SUMMARY OF MEDICARE
PRESCRIPTION DRUG DISCOUNT CARDS
AS PASSED BY CONGRESS NOVEMBER 25, 2003
PRESCRIPTION DRUG DISCOUNT CARDS
Card holders will have access to negotiated prices.
Card holders will have access to convenient pharmacies that dispense the covered discount card drugs at negotiated prices.
A discount card eligible individual is an individual who:
is entitled to Medicare benefits or enrolled under Part A or enrolled under Part B; and
who is not entitled to any medical assistance for outpatient prescribed drugs or for discount cards due to enrollment under Title XIX or under a § 1115 waiver.
The Secretary shall provide for appropriate rules for the treatment of medically needy individuals as discount card eligible individuals and as transitional assistance eligible individuals.
Annual Enrollment Fee
Annual enrollment fee cannot exceed $30.00.
The annual enrollment fee for transitional assistance eligible individuals shall be paid by the Secretary.
The State may pay enrollment fees for enrollees who are not transitional assistance eligible individuals.
The Secretary shall provide special rules in the case of payment of an annual enrollment fee for a discount card eligible individual who changes endorsed programs during a year.
Enrollment Period: Continuous Open Enrollment for the duration of the program.
Enrollment in Only One Program
An enrollee may be enrolled in only one Program.
Once enrolled in a Program, enrollees will not be able to change Programs until the next year unless exceptional circumstances exist.
Enrollees who change residences and are thus outside of their Programs’ service areas may change Programs.
Secretary may recognize other exceptional circumstances.
If the discount card eligible individual is enrolled in a plan under Medicare Part C (e.g., Medicare HMO) and that plan offers an endorsed discount card program, then that individual may only enroll in that particular plan.
An enrollee may voluntarily disenroll from a Program. In the case of such a voluntary disenrollment, the individual may not enroll in another endorsed program, except under exceptional circumstances or during the annual coordinated enrollment period.
An enrollee who is not a transitional assistance eligible individual may be disenrolled by the program’s Sponsor for failure to pay the annual enrollment fee.
Discount cards and transitional assistance are to be
available not later than six months after the date of the law’s enactment.
Information shall be disseminated at least thirty days
prior to the initial enrollment date which compares the annual enrollment
fees and other features of the various Programs (e.g., comparative prices
for covered discount drugs). The information shall include educational
materials on the variability of discounts on prices of covered discount card
drugs under an endorsed program and where possible, be coordinated with the
dissemination of educational materials on other Medicare options.
Transitional Assistance Program
Payment made for annual enrollment fees; and
If the enrollee is not a special transitional assistance eligible individual, payment for 90% of costs incurred for covered discount card drugs obtained through the program.
Payment available for up to $600 of costs in 2004.
Up to $600 in 2005, plus remainder of what was not used in 2004. However, if the enrollee voluntarily disenrolls from a Program without exceptional circumstances, then there will be no rollover of leftover funds.
If the enrollee is a special transitional assistance eligible individual, the payment is 95% of costs incurred.
Transitional Assistance Eligible Individual: A
discount card eligible individual whose income is not more than 135% of
poverty and who does not have coverage, or assistance for covered discount
card drugs under any of the following: Group health plan or health insurance
coverage; Insurance related to uniformed service; or Federal employees’
health benefits program.
Special Transitional Assistance Eligible Individual:
A discount card eligible individual whose income is not more than 100% of
the poverty line.
Self-Certification for Transitional Assistance:
An individual who wishes to be treated as a transitional assistance eligible individual or a special transitional assistance eligible individual shall certify on the enrollment form, through a simplified means specified by the Secretary and under penalty of perjury or similar sanction for false statements, as to the amount of the individual’s income, family size, and individual’s prescription drug coverage (if any) insofar as they relate to eligibility.
A certification may be provided before, on, or after the time of enrollment. Certification lasts for the entire period of the enrollment.
The Secretary shall establish methods to verify eligibility for individuals who seek to enroll in an endorsed program and for individuals who provide a certification for Transitional Assistance.
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