42 USC 1395w-101 - Eligibility, enrollment, and information

U.S Code last checked for updates: Nov 22, 2024

§ 1395w–101.

Eligibility, enrollment, and information

(a)

Provision of qualified prescription drug coverage through enrollment in plans

(1)

In general

Subject to the succeeding provisions of this part, each part D eligible individual (as defined in paragraph (3)(A)) is entitled to obtain qualified prescription drug coverage (described in section 1395w–102(a) of this title) as follows:

(A)

Fee-for-service enrollees may receive coverage through a prescription drug plan

(B)

Medicare Advantage enrollees

(i)

Enrollees in a plan providing qualified prescription drug coverage receive coverage through the plan

(ii)

Limitation on enrollment of MA plan enrollees in prescription drug plans

(iii)

Private fee-for-service enrollees in MA plans not providing qualified prescription drug coverage permitted to enroll in a prescription drug plan

(iv)

Enrollees in MSA plans permitted to enroll in a prescription drug plan

(2)

Coverage first effective January 1, 2006

(3)

Definitions

For purposes of this part:

(A)

Part D eligible individual

(B)

MA plan

(C)

MA–PD plan

(b)

Enrollment process for prescription drug plans

(1)

Establishment of process

(A)

In general

(B)

Application of MA rules

In establishing such process, the Secretary shall use rules similar to (and coordinated with) the rules for enrollment, disenrollment, termination, and change of enrollment with an MA–PD plan under the following provisions of section 1395w–21 of this title:

(i)

Residence requirements

(ii)

Exercise of choice

(iii)

Coverage election periods

(iv)

Coverage periods

(v)

Guaranteed issue and renewal

(vi)

Marketing material and application forms

In applying clauses (ii), (iv), and (v) of this subparagraph, any reference to section 1395w–21(e) of this title shall be treated as a reference to such section as applied pursuant to clause (iii) of this subparagraph.

(C)

Special rule

(D)

Special rule for plans that waive de minimis premiums

(2)

Initial enrollment period

(A)

Program initiation

(B)

Continuing periods

(3)

Additional special enrollment periods

The Secretary shall establish special enrollment periods, including the following:

(A)

Involuntary loss of creditable prescription drug coverage

(i)

In general

(ii)

Notice

(iii)

Failure to pay premium

(iv)

Reduction in coverage

(B)

Errors in enrollment

(C)

Exceptional circumstances

(D)

Medicaid coverage

(E)

Discontinuance of MA–PD election during first year of eligibility

(4)

Information to facilitate enrollment

(A)

In general

(B)

Limitation

(i)

Provision of information

(ii)

Use of information

(5)

Reference to enrollment procedures for MA–PD plans

(6)

Reference to penalties for late enrollment

(A)

enroll in a prescription drug plan or an MA–PD plan after the initial enrollment period described in paragraph (2); and

(B)

fail to maintain continuous creditable prescription drug coverage during the period of non-enrollment.

(c)

Providing information to beneficiaries

(1)

Activities

(2)

Requirements

The activities described in paragraph (1) shall—

(A)

be similar to the activities performed by the Secretary under section 1395w–21(d) of this title, including dissemination (including through the toll-free telephone number 1–800–MEDICARE) of comparative information for prescription drug plans and MA–PD plans; and

(B)

be coordinated with the activities performed by the Secretary under such section and under section 1395b–2 of this title.

(3)

Comparative information

(A)

In general

Subject to subparagraph (B), the comparative information referred to in paragraph (2)(A) shall include a comparison of the following with respect to qualified prescription drug coverage:

(i)

Benefits

(ii)

Monthly beneficiary premium

(iii)

Quality and performance

(iv)

Beneficiary cost-sharing

(v)

Consumer satisfaction surveys

(B)

Exception for unavailability of information

The Secretary is not required to provide comparative information under clauses (iii) and (v) of subparagraph (A) with respect to a plan—

(i)

for the first plan year in which it is offered; and

(ii)

for the next plan year if it is impracticable or the information is otherwise unavailable.

(4)

Information on late enrollment penalty

(Aug. 14, 1935, ch. 531, title XVIII, § 1860D–1, as added Pub. L. 108–173, title I, § 101(a)(2), Dec. 8, 2003, 117 Stat. 2071; amended Pub. L. 109–432, div. B, title II, § 206(b), Dec. 20, 2006, 120 Stat. 2990; Pub. L. 111–148, title III, § 3303(b), Mar. 23, 2010, 124 Stat. 469; Pub. L. 114–10, title II, § 209(b)(2)(B)(ii), Apr. 16, 2015, 129 Stat. 149; Pub. L. 114–198, title VII, § 704(a)(3), July 22, 2016, 130 Stat. 748; Pub. L. 116–260, div. CC, title IV, § 402(g), Dec. 27, 2020, 134 Stat. 3002.)

cite as: 42 USC 1395w-101