H.R. 3200/Division B/Title II/Subtitle A

{{SECTION|SEC. 1201.|SEC. 1201}}. IMPROVING ASSETS TESTS FOR MEDICARE SAVINGS PROGRAM AND LOW-INCOME SUBSIDY PROGRAM.

 * (a) Application of Highest Level Permitted Under LIS to All Subsidy Eligible Individuals.—
 * (1) In General.—
 * Section 1860D–14(a)(1) of the Social Security Act (42 U.S.C. 1395w–114(a)(1)) is amended in the matter before subparagraph (A), by inserting ``(or, beginning with 2012, paragraph (3)(E))´´ after ``paragraph (3)(D)´´.


 * (2) Annual Increase in LIS Resource Test.—
 * Section 1860D–14(a)(3)(E)(i) of such Act (42 U.S.C. 1395w–114(a)(3)(E)(i)) is amended—
 * (A) by striking ``and´´ at the end of subclause (I);


 * (B) in subclause (II), by inserting ``(before 2012)´´ after ``subsequent year´´;


 * (C) by striking the period at the end of subclause (II) and inserting a semicolon;


 * (D) by inserting after subclause (II) the following new subclauses:


 * ``(III) for 2012, $17,000 (or $34,000 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 subclause (or subclause (III)) 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


 * (E) in the last sentence, by inserting ``or (IV)´´ after ``subclause (II)´´.


 * (3) Application of LIS Test Under Medicare Savings Program.—
 * Section 1905(p)(1)(C) of such Act (42 U.S.C. 1396d(p)(1)(C)) is amended—
 * (A) by striking ``effective beginning with January 1, 2010´´ and inserting ``effective for the period beginning with January 1, 2010, and ending with December 31, 2011´´; and


 * (B) by inserting before the period at the end the following: ``or, effective beginning with January 1, 2012, whose resources (as so determined) do not exceed the maximum resource level applied for the year under subparagraph (E) of section 1860D–14(a)(3) (determined without regard to the life insurance policy exclusion provided under subparagraph (G) of such section) applicable to an individual or to the individual and the individual’s spouse (as the case may be)´´.


 * (b) Effective Date.—
 * The amendments made by subsection (a) shall apply to eligibility determinations for income-related subsidies and medicare cost-sharing furnished for periods beginning on or after January 1, 2012.

{{SECTION|SEC. 1202.|SEC. 1202}}. ELIMINATION OF PART D COST-SHARING FOR CERTAIN NON-INSTITUTIONALIZED FULL-BENEFIT DUAL ELIGIBLE INDIVIDUALS.

 * (a) In General.—
 * Section 1860D–14(a)(1)(D)(i) of the Social Security Act (42 U.S.C. 1395w–114(a)(1)(D)(i)) is amended—


 * (1) by striking ``Institutionalized individuals.—In´´ and inserting ``Elimination of cost-sharing for certain full-benefit dual eligible individuals.—


 * ``(I) Institutionalized individuals.—In´´; and


 * (2) by adding at the end the following new subclause:


 * ``(II) Certain other individuals.—In the case of an individual who is a full-benefit dual eligible individual and with respect to whom there has been a determination that but for the provision of home and community based care (whether under section 1915, 1932, or under a waiver under section 1115) the individual would require the level of care provided in a hospital or a nursing facility or intermediate care facility for the mentally retarded the cost of which could be reimbursed under the State plan under title XIX, the elimination of any beneficiary coinsurance described in section 1860D–2(b)(2) (for all amounts through the total amount of expenditures at which benefits are available under section 1860D–2(b)(4)).´´.


 * (b) Effective Date.—
 * The amendments made by subsection (a) shall apply to drugs dispensed on or after January 1, 2011.

{{SECTION|SEC. 1203.|SEC. 1203}}. ELIMINATING BARRIERS TO ENROLLMENT.

 * (a) Administrative Verification of Income and Resources Under the Low-Income Subsidy Program.—
 * (1) In General.—
 * Clause (iii) of section 1860D–14(a)(3)(E) of the Social Security Act (42 U.S.C. 1395w–114(a)(3)(E)) is amended to read as follows:


 * ``(iii) Certification of income and resources.—For purposes of applying this section—
 * ``(I) an individual shall be permitted to apply on the basis of self-certification of income and resources; and


 * ``(II) matters attested to in the application shall be subject to appropriate methods of verification without the need of the individual to provide additional documentation, except in extraordinary situations as determined by the Commissioner.´´.


 * (2) Effective Date.—
 * The amendment made by paragraph (1) shall apply beginning January 1, 2010.


 * (b) Disclosures to facilitate Identification of Individuals Likely to be Ineligible for the Low-Income Assistance Under the Medicare Prescription Drug Program to Assist Social Security Administration's Outreach to Eligible Individuals.—
 * For provision authorizing disclosure of return information to facilitate identification of individuals likely to be ineligible for low-income subsidies under Medicare prescription drug program, see section 1801.

{{SECTION|SEC. 1204.|SEC. 1204}}. ENHANCED OVERSIGHT RELATING TO REIMBURSEMENTS FOR RETROACTIVE LOW INCOME SUBSIDY ENROLLMENT.

 * (a) In General.—
 * In the case of a retroactive LIS enrollment beneficiary 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), the beneficiary (or any eligible third party) is entitled to reimbursement by the plan for covered drug costs 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 (c)(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 (c)(4)(A)(i) without further information required to be filed with the plan by the beneficiary.


 * (b) Administrative Requirements Relating to Reimbursements.—
 * (1) Line-Item Description.—
 * Each reimbursement made by a prescription drug plan or MA–PD plan under subsection (a) shall include a line-item description of the items for which the reimbursement is made.


 * (2) Timing of Reimbursements.—
 * A prescription drug plan or MA–PD plan must make a reimbursement under subsection (a) to a retroactive LIS enrollment beneficiary, with respect to a claim, not later than 45 days after—
 * (A) in the case of a beneficiary described in subsection (c)(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 (c)(4)(A)(ii), the date on which the beneficiary files the claim with the plan.


 * (3) Reporting Requirement.—
 * For each month beginning with January 2011, each prescription drug plan and each MA–PD plan shall report to the Secretary the following:
 * (A) The number of claims the plan has readjudicated during the month due to a beneficiary becoming retroactively eligible for subsidies available under section 1860D–14 of the Social Security Act.


 * (B) The total value of the readjudicated claim amount for the month.


 * (C) The Medicare Health Insurance Claims Number of beneficiaries for whom claims were readjudicated.


 * (D) For the claims described in subparagraphs (A) and (B), an attestation to the Administrator of the Centers for Medicare & Medicaid Services of the total amount of reimbursement the plan has provided to beneficiaries for premiums and cost-sharing that the beneficiary overpaid for which the plan received payment from the Centers for Medicare & Medicaid Services.


 * (c) Definitions.—
 * For purposes of this section:
 * (1) Covered Drug Costs.—
 * 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) Eligible Third Party.—
 * The term ``eligible third party´´ means, with respect to a retroactive LIS enrollment beneficiary, an organization or other third party that is owed payment on behalf of such beneficiary for covered drug costs incurred by such beneficiary during the retroactive coverage period of such beneficiary.


 * (3) Retroactive Coverage Period.—
 * The 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) In General.—
 * 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), (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 General.—
 * 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) RFP contract described.—
 * 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.

{{SECTION|SEC. 1205.|SEC. 1205}}. INTELLIGENT ASSIGNMENT IN ENROLLMENT.

 * (a) In General.—
 * Section 1860D–1(b)(1)(C) of the Social Security Act (42 U.S.C. 1395w–101(b)(1)(C)) is amended by adding after ``PDP region´´ the following: ``or through use of an intelligent assignment process that is designed to maximize the access of such individual to necessary prescription drugs while minimizing costs to such individual and to the program under this part to the greatest extent possible. In the case the Secretary enrolls such individuals through use of an intelligent assignment process, such process shall take into account the extent to which prescription drugs necessary for the individual are covered in the case of a PDP sponsor of a prescription drug plan that uses a formulary, the use of prior authorization or other restrictions on access to coverage of such prescription drugs by such a sponsor, and the overall quality of a prescription drug plan as measured by quality ratings established by the Secretary.´´


 * (b) Effective Date.—
 * The amendment made by subsection (a) shall take effect for contract years beginning with 2012.

{{SECTION|SEC. 1206.|SEC. 1206}}. SPECIAL ENROLLMENT PERIOD AND AUTOMATIC ENROLLMENT PROCESS FOR CERTAIN SUBSIDY ELIGIBLE INDIVIDUALS.

 * (a) Special Enrollment Period.—
 * Section 1860D–1(b)(3)(D) of the Social Security Act (42 U.S.C. 1395w–101(b)(3)(D)) is amended to read as follows:


 * ``(D) Subsidy eligible individuals.—In the case of an individual (as determined by the Secretary) who is determined under subparagraph (B) of section 1860D–14(a)(3) to be a subsidy eligible individual.´´.


 * (b) Automatic Enrollment.—
 * Section 1860D–1(b)(1) of the Social Security Act (42 U.S.C. 1395w–101(b)(1)) is amended by adding at the end the following new subparagraph:


 * ``(D) Special rule for subsidy eligible individuals.—The process established under subparagraph (A) shall include, in the case of an individual described in section 1860D–1(b)(3)(D) who fails to enroll in a prescription drug plan or an MA–PD plan during the special enrollment established under such section applicable to such individual, the application of the assignment process described in subparagraph (C) to such individual in the same manner as such assignment process applies to a part D eligible individual described in such subparagraph (C). Nothing in the previous sentence shall prevent an individual described in such sentence from declining enrollment in a plan determined appropriate by the Secretary (or in the program under this part) or from changing such enrollment.´´.


 * (c) Effective Date.—
 * The amendments made by this section shall apply to subsidy determinations made for months beginning with January 2011.

{{SECTION|SEC. 1207.|SEC. 1207}}. APPLICATION OF MA PREMIUMS PRIOR TO REBATE IN CALCULATION OF LOW INCOME SUBSIDY BENCHMARK.

 * (a) In General.—
 * Section 1860D–14(b)(2)(B)(iii) of the Social Security Act (42 U.S.C. 1395w–114(b)(2)(B)(iii)) is amended by inserting before the period the following: ``before the application of the monthly rebate computed under section 1854(b)(1)(C)(i) for that plan and year involved´´.


 * (b) Effective Date.—
 * The amendment made by subsection (a) shall apply to subsidy determinations made for months beginning with January 2011.