{"identifier":"/us/usc/t42/s1395w\u2013115","title":42,"num":"\u00a7\u202f1395w\u2013115.","heading":"Subsidies for part D eligible individuals for qualified prescription drug coverage","text":"\u00a7\u202f1395w\u2013115.\nSubsidies for part D eligible individuals for qualified prescription drug coverage\n(a)\nSubsidy payment\nIn order to reduce premium levels applicable to qualified prescription drug coverage for part D eligible individuals consistent with an overall subsidy level of 74.5 percent (or, for each of 2024 through 2029, the percent applicable as a result of the application of\n(1)\nDirect subsidy\nA direct subsidy for each part D eligible individual enrolled in a prescription drug plan or MA\u2013PD plan for a month equal to\u2014\n(A) the amount of the plan\u2019s standardized bid amount (as defined in\nsection 1395w\u2013113(a)(5) of this title\n(B) the base beneficiary premium (as computed under paragraph (2) or (8) of\nsection 1395w\u2013113(a) of this title\n(2)\nSubsidy through reinsurance\nThe reinsurance payment amount (as defined in subsection (b)).\nThis section constitutes budget authority in advance of appropriations Acts and represents the obligation of the Secretary to provide for the payment of amounts provided under this section.\n(b)\nReinsurance payment amount\n(1)\nIn general\nThe reinsurance payment amount under this subsection for a part D eligible individual enrolled in a prescription drug plan or MA\u2013PD plan for a coverage year is an amount equal to\u2014\n(A) for a year preceding 2025, 80 percent of the allowable reinsurance costs (as specified in paragraph (2)) attributable to that portion of gross covered prescription drug costs as specified in paragraph (3) incurred in the coverage year after such individual has incurred costs that exceed the annual out-of-pocket threshold specified in\nsection 1395w\u2013102(b)(4)(B) of this title\n(B) for 2025 and each subsequent year, the sum of\u2014\n(i) with respect to applicable drugs (as defined in\nsection 1395w\u2013114c(g)(2) of this title\nsection 1395w\u2013102(b)(4)(B) of this title\n(ii) with respect to covered part D drugs that are not applicable drugs (as so defined), an amount equal to 40 percent of such allowable reinsurance costs attributable to that portion of gross covered prescription drug costs as specified in paragraph (3) incurred in the coverage year after such individual has incurred costs that exceed the annual out-of-pocket threshold specified in\nsection 1395w\u2013102(b)(4)(B) of this title\n(2)\nAllowable reinsurance costs\n(A)\nIn general\nSubject to subparagraph (B), for purposes of this section, the term \u201callowable reinsurance costs\u201d means, with respect to gross covered prescription drug costs under a prescription drug plan offered by a PDP sponsor or an MA\u2013PD plan offered by an MA organization, the part of such costs that are actually paid (net of discounts, chargebacks, and average percentage rebates) by the sponsor or organization or by (or on behalf of) an enrollee under the plan, but in no case more than the part of such costs that would have been paid under the plan if the prescription drug coverage under the plan were basic prescription drug coverage, or, in the case of a plan providing supplemental prescription drug coverage, if such coverage were standard prescription drug coverage.\n(B)\nInclusion of manufacturer discounts on applicable drugs\nFor purposes of applying subparagraph (A), the term \u201callowable reinsurance costs\u201d shall include the portion of the negotiated price (as defined in\nsection 1395w\u2013114c(g)(6) of this title\nsection 1395w\u2013114c(g)(2) of this title\nsection 1395w\u2013114c of this title\n(3)\nGross covered prescription drug costs\nSubject to paragraph (2)(B), for purposes of this section, the term \u201cgross covered prescription drug costs\u201d means, with respect to a part D eligible individual enrolled in a prescription drug plan or MA\u2013PD plan during a coverage year, the costs incurred under the plan, not including administrative costs, but including costs directly related to the dispensing of covered part D drugs during the year and costs relating to the deductible. Such costs shall be determined whether they are paid by the individual or under the plan (or, with respect to 2025 and subsequent years, in the case of an applicable drug, as defined in\nsection 1395w\u2013114c(g)(2) of this title\n(4)\nCoverage year defined\nFor purposes of this section, the term \u201ccoverage year\u201d means a calendar year in which covered part D drugs are dispensed if the claim for such drugs (and payment on such claim) is made not later than such period after the end of such year as the Secretary specifies.\n(c)\nAdjustments relating to bids\n(1)\nHealth status risk adjustment\n(A)\nEstablishment of risk adjustors\nThe Secretary shall establish an appropriate methodology for adjusting the standardized bid amount under subsection (a)(1)(A) to take into account variation in costs for basic prescription drug coverage among prescription drug plans and MA\u2013PD plans based on the differences in actuarial risk of different enrollees being served. Any such risk adjustment shall be designed in a manner so as not to result in a change in the aggregate amounts payable to such plans under subsection (a)(1) and through that portion of the monthly beneficiary prescription drug premiums described in subsection (a)(1)(B) and MA monthly prescription drug beneficiary premiums.\n(B)\nConsiderations\nIn establishing the methodology under subparagraph (A), the Secretary may take into account the similar methodologies used under\nsection 1395w\u201323(a)(3) of this title\n(C)\nData collection\nIn order to carry out this paragraph, the Secretary shall require\u2014\n(i) PDP sponsors to submit data regarding drug claims that can be linked at the individual level to part A and part B data and such other information as the Secretary determines necessary; and\n(ii) MA organizations that offer MA\u2013PD plans to submit data regarding drug claims that can be linked at the individual level to other data that such organizations are required to submit to the Secretary and such other information as the Secretary determines necessary.\n(D)\nPublication\nAt the time of publication of risk adjustment factors under\nsection 1395w\u201323(b)(1)(B)(i)(II) of this title\n(2)\nGeographic adjustment\n(A)\nIn general\nSubject to subparagraph (B), for purposes of\nsection 1395w\u2013113(a)(1)(B)(iii) of this title\nsection 1395w\u2013113(a)(4) of this title\n(B)\nDe minimis rule\nIf the Secretary determines that the price variations described in subparagraph (A) among PDP regions are de minimis, the Secretary shall not provide for adjustment under this paragraph.\n(C)\nBudget neutral adjustment\nAny adjustment under this paragraph shall be applied in a manner so as to not result in a change in the aggregate payments made under this part that would have been made if the Secretary had not applied such adjustment.\n(d)\nPayment methods\n(1)\nIn general\nPayments under this section shall be based on such a method as the Secretary determines. The Secretary may establish a payment method by which interim payments of amounts under this section are made during a year based on the Secretary\u2019s best estimate of amounts that will be payable after obtaining all of the information.\n(2)\nRequirement for provision of information\n(A)\nRequirement\nPayments under this section to a PDP sponsor or MA organization are conditioned upon the furnishing to the Secretary, in a form and manner specified by the Secretary, of such information as may be required to carry out this section.\n(B)\nRestriction on use of information\nInformation disclosed or obtained pursuant to subparagraph (A) may be used by officers, employees, and contractors of the Department of Health and Human Services only for the purposes of, and to the extent necessary in, carrying out this section.\n(3)\nSource of payments\nPayments under this section shall be made from the Medicare Prescription Drug Account.\n(4)\nApplication of enrollee adjustment\nThe provisions of\nsection 1395w\u201323(a)(2) of this title\nsection 1395w\u201323(a) of this title\n(e)\nPortion of total payments to a sponsor or organization subject to risk (application of risk corridors)\n(1)\nComputation of adjusted allowable risk corridor costs\n(A)\nIn general\nFor purposes of this subsection, the term \u201cadjusted allowable risk corridor costs\u201d means, for a plan for a coverage year (as defined in subsection (b)(4))\u2014\n(i) the allowable risk corridor costs (as defined in subparagraph (B)) for the plan for the year, reduced by\n(ii) the sum of (I) the total reinsurance payments made under subsection (b) to the sponsor of the plan for the year, and (II) the total subsidy payments made under\nsection 1395w\u2013114 of this title\n(B)\nAllowable risk corridor costs\nFor purposes of this subsection, the term \u201callowable risk corridor costs\u201d means, with respect to a prescription drug plan offered by a PDP sponsor or an MA\u2013PD plan offered by an MA organization, the part of costs (not including administrative costs, but including costs directly related to the dispensing of covered part D drugs during the year) incurred by the sponsor or organization under the plan that are actually paid (net of discounts, chargebacks, and average percentage rebates) by the sponsor or organization under the plan, but in no case more than the part of such costs that would have been paid under the plan if the prescription drug coverage under the plan were basic prescription drug coverage, or, in the case of a plan providing supplemental prescription drug coverage, if such coverage were basic prescription drug coverage taking into account the adjustment under\nsection 1395w\u2013111(c)(2) of this title\nsection 1395w\u2013114(a) of this title\n(2)\nAdjustment of payment\n(A)\nNo adjustment if adjusted allowable risk corridor costs within risk corridor\nIf the adjusted allowable risk corridor costs (as defined in paragraph (1)) for the plan for the year are at least equal to the first threshold lower limit of the risk corridor (specified in paragraph (3)(A)(i)), but not greater than the first threshold upper limit of the risk corridor (specified in paragraph (3)(A)(iii)) for the plan for the year, then no payment adjustment shall be made under this subsection.\n(B)\nIncrease in payment if adjusted allowable risk corridor costs above upper limit of risk corridor\n(i)\nCosts between first and second threshold upper limits\nIf the adjusted allowable risk corridor costs for the plan for the year are greater than the first threshold upper limit, but not greater than the second threshold upper limit, of the risk corridor for the plan for the year, the Secretary shall increase the total of the payments made to the sponsor or organization offering the plan for the year under this section by an amount equal to 50 percent (or, for 2006 and 2007, 75 percent or 90 percent if the conditions described in clause (iii) are met for the year) of the difference between such adjusted allowable risk corridor costs and the first threshold upper limit of the risk corridor.\n(ii)\nCosts above second threshold upper limits\nIf the adjusted allowable risk corridor costs for the plan for the year are greater than the second threshold upper limit of the risk corridor for the plan for the year, the Secretary shall increase the total of the payments made to the sponsor or organization offering the plan for the year under this section by an amount equal to the sum of\u2014\n(I) 50 percent (or, for 2006 and 2007, 75 percent or 90 percent if the conditions described in clause (iii) are met for the year) of the difference between the second threshold upper limit and the first threshold upper limit; and\n(II) 80 percent of the difference between such adjusted allowable risk corridor costs and the second threshold upper limit of the risk corridor.\n(iii)\nConditions for application of higher percentage for 2006 and 2007\nThe conditions described in this clause are met for 2006 or 2007 if the Secretary determines with respect to such year that\u2014\n(I) at least 60 percent of prescription drug plans and MA\u2013PD plans to which this subsection applies have adjusted allowable risk corridor costs for the plan for the year that are more than the first threshold upper limit of the risk corridor for the plan for the year; and\n(II) such plans represent at least 60 percent of part D eligible individuals enrolled in any prescription drug plan or MA\u2013PD plan.\n(C)\nReduction in payment if adjusted allowable risk corridor costs below lower limit of risk corridor\n(i)\nCosts between first and second threshold lower limits\nIf the adjusted allowable risk corridor costs for the plan for the year are less than the first threshold lower limit, but not less than the second threshold lower limit, of the risk corridor for the plan for the year, the Secretary shall reduce the total of the payments made to the sponsor or organization offering the plan for the year under this section by an amount (or otherwise recover from the sponsor or organization an amount) equal to 50 percent (or, for 2006 and 2007, 75 percent) of the difference between the first threshold lower limit of the risk corridor and such adjusted allowable risk corridor costs.\n(ii)\nCosts below second threshold lower limit\nIf the adjusted allowable risk corridor costs for the plan for the year are less the second threshold lower limit of the risk corridor for the plan for the year, the Secretary shall reduce the total of the payments made to the sponsor or organization offering the plan for the year under this section by an amount (or otherwise recover from the sponsor or organization an amount) equal to the sum of\u2014\n(I) 50 percent (or, for 2006 and 2007, 75 percent) of the difference between the first threshold lower limit and the second threshold lower limit; and\n(II) 80 percent of the difference between the second threshold upper limit of the risk corridor and such adjusted allowable risk corridor costs.\n(3)\nEstablishment of risk corridors\n(A)\nIn general\nFor each plan year the Secretary shall establish a risk corridor for each prescription drug plan and each MA\u2013PD plan. The risk corridor for a plan for a year shall be equal to a range as follows:\n(i)\nFirst threshold lower limit\nThe first threshold lower limit of such corridor shall be equal to\u2014\n(I) the target amount described in subparagraph (B) for the plan; minus\n(II) an amount equal to the first threshold risk percentage for the plan (as determined under subparagraph (C)(i)) of such target amount.\n(ii)\nSecond threshold lower limit\nThe second threshold lower limit of such corridor shall be equal to\u2014\n(I) the target amount described in subparagraph (B) for the plan; minus\n(II) an amount equal to the second threshold risk percentage for the plan (as determined under subparagraph (C)(ii)) of such target amount.\n(iii)\nFirst threshold upper limit\nThe first threshold upper limit of such corridor shall be equal to the sum of\u2014\n(I) such target amount; and\n(II) the amount described in clause (i)(II).\n(iv)\nSecond threshold upper limit\nThe second threshold upper limit of such corridor shall be equal to the sum of\u2014\n(I) such target amount; and\n(II) the amount described in clause (ii)(II).\n(B)\nTarget amount described\nThe target amount described in this paragraph is, with respect to a prescription drug plan or an MA\u2013PD plan in a year, the total amount of payments paid to the PDP sponsor or MA\u2013PD organization for the plan for the year, taking into account amounts paid by the Secretary and enrollees, based upon the standardized bid amount (as defined in\nsection 1395w\u2013113(a)(5) of this title\n(C)\nFirst and second threshold risk percentage defined\n(i)\nFirst threshold risk percentage\nSubject to clause (iii), for purposes of this section, the first threshold risk percentage is\u2014\n(I) for 2006 and 2007, and\n1\n1 So in original. The word \u201cand\u201d probably should not appear.\n(II) for 2008 through 2011, 5 percent; and\n(III) for 2012 and subsequent years, a percentage established by the Secretary, but in no case less than 5 percent.\n(ii)\nSecond threshold risk percentage\nSubject to clause (iii), for purposes of this section, the second threshold risk percentage is\u2014\n(I) for 2006 and 2007, 5 percent;\n(II) for 2008 through 2011, 10 percent; and\n(III) for 2012 and subsequent years, a percentage established by the Secretary that is greater than the percent established for the year under clause (i)(III), but in no case less than 10 percent.\n(iii)\nReduction of risk percentage to ensure 2 plans in an area\nPursuant to\nsection 1395w\u2013111(b)(2)(E)(ii) of this title\n(4)\nPlans at risk for entire amount of supplemental prescription drug coverage\nA PDP sponsor and MA organization that offers a plan that provides supplemental prescription drug benefits shall be at full financial risk for the provision of such supplemental benefits.\n(5)\nNo effect on monthly premium\nNo adjustment in payments made by reason of this subsection shall affect the monthly beneficiary premium or the MA monthly prescription drug beneficiary premium.\n(f)\nDisclosure of information\n(1)\nIn general\nEach contract under this part and under part C shall provide that\u2014\n(A) the PDP sponsor offering a prescription drug plan or an MA organization offering an MA\u2013PD plan shall provide the Secretary with such information as the Secretary determines is necessary to carry out this section; and\n(B) the Secretary shall have the right in accordance with\nsection 1395w\u201327(d)(2)(B) of this title\nsection 1395w\u2013112(b)(3)(C) of this title\n(2)\nRestriction on use of information\nInformation disclosed or obtained pursuant to the provisions of this section may be used\u2014\n(A) by officers, employees, and contractors of the Department of Health and Human Services for the purposes of, and to the extent necessary in\u2014\n(i) carrying out this section or part E of subchapter XI; and\n(ii) conducting oversight, evaluation, and enforcement under this subchapter;\n(B) by the Attorney General and the Comptroller General of the United States for the purposes of, and to the extent necessary in, carrying out health oversight activities;\n(C) by the Executive Director of the Medicare Payment Advisory Commission for purposes of monitoring, making recommendations for, and analysis of the program under this subchapter and by the Executive Director of the Medicaid and CHIP Payment and Access Commission for purposes of monitoring, making recommendations for, and analysis of the Medicaid program established under subchapter XIX and the Children\u2019s Health Insurance Program under subchapter XXI; and\n(D) by the Director of the Congressional Budget Office for the purposes of analysis of programs authorized under this chapter, as applicable, and the fulfilment of such Director\u2019s duties under the Congressional Budget and Impoundment Control Act of 1974.\n(3)\nAdditional restrictions on disclosure of information\n(A)\nIn general\nThe Executive Directors described in paragraph (2)(C) shall not disclose any of the following information disclosed to such Executive Directors or obtained by such Executive Directors pursuant to such paragraph, with respect to a prescription drug plan offered by a PDP sponsor or an MA\u2013PD plan offered by an MA organization:\n(i) The specific amounts or the identity of the source of any rebates, discounts, price concessions, or other forms of direct or indirect remuneration under such prescription drug plan or such MA\u2013PD plan.\n(ii) Information submitted with the bid submitted under\nsection 1395w\u2013111(b) of this title\nsection 1395w\u201324(a) of this title\n(iii) In the case of such information from prescription drug event records, information in a form that would not be permitted under section 423.505(m) of title 42, Code of Federal Regulations, or any successor regulation, if released by the Centers for Medicare & Medicaid Services.\n(B)\nClarification\nThe restrictions on disclosures described in subparagraph (A) shall also apply to disclosures to individual Commissioners of the Medicare Payment Advisory Commission or of the Medicaid and CHIP Payment and Access Commission.\n(g)\nPayment for fallback prescription drug plans\nIn lieu of the amounts otherwise payable under this section to a PDP sponsor offering a fallback prescription drug plan (as defined in\nsection 1395w\u2013111(g)(4) of this title\n2\n2 See References in Text note below.\nsection 1395w\u2013111(g)(5) of this title\n(h)\nTemporary retrospective subsidy for reduction in cost-sharing and deductible for adult vaccines recommended by the Advisory Committee on Immunization Practices and Insulin During 2023\n(1)\nIn general\nIn addition to amounts otherwise payable under this section to a PDP sponsor of a prescription drug plan or an MA organization offering an MA\u2013PD plan, for plan year 2023, the Secretary shall provide the PDP sponsor or MA organization offering the plan subsidies in an amount equal to the aggregate reduction in cost-sharing and deductible by reason of the application of paragraph (8) or (9) of\nsection 1395w\u2013102(b) of this title\n(2)\nTiming\nThe Secretary shall provide a subsidy under paragraph (1), as applicable, not later than 18 months following the end of the applicable plan year.","url":"https://projectusc.org/usc/t42/s1395w\u2013115.html","content":[{"t":"sec","id":"/us/usc/t42/s1395w\u2013115","children":[{"t":"num","text":"\u00a7\u202f1395w\u2013115."},{"t":"heading","text":"Subsidies for part D eligible individuals for qualified prescription drug coverage"},{"t":"subsec","id":"/us/usc/t42/s1395w\u2013115/a","children":[{"t":"num","text":"(a)"},{"t":"heading","text":"Subsidy payment"},{"t":"chapeau","text":"In order to reduce premium levels applicable to qualified prescription drug coverage for part D eligible individuals consistent with an overall subsidy level of 74.5 percent (or, for each of 2024 through 2029, the percent applicable as a result of the application of ","children":[{"t":"ref","text":"section 1395w\u2013113(a)(8) of this title","href":"/us/usc/t42/s1395w\u2013113/a/8","tail":", or, for 2030 and each subsequent year, 100 percent minus the percent specified under "},{"t":"ref","text":"section 1395w\u2013113(a)(9) of this title","href":"/us/usc/t42/s1395w\u2013113/a/9","tail":") for basic prescription drug coverage, to reduce adverse selection among prescription drug plans and MA\u2013PD plans, and to promote the participation of PDP sponsors under this part and MA organizations under part C, the Secretary shall provide for payment to a PDP sponsor that offers a prescription drug plan and an MA organization that offers an MA\u2013PD plan of the following subsidies in accordance with this section:"}]},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/a/1","children":[{"t":"num","text":"(1)"},{"t":"heading","text":"Direct subsidy"},{"t":"chapeau","text":"A direct subsidy for each part D eligible individual enrolled in a prescription drug plan or MA\u2013PD plan for a month equal to\u2014"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/a/1/A","children":[{"t":"num","text":"(A)"},{"t":"content","text":" the amount of the plan\u2019s standardized bid amount (as defined in ","children":[{"t":"ref","text":"section 1395w\u2013113(a)(5) of this title","href":"/us/usc/t42/s1395w\u2013113/a/5","tail":"), adjusted under subsection (c)(1), reduced by"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/a/1/B","children":[{"t":"num","text":"(B)"},{"t":"content","text":" the base beneficiary premium (as computed under paragraph (2) or (8) of ","children":[{"t":"ref","text":"section 1395w\u2013113(a) of this title","href":"/us/usc/t42/s1395w\u2013113/a","tail":" (as applicable) and as adjusted under paragraph (1)(B) of such section)."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/a/2","children":[{"t":"num","text":"(2)"},{"t":"heading","text":"Subsidy through reinsurance"},{"t":"content","children":[{"t":"p","text":"The reinsurance payment amount (as defined in subsection (b)).","tail":"\n"}],"tail":"\n"}],"tail":"\n\n"},{"t":"continuation","text":"This section constitutes budget authority in advance of appropriations Acts and represents the obligation of the Secretary to provide for the payment of amounts provided under this section.","tail":"\n"}],"tail":"\n"},{"t":"subsec","id":"/us/usc/t42/s1395w\u2013115/b","children":[{"t":"num","text":"(b)"},{"t":"heading","text":"Reinsurance payment amount"},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/b/1","children":[{"t":"num","text":"(1)"},{"t":"heading","text":"In general"},{"t":"chapeau","text":"The reinsurance payment amount under this subsection for a part D eligible individual enrolled in a prescription drug plan or MA\u2013PD plan for a coverage year is an amount equal to\u2014"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/b/1/A","children":[{"t":"num","text":"(A)"},{"t":"content","text":" for a year preceding 2025, 80 percent of the allowable reinsurance costs (as specified in paragraph (2)) attributable to that portion of gross covered prescription drug costs as specified in paragraph (3) incurred in the coverage year after such individual has incurred costs that exceed the annual out-of-pocket threshold specified in ","children":[{"t":"ref","text":"section 1395w\u2013102(b)(4)(B) of this title","href":"/us/usc/t42/s1395w\u2013102/b/4/B","tail":"; and"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/b/1/B","children":[{"t":"num","text":"(B)"},{"t":"chapeau","text":" for 2025 and each subsequent year, the sum of\u2014"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/b/1/B/i","children":[{"t":"num","text":"(i)"},{"t":"content","text":" with respect to applicable drugs (as defined in ","children":[{"t":"ref","text":"section 1395w\u2013114c(g)(2) of this title","href":"/us/usc/t42/s1395w\u2013114c/g/2","tail":"), an amount equal to 20 percent of such allowable reinsurance costs attributable to that portion of gross covered prescription drug costs as specified in paragraph (3) incurred in the coverage year after such individual has incurred costs that exceed the annual out-of-pocket threshold specified in "},{"t":"ref","text":"section 1395w\u2013102(b)(4)(B) of this title","href":"/us/usc/t42/s1395w\u2013102/b/4/B","tail":"; and"}],"tail":"\n"}],"tail":"\n"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/b/1/B/ii","children":[{"t":"num","text":"(ii)"},{"t":"content","text":" with respect to covered part D drugs that are not applicable drugs (as so defined), an amount equal to 40 percent of such allowable reinsurance costs attributable to that portion of gross covered prescription drug costs as specified in paragraph (3) incurred in the coverage year after such individual has incurred costs that exceed the annual out-of-pocket threshold specified in ","children":[{"t":"ref","text":"section 1395w\u2013102(b)(4)(B) of this title","href":"/us/usc/t42/s1395w\u2013102/b/4/B","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/b/2","children":[{"t":"num","text":"(2)"},{"t":"heading","text":"Allowable reinsurance costs"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/b/2/A","children":[{"t":"num","text":"(A)"},{"t":"heading","text":"In general"},{"t":"content","children":[{"t":"p","text":"Subject to subparagraph (B), for purposes of this section, the term \u201callowable reinsurance costs\u201d means, with respect to gross covered prescription drug costs under a prescription drug plan offered by a PDP sponsor or an MA\u2013PD plan offered by an MA organization, the part of such costs that are actually paid (net of discounts, chargebacks, and average percentage rebates) by the sponsor or organization or by (or on behalf of) an enrollee under the plan, but in no case more than the part of such costs that would have been paid under the plan if the prescription drug coverage under the plan were basic prescription drug coverage, or, in the case of a plan providing supplemental prescription drug coverage, if such coverage were standard prescription drug coverage.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/b/2/B","children":[{"t":"num","text":"(B)"},{"t":"heading","text":"Inclusion of manufacturer discounts on applicable drugs"},{"t":"content","children":[{"t":"p","text":"For purposes of applying subparagraph (A), the term \u201callowable reinsurance costs\u201d shall include the portion of the negotiated price (as defined in ","children":[{"t":"ref","text":"section 1395w\u2013114c(g)(6) of this title","href":"/us/usc/t42/s1395w\u2013114c/g/6","tail":") of an applicable drug (as defined in "},{"t":"ref","text":"section 1395w\u2013114c(g)(2) of this title","href":"/us/usc/t42/s1395w\u2013114c/g/2","tail":") that was paid by a manufacturer under the manufacturer discount program under "},{"t":"ref","text":"section 1395w\u2013114c of this title","href":"/us/usc/t42/s1395w\u2013114c","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/b/3","children":[{"t":"num","text":"(3)"},{"t":"heading","text":"Gross covered prescription drug costs"},{"t":"content","children":[{"t":"p","text":"Subject to paragraph (2)(B), for purposes of this section, the term \u201cgross covered prescription drug costs\u201d means, with respect to a part D eligible individual enrolled in a prescription drug plan or MA\u2013PD plan during a coverage year, the costs incurred under the plan, not including administrative costs, but including costs directly related to the dispensing of covered part D drugs during the year and costs relating to the deductible. Such costs shall be determined whether they are paid by the individual or under the plan (or, with respect to 2025 and subsequent years, in the case of an applicable drug, as defined in ","children":[{"t":"ref","text":"section 1395w\u2013114c(g)(2) of this title","href":"/us/usc/t42/s1395w\u2013114c/g/2","tail":", by a manufacturer), regardless of whether the coverage under the plan exceeds basic prescription drug coverage."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/b/4","children":[{"t":"num","text":"(4)"},{"t":"heading","text":"Coverage year defined"},{"t":"content","children":[{"t":"p","text":"For purposes of this section, the term \u201ccoverage year\u201d means a calendar year in which covered part D drugs are dispensed if the claim for such drugs (and payment on such claim) is made not later than such period after the end of such year as the Secretary specifies.","tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subsec","id":"/us/usc/t42/s1395w\u2013115/c","children":[{"t":"num","text":"(c)"},{"t":"heading","text":"Adjustments relating to bids"},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/c/1","children":[{"t":"num","text":"(1)"},{"t":"heading","text":"Health status risk adjustment"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/c/1/A","children":[{"t":"num","text":"(A)"},{"t":"heading","text":"Establishment of risk adjustors"},{"t":"content","children":[{"t":"p","text":"The Secretary shall establish an appropriate methodology for adjusting the standardized bid amount under subsection (a)(1)(A) to take into account variation in costs for basic prescription drug coverage among prescription drug plans and MA\u2013PD plans based on the differences in actuarial risk of different enrollees being served. Any such risk adjustment shall be designed in a manner so as not to result in a change in the aggregate amounts payable to such plans under subsection (a)(1) and through that portion of the monthly beneficiary prescription drug premiums described in subsection (a)(1)(B) and MA monthly prescription drug beneficiary premiums.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/c/1/B","children":[{"t":"num","text":"(B)"},{"t":"heading","text":"Considerations"},{"t":"content","children":[{"t":"p","text":"In establishing the methodology under subparagraph (A), the Secretary may take into account the similar methodologies used under ","children":[{"t":"ref","text":"section 1395w\u201323(a)(3) of this title","href":"/us/usc/t42/s1395w\u201323/a/3","tail":" to adjust payments to MA organizations for benefits under the original medicare fee-for-service program option."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/c/1/C","children":[{"t":"num","text":"(C)"},{"t":"heading","text":"Data collection"},{"t":"chapeau","text":"In order to carry out this paragraph, the Secretary shall require\u2014"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/c/1/C/i","children":[{"t":"num","text":"(i)"},{"t":"content","text":" PDP sponsors to submit data regarding drug claims that can be linked at the individual level to part A and part B data and such other information as the Secretary determines necessary; and","tail":"\n"}],"tail":"\n"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/c/1/C/ii","children":[{"t":"num","text":"(ii)"},{"t":"content","text":" MA organizations that offer MA\u2013PD plans to submit data regarding drug claims that can be linked at the individual level to other data that such organizations are required to submit to the Secretary and such other information as the Secretary determines necessary.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/c/1/D","children":[{"t":"num","text":"(D)"},{"t":"heading","text":"Publication"},{"t":"content","children":[{"t":"p","text":"At the time of publication of risk adjustment factors under ","children":[{"t":"ref","text":"section 1395w\u201323(b)(1)(B)(i)(II) of this title","href":"/us/usc/t42/s1395w\u201323/b/1/B/i/II","tail":", the Secretary shall publish the risk adjusters established under this paragraph for the succeeding year."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/c/2","children":[{"t":"num","text":"(2)"},{"t":"heading","text":"Geographic adjustment"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/c/2/A","children":[{"t":"num","text":"(A)"},{"t":"heading","text":"In general"},{"t":"content","children":[{"t":"p","text":"Subject to subparagraph (B), for purposes of ","children":[{"t":"ref","text":"section 1395w\u2013113(a)(1)(B)(iii) of this title","href":"/us/usc/t42/s1395w\u2013113/a/1/B/iii","tail":", the Secretary shall establish an appropriate methodology for adjusting the national average monthly bid amount (computed under "},{"t":"ref","text":"section 1395w\u2013113(a)(4) of this title","href":"/us/usc/t42/s1395w\u2013113/a/4","tail":") to take into account differences in prices for covered part D drugs among PDP regions."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/c/2/B","children":[{"t":"num","text":"(B)"},{"t":"heading","text":"De minimis rule"},{"t":"content","children":[{"t":"p","text":"If the Secretary determines that the price variations described in subparagraph (A) among PDP regions are de minimis, the Secretary shall not provide for adjustment under this paragraph.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/c/2/C","children":[{"t":"num","text":"(C)"},{"t":"heading","text":"Budget neutral adjustment"},{"t":"content","children":[{"t":"p","text":"Any adjustment under this paragraph shall be applied in a manner so as to not result in a change in the aggregate payments made under this part that would have been made if the Secretary had not applied such adjustment.","tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subsec","id":"/us/usc/t42/s1395w\u2013115/d","children":[{"t":"num","text":"(d)"},{"t":"heading","text":"Payment methods"},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/d/1","children":[{"t":"num","text":"(1)"},{"t":"heading","text":"In general"},{"t":"content","children":[{"t":"p","text":"Payments under this section shall be based on such a method as the Secretary determines. The Secretary may establish a payment method by which interim payments of amounts under this section are made during a year based on the Secretary\u2019s best estimate of amounts that will be payable after obtaining all of the information.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/d/2","children":[{"t":"num","text":"(2)"},{"t":"heading","text":"Requirement for provision of information"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/d/2/A","children":[{"t":"num","text":"(A)"},{"t":"heading","text":"Requirement"},{"t":"content","children":[{"t":"p","text":"Payments under this section to a PDP sponsor or MA organization are conditioned upon the furnishing to the Secretary, in a form and manner specified by the Secretary, of such information as may be required to carry out this section.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/d/2/B","children":[{"t":"num","text":"(B)"},{"t":"heading","text":"Restriction on use of information"},{"t":"content","children":[{"t":"p","text":"Information disclosed or obtained pursuant to subparagraph (A) may be used by officers, employees, and contractors of the Department of Health and Human Services only for the purposes of, and to the extent necessary in, carrying out this section.","tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/d/3","children":[{"t":"num","text":"(3)"},{"t":"heading","text":"Source of payments"},{"t":"content","children":[{"t":"p","text":"Payments under this section shall be made from the Medicare Prescription Drug Account.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/d/4","children":[{"t":"num","text":"(4)"},{"t":"heading","text":"Application of enrollee adjustment"},{"t":"content","children":[{"t":"p","text":"The provisions of ","children":[{"t":"ref","text":"section 1395w\u201323(a)(2) of this title","href":"/us/usc/t42/s1395w\u201323/a/2","tail":" shall apply to payments to PDP sponsors under this section in the same manner as they apply to payments to MA organizations under "},{"t":"ref","text":"section 1395w\u201323(a) of this title","href":"/us/usc/t42/s1395w\u201323/a","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subsec","id":"/us/usc/t42/s1395w\u2013115/e","children":[{"t":"num","text":"(e)"},{"t":"heading","text":"Portion of total payments to a sponsor or organization subject to risk (application of risk corridors)"},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/e/1","children":[{"t":"num","text":"(1)"},{"t":"heading","text":"Computation of adjusted allowable risk corridor costs"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/e/1/A","children":[{"t":"num","text":"(A)"},{"t":"heading","text":"In general"},{"t":"chapeau","text":"For purposes of this subsection, the term \u201cadjusted allowable risk corridor costs\u201d means, for a plan for a coverage year (as defined in subsection (b)(4))\u2014"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/e/1/A/i","children":[{"t":"num","text":"(i)"},{"t":"content","text":" the allowable risk corridor costs (as defined in subparagraph (B)) for the plan for the year, reduced by","tail":"\n"}],"tail":"\n"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/e/1/A/ii","children":[{"t":"num","text":"(ii)"},{"t":"content","text":" the sum of (I) the total reinsurance payments made under subsection (b) to the sponsor of the plan for the year, and (II) the total subsidy payments made under ","children":[{"t":"ref","text":"section 1395w\u2013114 of this title","href":"/us/usc/t42/s1395w\u2013114","tail":" to the sponsor of the plan for the year."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/e/1/B","children":[{"t":"num","text":"(B)"},{"t":"heading","text":"Allowable risk corridor costs"},{"t":"content","children":[{"t":"p","text":"For purposes of this subsection, the term \u201callowable risk corridor costs\u201d means, with respect to a prescription drug plan offered by a PDP sponsor or an MA\u2013PD plan offered by an MA organization, the part of costs (not including administrative costs, but including costs directly related to the dispensing of covered part D drugs during the year) incurred by the sponsor or organization under the plan that are actually paid (net of discounts, chargebacks, and average percentage rebates) by the sponsor or organization under the plan, but in no case more than the part of such costs that would have been paid under the plan if the prescription drug coverage under the plan were basic prescription drug coverage, or, in the case of a plan providing supplemental prescription drug coverage, if such coverage were basic prescription drug coverage taking into account the adjustment under ","children":[{"t":"ref","text":"section 1395w\u2013111(c)(2) of this title","href":"/us/usc/t42/s1395w\u2013111/c/2","tail":". In computing allowable costs under this paragraph, the Secretary shall compute such costs based upon imposition under paragraphs (1)(D) and (2)(E) of "},{"t":"ref","text":"section 1395w\u2013114(a) of this title","href":"/us/usc/t42/s1395w\u2013114/a","tail":" of the maximum amount of copayments permitted under such paragraphs."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/e/2","children":[{"t":"num","text":"(2)"},{"t":"heading","text":"Adjustment of payment"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/e/2/A","children":[{"t":"num","text":"(A)"},{"t":"heading","text":"No adjustment if adjusted allowable risk corridor costs within risk corridor"},{"t":"content","children":[{"t":"p","text":"If the adjusted allowable risk corridor costs (as defined in paragraph (1)) for the plan for the year are at least equal to the first threshold lower limit of the risk corridor (specified in paragraph (3)(A)(i)), but not greater than the first threshold upper limit of the risk corridor (specified in paragraph (3)(A)(iii)) for the plan for the year, then no payment adjustment shall be made under this subsection.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/e/2/B","children":[{"t":"num","text":"(B)"},{"t":"heading","text":"Increase in payment if adjusted allowable risk corridor costs above upper limit of risk corridor"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/e/2/B/i","children":[{"t":"num","text":"(i)"},{"t":"heading","text":"Costs between first and second threshold upper limits"},{"t":"content","children":[{"t":"p","text":"If the adjusted allowable risk corridor costs for the plan for the year are greater than the first threshold upper limit, but not greater than the second threshold upper limit, of the risk corridor for the plan for the year, the Secretary shall increase the total of the payments made to the sponsor or organization offering the plan for the year under this section by an amount equal to 50 percent (or, for 2006 and 2007, 75 percent or 90 percent if the conditions described in clause (iii) are met for the year) of the difference between such adjusted allowable risk corridor costs and the first threshold upper limit of the risk corridor.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/e/2/B/ii","children":[{"t":"num","text":"(ii)"},{"t":"heading","text":"Costs above second threshold upper limits"},{"t":"chapeau","text":"If the adjusted allowable risk corridor costs for the plan for the year are greater than the second threshold upper limit of the risk corridor for the plan for the year, the Secretary shall increase the total of the payments made to the sponsor or organization offering the plan for the year under this section by an amount equal to the sum of\u2014"},{"t":"subclause","id":"/us/usc/t42/s1395w\u2013115/e/2/B/ii/I","children":[{"t":"num","text":"(I)"},{"t":"content","text":" 50 percent (or, for 2006 and 2007, 75 percent or 90 percent if the conditions described in clause (iii) are met for the year) of the difference between the second threshold upper limit and the first threshold upper limit; and","tail":"\n"}],"tail":"\n"},{"t":"subclause","id":"/us/usc/t42/s1395w\u2013115/e/2/B/ii/II","children":[{"t":"num","text":"(II)"},{"t":"content","text":" 80 percent of the difference between such adjusted allowable risk corridor costs and the second threshold upper limit of the risk corridor.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/e/2/B/iii","children":[{"t":"num","text":"(iii)"},{"t":"heading","text":"Conditions for application of higher percentage for 2006 and 2007"},{"t":"chapeau","text":"The conditions described in this clause are met for 2006 or 2007 if the Secretary determines with respect to such year that\u2014"},{"t":"subclause","id":"/us/usc/t42/s1395w\u2013115/e/2/B/iii/I","children":[{"t":"num","text":"(I)"},{"t":"content","text":" at least 60 percent of prescription drug plans and MA\u2013PD plans to which this subsection applies have adjusted allowable risk corridor costs for the plan for the year that are more than the first threshold upper limit of the risk corridor for the plan for the year; and","tail":"\n"}],"tail":"\n"},{"t":"subclause","id":"/us/usc/t42/s1395w\u2013115/e/2/B/iii/II","children":[{"t":"num","text":"(II)"},{"t":"content","text":" such plans represent at least 60 percent of part D eligible individuals enrolled in any prescription drug plan or MA\u2013PD plan.","tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/e/2/C","children":[{"t":"num","text":"(C)"},{"t":"heading","text":"Reduction in payment if adjusted allowable risk corridor costs below lower limit of risk corridor"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/e/2/C/i","children":[{"t":"num","text":"(i)"},{"t":"heading","text":"Costs between first and second threshold lower limits"},{"t":"content","children":[{"t":"p","text":"If the adjusted allowable risk corridor costs for the plan for the year are less than the first threshold lower limit, but not less than the second threshold lower limit, of the risk corridor for the plan for the year, the Secretary shall reduce the total of the payments made to the sponsor or organization offering the plan for the year under this section by an amount (or otherwise recover from the sponsor or organization an amount) equal to 50 percent (or, for 2006 and 2007, 75 percent) of the difference between the first threshold lower limit of the risk corridor and such adjusted allowable risk corridor costs.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/e/2/C/ii","children":[{"t":"num","text":"(ii)"},{"t":"heading","text":"Costs below second threshold lower limit"},{"t":"chapeau","text":"If the adjusted allowable risk corridor costs for the plan for the year are less the second threshold lower limit of the risk corridor for the plan for the year, the Secretary shall reduce the total of the payments made to the sponsor or organization offering the plan for the year under this section by an amount (or otherwise recover from the sponsor or organization an amount) equal to the sum of\u2014"},{"t":"subclause","id":"/us/usc/t42/s1395w\u2013115/e/2/C/ii/I","children":[{"t":"num","text":"(I)"},{"t":"content","text":" 50 percent (or, for 2006 and 2007, 75 percent) of the difference between the first threshold lower limit and the second threshold lower limit; and","tail":"\n"}],"tail":"\n"},{"t":"subclause","id":"/us/usc/t42/s1395w\u2013115/e/2/C/ii/II","children":[{"t":"num","text":"(II)"},{"t":"content","text":" 80 percent of the difference between the second threshold upper limit of the risk corridor and such adjusted allowable risk corridor costs.","tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/e/3","children":[{"t":"num","text":"(3)"},{"t":"heading","text":"Establishment of risk corridors"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/e/3/A","children":[{"t":"num","text":"(A)"},{"t":"heading","text":"In general"},{"t":"chapeau","text":"For each plan year the Secretary shall establish a risk corridor for each prescription drug plan and each MA\u2013PD plan. The risk corridor for a plan for a year shall be equal to a range as follows:"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/e/3/A/i","children":[{"t":"num","text":"(i)"},{"t":"heading","text":"First threshold lower limit"},{"t":"chapeau","text":"The first threshold lower limit of such corridor shall be equal to\u2014"},{"t":"subclause","id":"/us/usc/t42/s1395w\u2013115/e/3/A/i/I","children":[{"t":"num","text":"(I)"},{"t":"content","text":" the target amount described in subparagraph (B) for the plan; minus","tail":"\n"}],"tail":"\n"},{"t":"subclause","id":"/us/usc/t42/s1395w\u2013115/e/3/A/i/II","children":[{"t":"num","text":"(II)"},{"t":"content","text":" an amount equal to the first threshold risk percentage for the plan (as determined under subparagraph (C)(i)) of such target amount.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/e/3/A/ii","children":[{"t":"num","text":"(ii)"},{"t":"heading","text":"Second threshold lower limit"},{"t":"chapeau","text":"The second threshold lower limit of such corridor shall be equal to\u2014"},{"t":"subclause","id":"/us/usc/t42/s1395w\u2013115/e/3/A/ii/I","children":[{"t":"num","text":"(I)"},{"t":"content","text":" the target amount described in subparagraph (B) for the plan; minus","tail":"\n"}],"tail":"\n"},{"t":"subclause","id":"/us/usc/t42/s1395w\u2013115/e/3/A/ii/II","children":[{"t":"num","text":"(II)"},{"t":"content","text":" an amount equal to the second threshold risk percentage for the plan (as determined under subparagraph (C)(ii)) of such target amount.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/e/3/A/iii","children":[{"t":"num","text":"(iii)"},{"t":"heading","text":"First threshold upper limit"},{"t":"chapeau","text":"The first threshold upper limit of such corridor shall be equal to the sum of\u2014"},{"t":"subclause","id":"/us/usc/t42/s1395w\u2013115/e/3/A/iii/I","children":[{"t":"num","text":"(I)"},{"t":"content","text":" such target amount; and","tail":"\n"}],"tail":"\n"},{"t":"subclause","id":"/us/usc/t42/s1395w\u2013115/e/3/A/iii/II","children":[{"t":"num","text":"(II)"},{"t":"content","text":" the amount described in clause (i)(II).","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/e/3/A/iv","children":[{"t":"num","text":"(iv)"},{"t":"heading","text":"Second threshold upper limit"},{"t":"chapeau","text":"The second threshold upper limit of such corridor shall be equal to the sum of\u2014"},{"t":"subclause","id":"/us/usc/t42/s1395w\u2013115/e/3/A/iv/I","children":[{"t":"num","text":"(I)"},{"t":"content","text":" such target amount; and","tail":"\n"}],"tail":"\n"},{"t":"subclause","id":"/us/usc/t42/s1395w\u2013115/e/3/A/iv/II","children":[{"t":"num","text":"(II)"},{"t":"content","text":" the amount described in clause (ii)(II).","tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/e/3/B","children":[{"t":"num","text":"(B)"},{"t":"heading","text":"Target amount described"},{"t":"content","children":[{"t":"p","text":"The target amount described in this paragraph is, with respect to a prescription drug plan or an MA\u2013PD plan in a year, the total amount of payments paid to the PDP sponsor or MA\u2013PD organization for the plan for the year, taking into account amounts paid by the Secretary and enrollees, based upon the standardized bid amount (as defined in ","children":[{"t":"ref","text":"section 1395w\u2013113(a)(5) of this title","href":"/us/usc/t42/s1395w\u2013113/a/5","tail":" and as risk adjusted under subsection (c)(1)), reduced by the total amount of administrative expenses for the year assumed in such standardized bid."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/e/3/C","children":[{"t":"num","text":"(C)"},{"t":"heading","text":"First and second threshold risk percentage defined"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/e/3/C/i","children":[{"t":"num","text":"(i)"},{"t":"heading","text":"First threshold risk percentage"},{"t":"chapeau","text":"Subject to clause (iii), for purposes of this section, the first threshold risk percentage is\u2014"},{"t":"subclause","id":"/us/usc/t42/s1395w\u2013115/e/3/C/i/I","children":[{"t":"num","text":"(I)"},{"t":"content","text":" for 2006 and 2007, and\u202f","children":[{"t":"ref","text":"1"},{"t":"num","text":"1","tail":"\u202fSo in original. The word \u201cand\u201d probably should not appear."},{"t":"text","text":"\u202fSo in original. The word \u201cand\u201d probably should not appear.","tail":" 2.5 percent;"}],"tail":"\n"}],"tail":"\n"},{"t":"subclause","id":"/us/usc/t42/s1395w\u2013115/e/3/C/i/II","children":[{"t":"num","text":"(II)"},{"t":"content","text":" for 2008 through 2011, 5 percent; and","tail":"\n"}],"tail":"\n"},{"t":"subclause","id":"/us/usc/t42/s1395w\u2013115/e/3/C/i/III","children":[{"t":"num","text":"(III)"},{"t":"content","text":" for 2012 and subsequent years, a percentage established by the Secretary, but in no case less than 5 percent.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/e/3/C/ii","children":[{"t":"num","text":"(ii)"},{"t":"heading","text":"Second threshold risk percentage"},{"t":"chapeau","text":"Subject to clause (iii), for purposes of this section, the second threshold risk percentage is\u2014"},{"t":"subclause","id":"/us/usc/t42/s1395w\u2013115/e/3/C/ii/I","children":[{"t":"num","text":"(I)"},{"t":"content","text":" for 2006 and 2007, 5 percent;","tail":"\n"}],"tail":"\n"},{"t":"subclause","id":"/us/usc/t42/s1395w\u2013115/e/3/C/ii/II","children":[{"t":"num","text":"(II)"},{"t":"content","text":" for 2008 through 2011, 10 percent; and","tail":"\n"}],"tail":"\n"},{"t":"subclause","id":"/us/usc/t42/s1395w\u2013115/e/3/C/ii/III","children":[{"t":"num","text":"(III)"},{"t":"content","text":" for 2012 and subsequent years, a percentage established by the Secretary that is greater than the percent established for the year under clause (i)(III), but in no case less than 10 percent.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/e/3/C/iii","children":[{"t":"num","text":"(iii)"},{"t":"heading","text":"Reduction of risk percentage to ensure 2 plans in an area"},{"t":"content","children":[{"t":"p","text":"Pursuant to ","children":[{"t":"ref","text":"section 1395w\u2013111(b)(2)(E)(ii) of this title","href":"/us/usc/t42/s1395w\u2013111/b/2/E/ii","tail":", a PDP sponsor may submit a bid that requests a decrease in the applicable first or second threshold risk percentages or an increase in the percents applied under paragraph (2)."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/e/4","children":[{"t":"num","text":"(4)"},{"t":"heading","text":"Plans at risk for entire amount of supplemental prescription drug coverage"},{"t":"content","children":[{"t":"p","text":"A PDP sponsor and MA organization that offers a plan that provides supplemental prescription drug benefits shall be at full financial risk for the provision of such supplemental benefits.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/e/5","children":[{"t":"num","text":"(5)"},{"t":"heading","text":"No effect on monthly premium"},{"t":"content","children":[{"t":"p","text":"No adjustment in payments made by reason of this subsection shall affect the monthly beneficiary premium or the MA monthly prescription drug beneficiary premium.","tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subsec","id":"/us/usc/t42/s1395w\u2013115/f","children":[{"t":"num","text":"(f)"},{"t":"heading","text":"Disclosure of information"},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/f/1","children":[{"t":"num","text":"(1)"},{"t":"heading","text":"In general"},{"t":"chapeau","text":"Each contract under this part and under part C shall provide that\u2014"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/f/1/A","children":[{"t":"num","text":"(A)"},{"t":"content","text":" the PDP sponsor offering a prescription drug plan or an MA organization offering an MA\u2013PD plan shall provide the Secretary with such information as the Secretary determines is necessary to carry out this section; and","tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/f/1/B","children":[{"t":"num","text":"(B)"},{"t":"content","text":" the Secretary shall have the right in accordance with ","children":[{"t":"ref","text":"section 1395w\u201327(d)(2)(B) of this title","href":"/us/usc/t42/s1395w\u201327/d/2/B","tail":" (as applied under "},{"t":"ref","text":"section 1395w\u2013112(b)(3)(C) of this title","href":"/us/usc/t42/s1395w\u2013112/b/3/C","tail":") to inspect and audit any books and records of a PDP sponsor or MA organization that pertain to the information regarding costs provided to the Secretary under subparagraph (A)."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/f/2","children":[{"t":"num","text":"(2)"},{"t":"heading","text":"Restriction on use of information"},{"t":"chapeau","text":"Information disclosed or obtained pursuant to the provisions of this section may be used\u2014"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/f/2/A","children":[{"t":"num","text":"(A)"},{"t":"chapeau","text":" by officers, employees, and contractors of the Department of Health and Human Services for the purposes of, and to the extent necessary in\u2014"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/f/2/A/i","children":[{"t":"num","text":"(i)"},{"t":"content","text":" carrying out this section or part E of subchapter XI; and","tail":"\n"}],"tail":"\n"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/f/2/A/ii","children":[{"t":"num","text":"(ii)"},{"t":"content","text":" conducting oversight, evaluation, and enforcement under this subchapter;","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/f/2/B","children":[{"t":"num","text":"(B)"},{"t":"content","text":" by the Attorney General and the Comptroller General of the United States for the purposes of, and to the extent necessary in, carrying out health oversight activities;","tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/f/2/C","children":[{"t":"num","text":"(C)"},{"t":"content","text":" by the Executive Director of the Medicare Payment Advisory Commission for purposes of monitoring, making recommendations for, and analysis of the program under this subchapter and by the Executive Director of the Medicaid and CHIP Payment and Access Commission for purposes of monitoring, making recommendations for, and analysis of the Medicaid program established under subchapter XIX and the Children\u2019s Health Insurance Program under subchapter XXI; and","tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/f/2/D","children":[{"t":"num","text":"(D)"},{"t":"content","text":" by the Director of the Congressional Budget Office for the purposes of analysis of programs authorized under this chapter, as applicable, and the fulfilment of such Director\u2019s duties under the Congressional Budget and Impoundment Control Act of 1974.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/f/3","children":[{"t":"num","text":"(3)"},{"t":"heading","text":"Additional restrictions on disclosure of information"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/f/3/A","children":[{"t":"num","text":"(A)"},{"t":"heading","text":"In general"},{"t":"chapeau","text":"The Executive Directors described in paragraph (2)(C) shall not disclose any of the following information disclosed to such Executive Directors or obtained by such Executive Directors pursuant to such paragraph, with respect to a prescription drug plan offered by a PDP sponsor or an MA\u2013PD plan offered by an MA organization:"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/f/3/A/i","children":[{"t":"num","text":"(i)"},{"t":"content","text":" The specific amounts or the identity of the source of any rebates, discounts, price concessions, or other forms of direct or indirect remuneration under such prescription drug plan or such MA\u2013PD plan.","tail":"\n"}],"tail":"\n"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/f/3/A/ii","children":[{"t":"num","text":"(ii)"},{"t":"content","text":" Information submitted with the bid submitted under ","children":[{"t":"ref","text":"section 1395w\u2013111(b) of this title","href":"/us/usc/t42/s1395w\u2013111/b","tail":" by such PDP sponsor or under "},{"t":"ref","text":"section 1395w\u201324(a) of this title","href":"/us/usc/t42/s1395w\u201324/a","tail":" by such MA organization."}],"tail":"\n"}],"tail":"\n"},{"t":"clause","id":"/us/usc/t42/s1395w\u2013115/f/3/A/iii","children":[{"t":"num","text":"(iii)"},{"t":"content","text":" In the case of such information from prescription drug event records, information in a form that would not be permitted under section 423.505(m) of title 42, Code of Federal Regulations, or any successor regulation, if released by the Centers for Medicare & Medicaid Services.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013115/f/3/B","children":[{"t":"num","text":"(B)"},{"t":"heading","text":"Clarification"},{"t":"content","children":[{"t":"p","text":"The restrictions on disclosures described in subparagraph (A) shall also apply to disclosures to individual Commissioners of the Medicare Payment Advisory Commission or of the Medicaid and CHIP Payment and Access Commission.","tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subsec","id":"/us/usc/t42/s1395w\u2013115/g","children":[{"t":"num","text":"(g)"},{"t":"heading","text":"Payment for fallback prescription drug plans"},{"t":"content","children":[{"t":"p","text":"In lieu of the amounts otherwise payable under this section to a PDP sponsor offering a fallback prescription drug plan (as defined in ","children":[{"t":"ref","text":"section 1395w\u2013111(g)(4) of this title","href":"/us/usc/t42/s1395w\u2013111/g/4","tail":"\u202f"},{"t":"ref","text":"2"},{"t":"num","text":"2","tail":"\u202fSee References in Text note below."},{"t":"text","text":"\u202fSee References in Text note below.","tail":"), the amount payable shall be the amounts determined under the contract for such plan pursuant to "},{"t":"ref","text":"section 1395w\u2013111(g)(5) of this title","href":"/us/usc/t42/s1395w\u2013111/g/5","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subsec","id":"/us/usc/t42/s1395w\u2013115/h","children":[{"t":"num","text":"(h)"},{"t":"heading","text":"Temporary retrospective subsidy for reduction in cost-sharing and deductible for adult vaccines recommended by the Advisory Committee on Immunization Practices and Insulin During 2023"},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/h/1","children":[{"t":"num","text":"(1)"},{"t":"heading","text":"In general"},{"t":"content","children":[{"t":"p","text":"In addition to amounts otherwise payable under this section to a PDP sponsor of a prescription drug plan or an MA organization offering an MA\u2013PD plan, for plan year 2023, the Secretary shall provide the PDP sponsor or MA organization offering the plan subsidies in an amount equal to the aggregate reduction in cost-sharing and deductible by reason of the application of paragraph (8) or (9) of ","children":[{"t":"ref","text":"section 1395w\u2013102(b) of this title","href":"/us/usc/t42/s1395w\u2013102/b","tail":" for individuals under the plan during the year."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013115/h/2","children":[{"t":"num","text":"(2)"},{"t":"heading","text":"Timing"},{"t":"content","children":[{"t":"p","text":"The Secretary shall provide a subsidy under paragraph (1), as applicable, not later than 18 months following the end of the applicable plan year.","tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"text","text":"\n"},{"t":"text","text":"\n"}]}]}