Ensuring Medicare-only PACE program enrollees have a choice of prescription drug plans under Medicare part D

Section 1860D–21(f) of the Social Security Act (42 U.S.C. 1395w–131(f)) is amended—(1)in paragraph (1), by striking and (3) and inserting (3), and (4); and(2)by adding at the end the following new paragraph:

(4)

Ensuring choice of prescription drug plans

(A)

In general

For plan years beginning on or after January 1, 2025, subject to the succeeding provisions of this paragraph, an applicable PACE program enrollee may elect to enroll in a qualified standalone prescription drug plan, in accordance with rules established by the Secretary pursuant to this paragraph, while enrolled under a PACE program.(B)

Definition of applicable pace program enrollee; qualified standalone prescription drug plan

In this paragraph:(i)

Applicable pace program enrollee

The term applicable PACE program enrollee means a part D eligible individual who—(I)is not entitled to medical assistance under title XIX; and(II)is enrolled under a PACE program offered by a PACE provider.(ii)

Qualified standalone prescription drug plan

The term qualified standalone prescription drug plan means, with respect to an applicable PACE program enrollee, a prescription drug plan—(I)that is not an MA–PD plan;(II)that is not operated by the PACE program under which the individual is enrolled; and(III)for which the Secretary determines, with respect to the applicable PACE program enrollees enrolled in a PACE program offered by such PACE provider, that—(aa)the estimated beneficiary out-of-pocket costs (as defined in clause (iii)) for the plan year for qualified prescription drug coverage under the plan is equal to or less than the estimated out-of-pocket costs for such coverage under the prescription drug plan offered by the PACE program in which the applicable PACE program enrollee is enrolled; and(bb)the estimated total amount of Federal subsidies for the plan year for qualified prescription drug coverage under the plan (which may be estimated using data from the previous plan year) is equal to or less than the estimated subsidy amount for such coverage under the prescription drug plan offered by the PACE program in which the applicable PACE program enrollee is enrolled.(iii)

Out-of-pocket costs defined

In this paragraph, the term out-of-pocket costs includes premiums imposed under a prescription drug plan and, in the case of coverage under a qualified standalone prescription drug plan, deductibles, copayments, coinsurance, and other cost-sharing.(C)

Out-of-pocket costs

In the case where an applicable PACE program enrollee elects to enroll in a qualified standalone prescription drug plan pursuant to this paragraph, the individual shall be responsible for any out-of-pocket costs imposed under the plan (including costs for nonformulary drugs) after the application of any subsidies under section 1860D–14 for an applicable PACE program enrollee who is a subsidy eligible individual (as defined in section 1860D–14(a)(3)).(D)

Requirements for pace programs

(i)

Educating and helping enroll beneficiaries into a part d plan option

A PACE program shall be required to provide—(I)information to all applicable PACE program enrollees who are enrolled under the PACE program regarding the option to enroll in a qualified standalone prescription drug plan under this paragraph; and(II)upon request of an applicable PACE program enrollee, counseling and coordination to assist applicable PACE program enrollees in making decisions regarding the selection of qualified standalone prescription drug plans available to them.(ii)

Monitoring drug utilization, adherence, and spend

A PACE program shall be required to monitor drug utilization, medication adherence, and drug spending (through claims data shared pursuant to subparagraph (F) and otherwise) throughout the year with respect to any applicable PACE program enrollee who elects to enroll in a qualified standalone prescription drug plan under this paragraph in order to coordinate with the PDP sponsor of such plan regarding the drug benefits offered by the plan, including upon request of an applicable PACE program enrollee the filing of any grievances or appeals with the plan on behalf of the applicable PACE program enrollee.(E)

Disenrollment

An applicable PACE program enrollee may disenroll from the qualified standalone prescription drug plan elected by such applicable PACE program enrollee under subparagraph (A) if the enrollee changes medication during the plan year or can demonstrate an unexpected increase in out-of-pocket costs post enrollment.(F)

Claims sharing

In the case where an applicable PACE program enrollee enrolls in a qualified standalone prescription drug plan, the PACE program in which the individual is enrolled and the PDP sponsor of the qualified standalone prescription drug plan shall share claims data with each other with respect to the applicable PACE program enrollee as needed to support care management for the applicable PACE program enrollee (including for purposes of monitoring and coordination required under subparagraph (D)(ii)) and for purposes of comprehensive risk adjustment under section 1894(d). Such data shall be shared without the need for any formal or informal request of the PACE program in which the individual is enrolled or the PDP sponsor of the qualified standalone prescription drug plan in which the applicable PACE program enrollee is enrolled.(G)

Rule of construction

The authority established under this paragraph for an applicable PACE program enrollee to elect to enroll in a qualified standalone prescription drug plan shall not be construed as permitting an applicable PACE program enrollee to enroll in a prescription drug plan that is not a qualified standalone prescription drug plan.(H)

Relation to PACE statutes

(i)

In general

The authority provided under this paragraph for an applicable PACE program enrollee to elect to enroll in a qualified standalone prescription drug plan shall apply notwithstanding subsection (a)(1)(B)(1) of section 1894 and such other provisions of sections 1894 and 1934 as the Secretary determines may conflict with the authority provided for under this paragraph, including subsections (a)(2)(B), (b)(1)(A)(i), (b)(1)(C), (f)(2)(B)(ii), and (f)(2)(B)(v) of such sections.(ii)

Clarification on payment for part D drug coverage

Insofar as an applicable PACE program enrollee is enrolled in a qualified standalone prescription drug plan under this paragraph, the PACE program shall not be entitled to payment under section 1894(d) for the provision of qualified prescription drug coverage under such standalone prescription drug plan with respect to such applicable PACE program enrollee.