sponsor or MA organization that an individual is eligible for a subsidy and the amount of the subsidy. The sponsor or entity would reduce the premiums or cost-sharing otherwise imposed by the amount of the subsidy. The Administrator will periodically, and on a timely basis, reimburse the sponsor or entity for the amount of the reductions. Reimbursement for cost-sharing subsidies may be computed on a capitated basis. The residents of the territories are not eligible for low-income subsidies. However, they may be eligible for financial assistance under the new section 1935(e), as added by Section 103. Subsidies for All Medicare Beneficiaries for Qualified Prescription Drug Coverage (New Section 1860D-15 of Conference agreement; New Section 1860D-8 of House bill; New Sections 1860D-20, 1860D-11, and 1860D-16 of Senate bill).