HR 6757 — Insulin Savings for Patients Act

(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 A part D eligible individual who is not enrolled in an MA plan may obtain qualified prescription drug coverage through enrollment in a prescription drug plan (as defined in section 1395w–151(a)(14) of this title). (B) Medicare Advantage enrollees (i) Enrollees in a plan providing qualified prescription drug coverage receive coverage through the plan A part D eligible individual who is enrolled in an MA–PD plan obtains such coverage through such plan. (ii) Limitation on enrollment of MA plan enrollees in prescription drug plans Except as provided in clauses (iii) and (iv), a part D eligible individual who is enrolled in an MA plan may not enroll in a prescription drug plan under this part. (iii) Private fee-for-service enrollees in MA plans not providing qualified prescription drug coverage permitted to enroll in a prescription drug plan A part D eligible individual who is enrolled in an MA private fee-for-service plan (as defined in section 1395w–28(b)(2) of this title) that does not provide qualified prescription drug coverage may obtain qualified prescription drug coverage through enrollment in a prescription drug plan. (iv) Enrollees in MSA plans permitted to enroll in a prescription drug plan A part D eligible individual who is enrolled in an MSA plan (as defined in section 1395w–28(b)(3) of this title) may obtain qualified prescription drug coverage through enrollment in a prescription drug plan. (2) Coverage first effective January 1, 2006 Coverage under prescription drug plans and MA–PD plans shall first be effective on January 1, 2006. (3) Definitions For purposes of this part: (A) Part D eligible individual The term “part D eligible individual” means an individual who is entitled to benefits under part A or enrolled under part B (but not including an individual enrolled solely for coverage of immunosuppressive drugs under section 1395o(b) of this title). (B) MA plan The term “MA plan” has the meaning given such term in section 1395w–28(b)(1) of this title. (C) MA–PD plan The term “MA–PD plan” means an MA plan that provides qualified prescription drug coverage. (b) Enrollment process for prescription drug plans (1) Establishment of process (A) In general The Secretary shall establish a process for the enrollment, disenrollment, termination, and change of enrollment of part D eligible individuals in prescription drug plans consistent with this subsection. (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 Section 1395w–21(b)(1)(A) of this title, relating to residence requirements. (ii) Exercise of choice Section 1395w–21(c) of this title (other than paragraph (3)(A) and paragraph (4) of such section), relating to exercise of choice. (iii) Coverage election periods Subject to paragraphs (2) and (3) of this subsection, section 1395w–21(e) of this title (other than subparagraphs (B), (C), (E), and (F) of paragraph (2) and the second sentence of paragraph (4) of such section), relating to coverage election periods, including initial periods, annual coordinated election periods, special election periods, and election periods for exceptional circumstances. (iv) Coverage periods Section 1395w–21(f) of this title, relating to effectiveness of elections and changes of elections. (v) Guaranteed issue and renewal Section 1395w–21(g) of this title (other than pa...

(a) Requirements (1) In general For purposes of this part and part C, the term “qualified prescription drug coverage” means either of the following: (A) Standard prescription drug coverage with access to negotiated prices Standard prescription drug coverage (as defined in subsection (b)) and access to negotiated prices under subsection (d). (B) Alternative prescription drug coverage with at least actuarially equivalent benefits and access to negotiated prices Coverage of covered part D drugs which meets the alternative prescription drug coverage requirements of subsection (c) and access to negotiated prices under subsection (d), but only if the benefit design of such coverage is approved by the Secretary, as provided under subsection (c). (2) Permitting supplemental prescription drug coverage (A) In general Subject to subparagraph (B), qualified prescription drug coverage may include supplemental prescription drug coverage consisting of either or both of the following: (i) Certain reductions in cost-sharing (I) In general A reduction in the annual deductible, a reduction in the coinsurance percentage or, for a year preceding 2025, an increase in the initial coverage limit with respect to covered part D drugs, or any combination thereof, insofar as such a reduction or increase increases the actuarial value of benefits above the actuarial value of basic prescription drug coverage. (II) Construction Nothing in this paragraph shall be construed as affecting the application of subsection (c)(3). (ii) Optional drugs Coverage of any product that would be a covered part D drug but for the application of subsection (e)(2)(A). (B) Requirement A PDP sponsor may not offer a prescription drug plan that provides supplemental prescription drug coverage pursuant to subparagraph (A) in an area unless the sponsor also offers a prescription drug plan in the area that only provides basic prescription drug coverage. (3) Basic prescription drug coverage For purposes of this part and part C, the term “basic prescription drug coverage” means either of the following: (A) Coverage that meets the requirements of paragraph (1)(A). (B) Coverage that meets the requirements of paragraph (1)(B) but does not have any supplemental prescription drug coverage described in paragraph (2)(A). (4) Application of secondary payor provisions The provisions of section 1395w–22(a)(4) of this title shall apply under this part in the same manner as they apply under part C. (5) Construction Nothing in this subsection shall be construed as changing the computation of incurred costs under subsection (b)(4). (b) Standard prescription drug coverage For purposes of this part and part C, the term “standard prescription drug coverage” means coverage of covered part D drugs that meets the following requirements: (1) Deductible (A) In general Subject to paragraphs (8) and (9), the coverage has an annual deductible— (i) for 2006, that is equal to $250; or (ii) for a subsequent year, that is equal to the amount specified under this paragraph for the previous year increased by the percentage specified in paragraph (6) for the year involved. (B) Rounding Any amount determined under subparagraph (A)(ii) that is not a multiple of $5 shall be rounded to the nearest multiple of $5. (2) Benefit structure (A) 25 percent coinsurance Subject to subparagraphs (C), (D), and (E) and paragraphs (8) and (9), the coverage has coinsurance (for costs above the annual deductible specified in paragraph (1) and up to the initial coverage limit under paragraph (3) for a year preceding 2025 and for costs above the annual deductible specified in paragraph (1) and up to the annual out-of-pocket threshold specified in paragraph (4)(B) for 2025 and each subsequent year) that is— (i) equal to 25 percent; or (ii) actuarially equivalent (using processes and methods established under section 1395w–111(c) of this title) to an average expected payment of 25 percent of such costs. (B) Use of tiers Nothing in this p...