1.Short title; table of
contents
(a)This Act may be cited
as the Prescription Coverage Now Act
of 2009
.
(b)The table of contents for this Act is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Expediting low-income subsidies under the Medicare
prescription drug program.
Sec. 3. Enhanced oversight and enforcement relating to
reimbursements for retroactive LIS enrollment.
Sec. 4. Modification of resource standards for determination of
eligibility for low-income subsidy; simplification of income and asset
rules.
Sec. 5. Indexing deductible and cost-sharing above annual
out-of-pocket threshold for individuals with income below
150 percent of poverty line.
Sec. 6. No impact on eligibility for benefits under other
programs.
Sec. 7. Requiring individuals eligible for Medicare savings
programs to be deemed to be subsidy eligible individuals.
Sec. 8. Special enrollment period for subsidy eligible
individuals.
2.Expediting
low-income subsidies under the Medicare prescription drug program
(a)Targeted
outreach for low-income subsidies
(1)Section 1860D–14 of the Social Security Act (42 U.S.C.
1395w–114) is amended by adding at the end the following new subsection:
(e)Targeted
outreach for low-income subsidies
(1)Targeted
identification of subsidy-eligible individuals
(A)The Commissioner of
Social Security shall provide for the identification of individuals who are
potentially eligible for low-income assistance under this section through
requests to the Secretary of the Treasury in accordance with the criterion
established under section 6103(l)(21) of the Internal Revenue Code of 1986 for
information indicating whether the individual involved is likely eligible for
such assistance.
(B)Initiation of
identificationsNot later
than 90 days after the date of the enactment of this subsection, the
Commissioner of Social Security shall begin the identification of individuals
through the process described in subparagraph (A) and shall, by such date and
through such process, submit to the Secretary of the Treasury requests for part
D eligible individuals who the Commissioner has identified as potentially
eligible for low-income subsidies under this section before such date of
enactment.
(2)Notification of
potentially eligible individualsIn the case of each individual identified
under paragraph (1) who has not otherwise applied for, or been determined
eligible for, benefits under this section (or who has applied for and been
determined ineligible for such benefits based on excess income, resources, or
both), the Commissioner shall transmit by mail to the individual a letter
including the information and application required to be provided under
subparagraphs (A), (B), and (D) of section 1144(c)(1).
(3)If an
individual to whom a letter is transmitted under paragraph (2) does not
affirmatively respond to such letter either by making an enrollment, completing
an application, or declining either or both, the Commissioner shall make
additional attempts to contact the individual to obtain such an affirmative
response.
(4)Use of preferred
language in subsequent communicationsIn the case an application is completed by
an individual pursuant to this subsection in which a language other than
English is specified, the Commissioner shall provide that subsequent
communications under this part to the individual shall be in such language as
needed.
(5)Nothing in this subsection shall be
construed as precluding the Commissioner from taking additional outreach
efforts to enroll eligible individuals under this part and to provide
low-income subsidies to eligible individuals.
(6)Maintenance of
effort with respect to outreachIn no case shall the level of
effort with respect to outreach to and enrollment of individuals who are
potentially eligible for low-income assistance under this section after the
date of the enactment of this subsection be less than such level of effort
before such date of enactment until at least 90 percent of such potentially
eligible individuals have affirmatively responded.
(7)Not later than 2
years after the date of the first submission to the Secretary of the Treasury
described in paragraph (1)(B), the Comptroller General of the United States
shall submit to Congress a report, with respect to the 18-month period
following the establishment of the process described in paragraph (1)(A),
on—
(A)the extent to
which the percentage of individuals who are eligible for low-income assistance
under this section but not enrolled under this part has decreased during such
period;
(B)how the Commissioner of Social Security has
used any savings resulting from the implementation of this section and section
6103(l)(21) of the Internal Revenue Code of 1986 to improve outreach to
individual described in subparagraph (A) to increase enrollment of such
individuals under this part;
(C)the effectiveness of using information from
the Secretary of the Treasury in accordance with section 6103(l)(21) of the
Internal Revenue Code of 1986 for purposes of indicating whether individuals
are eligible for low-income assistance under this section; and
(D)the effectiveness
of the outreach conducted by the Commissioner of Social Security based on the
data described in subparagraph
(C).
.
(2)Section 1144(c)(1) of the Social Security Act (42
U.S.C. 1320b–14(c)(1)) is amended by inserting (including through
request to the Secretary of the Treasury pursuant to section
1860D–14(e))
before , the Commissioner shall
.
(b)Improvements to
the low-income subsidy applicationsSection 1860D–14(a)(3) of the
Social Security Act (42 U.S.C. 1395w–114(a)(3)) is amended—
(1)in subparagraph
(E), by striking clauses (ii) and (iii) and redesignating clause (iv) as clause
(ii);
(2)by redesignating
subparagraphs (F) and (G) as subparagraphs (G) and (H), respectively;
and
(3)by inserting after
subparagraph (E) the following new subparagraph:
(F)Simplified
low-income subsidy application and process
(i)The Secretary,
jointly with the Commissioner of Social Security, shall—
(I)develop a model, simplified application
form and process consistent with clause (ii) for the determination and
verification of a part D eligible individual’s assets or resources under this
paragraph; and
(II)provide such form
to States.
(ii)Documentation
and safeguardsUnder such process—
(I)the application form shall consist of an
attestation under penalty of perjury regarding the level of assets or resources
(or combined assets and resources in the case of a married part D eligible
individual) and valuations of general classes of assets or resources;
(II)such form shall not require the submittal
of additional documentation regarding income or assets;
(III)matters attested to in the application
shall be subject to appropriate methods of administrative verification;
(IV)the applicant shall be permitted to
authorize another individual to act as the applicant’s personal representative
with respect to communications under this part and the enrollment of the
applicant into a prescription drug plan (or MA–PD plan) and for low-income
subsidies under this section; and
(V)the application form shall allow for the
specification of a language (other than English) that is preferred by the
individual for subsequent communications with respect to the individual under
this part.
(iii)No recovery
for certain subsidies improperly paidIf an individual in good faith and in the
absence of fraud is provided low-income subsidies under this section, and if
the individual is subsequently found not eligible for such subsidies, there
shall be no recovery made against the individual because of such subsidies
improperly
paid.
.
(c)Disclosures To
facilitate identification of individuals likely To be eligible for the
low-income assistance under the Medicare prescription drug program
(1)Subsection (l) of
section 6103 of the Internal Revenue Code of 1986 is amended by adding at the
end the following new paragraph:
(21)Disclosure of
return information to facilitate identification of individuals likely to be
eligible for low-income subsidies under Medicare prescription drug
program
(A)The Secretary, upon
written request from the Commissioner of Social Security, shall disclose to
officers and employees of the Social Security Administration, with respect to
any individual identified by the Commissioner—
(i)whether, based on
the criterion determined under subparagraph (B), such individual is likely to
be eligible for low-income assistance under section 1860D–14 of the Social
Security Act, or
(ii)that, based on
such criterion, there is insufficient information available to the Secretary to
make the determination described in clause (i).
(B)Not
later than 90 days after the date of the enactment of this paragraph, the
Secretary, in consultation with the Commissioner of Social Security, shall
develop the criterion by which the determination under subparagraph (A)(i)
shall be made (and the criterion for determining that insufficient information
is available to make such determination). Such criterion may include analysis
of information available on such individual’s return, the return of such
individual’s spouse, and any information related to such individual or such
individual’s spouse which is available on any information
return.
.
(2)Procedures and
recordkeeping related to disclosuresParagraph (4) of section
6103(p) of such Code is amended by striking or (17)
each place
it appears and inserting (17), or (21)
.
(3)The amendments made by this subsection shall apply to
disclosures made after the date of the enactment of this Act.
3.Enhanced
oversight and enforcement relating to reimbursements for retroactive LIS
enrollment
(a)In the case of a
retroactive LIS enrollment beneficiary (as defined in subsection (e)(4)) who is
enrolled under a prescription drug plan under part D of title XVIII of the
Social Security Act (or an MA–PD plan under part C of such title)—
(1)the beneficiary (or any eligible third
party) is entitled to reimbursement by the plan for covered drug costs (as
defined in subsection (e)(1)) incurred by the beneficiary during the
retroactive coverage period of the beneficiary in accordance with subsection
(b) and in the case of such a beneficiary described in subsection (e)(4)(A)(i),
such reimbursement shall be made automatically by the plan upon receipt of
appropriate notice the beneficiary is eligible for assistance described in such
subsection (e)(4)(A)(i) without further information required to be filed with
the plan by the beneficiary;
(2)the Secretary of
Health and Human Services (in this section referred to as the
Secretary
) shall not make payment to the plan—
(A)in the case that the beneficiary is
described in subsection (e)(4)(A)(i), for premium subsidies and cost sharing
subsidies under section 1860D–14 of the Social Security Act (42 U.S.C.
1395w–114) with respect to the provision of prescription drug coverage to the
beneficiary during such retroactive period; and
(B)in the case that the beneficiary is
described in subsection (e)(4)(A)(ii), for direct subsidies under section
1860D–15(a)(1) of such Act and premium subsidies and cost-sharing subsidies
under section 1860D–14 of such Act with respect to the provision of
prescription drug coverage to the beneficiary during such retroactive
period;
unless the
plan demonstrates to the Secretary that the plan has provided timely and
accurate reimbursement to the beneficiary (or eligible third party) in
accordance with paragraph (1);(3)the Secretary
shall not make any payment described in paragraph (2) to the plan with respect
to such beneficiary for any month of the retroactive enrollment period during
which no expenses for covered part D drugs (as defined in section 1860D–2(e) of
the Social Security Act (42 U.S.C. 1395w–102(e)) were incurred by such
beneficiary (or eligible third party on behalf of such beneficiary); and
(4)any payment owed
the plan pursuant to this section, taking into account paragraphs (2) and (3),
shall be made at the time the Centers for Medicare & Medicaid Services
reconciles payments for the entire plan year following the end of the plan
year, and not before such time.
(b)Administrative
requirements relating to reimbursements
(1)Each
reimbursement made by a prescription drug plan or MA–PD plan under subsection
(a)(1) shall include a line-item description of the items for which the
reimbursement is made.
(2)A prescription drug plan or MA–PD plan must make a
reimbursement under subsection (a)(1) to a retroactive LIS enrollment
beneficiary, with respect to a claim, not later than 30 days after—
(A)in the case of a
beneficiary described in subsection (e)(4)(A)(i), the date on which the plan
receives notice from the Secretary that the beneficiary is eligible for
assistance described in such subsection; or
(B)in the case of a
beneficiary described in subsection (e)(4)(A)(ii), the date on which the
beneficiary files the claim with the plan.
(c)
(1)By Secretary of
HHS and Commission of the Social Security AdministrationThe
Secretary, jointly with the Commissioner of the Social Security Administration,
shall ensure that each retroactive LIS enrollment beneficiary receives, with
any letter or notification of eligibility for a low-income subsidy under
section 1860D–14 of the Social Security Act, a notice of their right to
reimbursement described in subsection (a)(1) for covered drug costs incurred
during the retroactive coverage period of the beneficiary. Such notice
shall—
(A)with respect to a
beneficiary described in subsection (e)(4)(A)(i), inform the beneficiary of the
beneficiary’s right to automatic reimbursement as described in subsection
(a)(1); and
(B)with respect to a
beneficiary described in subsection (e)(4)(A)(ii), include a description of a
clear process that the beneficiary should follow to seek such
reimbursement.
(2)By prescription
drug plans
(A)Each prescription drug plan under part D of title XVIII
of the Social Security Act (and MA–PD plan under part C of such title) shall
include in a notice from the plan to a retroactive LIS enrollment beneficiary
described in subsection (e)(4)(A)(ii) a model notice developed under
subparagraph (B) describing the process the beneficiary must follow to seek
retroactive reimbursement. Such notice shall include any form required by the
plan to complete such reimbursement and shall indicate the period of
retroactive coverage for which the beneficiary is eligible for such
reimbursement.
(B)The Secretary, jointly with the Commissioner of Social
Security, shall develop a model notice for purposes of subparagraph (A) and
shall make such model notice available to all prescription drug plans under
part D of title XVIII of the Social Security Act (and MA–PD plans under part C
of such title).
(d)Public posting
To track payments
(1)Not later than one year after the date of the enactment
of this Act, the Secretary shall post (and annually update) on the public
Internet website of the Department of Health and Human Services information on
the total amount of payments made by the Secretary under subsection (a)(2) to
prescription drug plans during the most recent plan year for which plan data is
available.
(2)Such information posted—
(A)in 2010 or in a
subsequent year before 2016, shall include information on payments made for
years beginning with 2006 and ending with the year for which the most current
information is available; and
(B)in 2016 or a
subsequent year, shall include information on payments made for at least the 10
previous years.
(e)In this section:
(1)The term covered
drug costs means, with respect to a retroactive LIS enrollment
beneficiary enrolled under a prescription drug plan under part D of title XVIII
of the Social Security Act (or an MA–PD plan under part C of such title), the
amount by which—
(A)the costs incurred
by such beneficiary during the retroactive coverage period of the beneficiary
for covered part D drugs, premiums, and cost-sharing under such title;
exceeds
(B)such costs that
would have been incurred by such beneficiary during such period if the
beneficiary had been both enrolled in the plan and recognized by such plan as
qualified during such period for the low income subsidy under section 1860D–14
of the Social Security Act to which the individual is entitled.
(2)The term eligible third party means, with
respect to a retroactive LIS enrollment beneficiary, an organization or other
third party that paid on behalf of such beneficiary for covered drug costs
incurred by such beneficiary during the retroactive coverage period of such
beneficiary.
(3)Retroactive
coverage periodThe term
retroactive coverage period means—
(A)with respect to a
retroactive LIS enrollment beneficiary described in paragraph (4)(A)(i), the
period—
(i)beginning on the
effective date of the assistance described in such paragraph for which the
individual is eligible; and
(ii)ending on the
date the plan effectuates the status of such individual as so eligible;
and
(B)with respect to a retroactive LIS
enrollment beneficiary described in paragraph (4)(A)(ii), the period—
(i)beginning on the
date the individual is both entitled to benefits under part A, or enrolled
under part B, of title XVIII of the Social Security Act and eligible for
medical assistance under a State plan under title XIX of such Act; and
(ii)ending on the
date the plan effectuates the status of such individual as a full-benefit dual
eligible individual (as defined in section 1935(c)(6) of such Act).
(4)Retroactive LIS
enrollment beneficiary
(A)The term retroactive LIS enrollment
beneficiary means an individual who—
(i)is enrolled in a
prescription drug plan under part D of title XVIII of the Social Security Act
(or an MA–PD plan under part C of such title) and subsequently becomes eligible
as a full-benefit dual eligible individual (as defined in section 1935(c)(6) of
such Act), an individual receiving a low-income subsidy under section 1860D–14
of such Act, an individual receiving assistance under the Medicare Savings
Program implemented under clauses (i), (ii), (iii), and (iv) of section
1902(a)(10)(E) of such Act, or an individual receiving assistance under the
supplemental security income program under section 1611 of such Act; or
(ii)subject to subparagraph (B)(i), is a
full-benefit dual eligible individual (as defined in section 1935(c)(6) of such
Act) who is automatically enrolled in such a plan under section
1860D–1(b)(1)(C) of such Act.
(B)Exception for
beneficiaries enrolled in RFP plan
(i)In no case shall an individual described in subparagraph
(A)(ii) include an individual who is enrolled, pursuant to a RFP contract
described in clause (ii), in a prescription drug plan offered by the sponsor of
such plan awarded such contract.
(ii)The RFP contract described in this section is a
contract entered into between the Secretary and a sponsor of a prescription
drug plan pursuant to the Centers for Medicare & Medicaid Services’ request
for proposals issued on February 17, 2009, relating to Medicare part D
retroactive coverage for certain low income beneficiaries, or a similar
subsequent request for proposals.
(f)Not later than 24
months after the date of the enactment of this Act, the Comptroller General of
the United States shall submit to Congress a report on the extent to which the
provisions of this section improve reimbursement for covered drug costs to
retroactive LIS enrollment beneficiaries and lower the amounts of payments made
by the Secretary, with respect to such beneficiaries, to prescription drug
plans under part D of title XVIII of the Social Security Act (and MA–PD plans
under part C of such title).
(g)In the case that an
RFP contract described in subsection (e)(4)(B)(ii) is awarded, not later than
two years after the effective date of such contract, the Secretary of Health
and Human Services shall submit to Congress a report evaluating the program
carried out through such contract.
(h)Paragraphs (2) and (3) of subsection (a) and subsections (b)
and (c) shall apply to subsidy determinations made on or after the date that is
3 months after the date of the enactment of this Act.
4.Modification of
resource standards for determination of eligibility for low-income subsidy;
simplification of income and asset rules
(a)Single and
increased resource standard for low-income subsidiesSection 1860D–14(a) of the Social Security
Act (42 U.S.C. 1395w–114(a)) is amended—
(1)in paragraph (1),
by inserting (or, for years after 2010, paragraph (3)(E))
after
paragraph (3)(D)
;
(2)in paragraph
(3)—
(A)in subparagraph (A)(iii), by inserting
(or for a year after 2010, subparagraph (E))
before the
period;
(B)in subparagraph
(D)(ii), by inserting before 2011
after subsequent
year
; and
(C)in subparagraph
(E)(i)—
(i)by striking
and
at the end of subclause (I);
(ii)in subclause
(II)—
(I)by striking
a subsequent year
and inserting each of 2007 through
2010
;
(II)by striking the
period at the end and inserting a semicolon;
(iii)by inserting after subclause (II) the
following new subclauses:
(III)for 2011,
$27,500 (or $55,000 in the case of the combined value of the individual’s
assets or resources and the assets or resources of the individual’s spouse);
and
(IV)for a subsequent
year the dollar amounts specified in this clause for the previous year
increased by the annual percentage increase in the consumer price index (all
items; U.S. city average) as of September of such previous year.
; and
(iv)in the last
sentence, by inserting or (IV)
after subclause
(II)
.
(b)Exemptions from
resources
(1)Section 1860D–14(a)(3) of the Social Security Act (42
U.S.C. 1395w–114(a)(3) is further amended—
(A)in subparagraphs
(D) and (E), by inserting and the retirement plan exclusion under
subparagraph (H)
after subparagraph (G)
each place it
appears; and
(B)by adding at the
end the following new subparagraph:
(H)Retirement
benefit exclusionIn
determining the resources of an individual (and their eligible spouse, if any)
under section 1613 for purposes of subparagraphs (D) and (E), no retirement
benefit, such as an individual retirement account or plan under section 401(k)
of the Internal Revenue Code of 1986, shall be taken into account.
.
(2)The amendments made by paragraph (1) shall apply for months
beginning after 2011.
(c)Clarification
relating to including retirement benefits as incomeNothing in subparagraph (H) of section
1860D–14(a)(3) of the Social Security Act (42 U.S.C. 1395w–114(a)(3)), as added
by subsection (b), shall be construed as affecting the inclusion of retirement
benefits as income under section 1612(a)(2)(B) of such Act (42 U.S.C.
1382a(a)(2)(B)).
(d)Clarification
relating to MIPPA effective date for in kind exclusions from
incomeSection 116(b) of the Medicare Improvements for Patients
and Providers Act of 2008 is amended—
(1)by inserting (other than subsection
(a)(1))
after this section
; and
(2)by adding at the
end the following new sentence: The amendment made by subsection (a)(1)
shall take effect with respect to benefits provided after such date.
.
(e)Increasing
income limits for partial LIS eligibility to 200 percent FPL and for full LIS
to 150 percent FPL
(1)Section 1860D–14(a) of the Social Security Act (42 U.S.C.
1395w–114(a)) is amended—
(A)in the heading, by
striking 150
and inserting 200
;
(B)in paragraph
(1)—
(i)in
the heading, by striking 135
and inserting 150
; and
(ii)by
striking 135
and inserting 150
;
(C)in paragraph
(2)—
(i)in
the heading, by striking 150
and inserting 200
; and
(ii)in
subparagraph (A), by striking 135
and 150
and
inserting 150
and 200
, respectively; and
(D)in paragraph
(3)(A)(ii), by striking 150
and inserting
200
.
(2)The amendments made by paragraph (1) shall apply to
determinations made on or after January 1, 2011.
5.Indexing deductible
and cost-sharing above annual out-of-pocket threshold for individuals with
income below 200 percent of poverty
line
(a)Section 1860D–14(a)(4)(B) of the Social Security Act
(42 U.S.C. 1395w–114(a)(4)(B)) is amended—
(1)in clause (i), by
striking or
;
(2)in clause
(ii)—
(A)by striking a subsequent
year
and inserting 2008, 2009, and 2010
; and
(B)by striking the
period at the end and inserting ; and
;
(3)by inserting after
clause (ii) the following new clause:
(iii)for 2011 and each succeeding year, the
amount determined under this clause (or clause (ii)) for the previous year
increased by the annual percentage increase in the consumer price index (all
items; U.S. city average) as of September of such previous
year.
;
and
(4)in the last
sentence, by striking clause (i) or (ii)
and inserting
clause (i), (ii), or (iii)
.
(b)Section
1860D–14(a) of the Social Security Act (42 U.S.C. 1395w–114(a)) is
amended—
(1)in paragraph
(1)(D)(iii), by striking exceed the copayment amount
and all
that follows through the period at the end and inserting “exceed—
(I)for each of 2006 through 2010, the
copayment amount specified under section 1860D–2(b)(4)(A)(i)(I) for the drug
and year involved; and
(II)for 2011 and each succeeding year, the
amount determined under this subparagraph for the previous year increased by
the annual percentage increase in the consumer price index (all items; U.S.
city average) as of September of such previous
year.
;
and
(2)in paragraph
(2)(E), by striking exceed the copayment or coinsurance amount
and all that follows through the period at the end and inserting
“exceed—
(i)for each of 2006 through 2010, the
copayment or coinsurance amount specified under section 1860D–2(b)(4)(A)(i)(I)
for the drug and year involved; and
(ii)for 2011 and each succeeding year, the
amount determined under this clause for the previous year increased by the
annual percentage increase in the consumer price index (all items; U.S. city
average) as of September of such previous
year.
.
6.No impact on
eligibility for benefits under other programs
(a)Section 1860D–14(a)(3) of the Social Security Act (42
U.S.C. 1395w–114(a)(3)), as amended by section 4(b)(1)(B), is further
amended—
(1)in subparagraph
(A), in the matter preceding clause (i), by striking subparagraph
(F)
and inserting subparagraphs (F) and (I)
; and
(2)by adding at the
end the following new subparagraph:
(I)No impact on
eligibility for benefits under other programsThe availability of
premium and cost-sharing subsidies under this section shall not be treated as
benefits or otherwise taken into account in determining an individual’s
eligibility for, or the amount of benefits under, any other Federal
program.
.
(b)The amendments made by
subsection (a) shall apply to premium and cost-sharing subsidies for months
beginning after the date of the enactment of this Act.
7.Requiring individuals
eligible for Medicare savings programs to be deemed to be subsidy eligible
individuals
(a)Section
1860D–14(a)(3)(B)(v) of the Social Security Act (42 U.S.C.
1395w–114(a)(3)(B)(v)) is amended—
(1)in subclause
(II)—
(A)by striking
may
and inserting shall
; and
(B)by inserting
(ii),
after clause (i),
; and
(2)by striking the
second sentence.
(b)The amendment made by subsection (a) shall take effect as of
the date of the enactment of this Act and apply to determinations made for
purposes of title XIX on or after the first date of the first plan year
beginning after the date of the enactment of this Act.
8.Special enrollment
period for subsidy eligible individuals
(a)Section 1860D–1(b)(3) of the Social Security Act (42
U.S.C. 1395w–101(b)(3)) is amended by adding at the end the following new
subparagraph:
(F)Eligibility for
low-income subsidy
(i)In the case of an applicable subsidy eligible individual
(as defined in clause (ii)), the special enrollment period described in clause
(iii).
(ii)Applicable
subsidy eligible individual definedFor purposes of this
subparagraph, the term applicable subsidy eligible individual
means a part D eligible individual who is not described in subparagraph (D) and
who is determined under subparagraph (B) of section 1860D–14(a)(3) to be a
subsidy eligible individual (as defined in subparagraph (A) of such section),
including such an individual who was enrolled in a prescription drug plan or an
MA–PD plan on the date of such determination.
(iii)Special
enrollment period describedThe special enrollment period
described in this clause, with respect to an applicable subsidy eligible
individual, is the period beginning on the date the individual receives
notification that such individual has been determined under section
1860D–14(a)(3)(B) to be a subsidy eligible individual (as so defined) and
ending on the date the individual is no longer so
eligible.
.
(b)The amendments made by this section shall apply to subsidy
determinations made for months beginning with January 2010.