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Medicare Transitional Drug Assistance Program for States
The Department of Health and Human Services is the Federal government's principal agency for protecting the health of all Americans and providing essential human services, especially to those who are least able to help themselves.
Program Accomplishments
In fiscal year 2004 credits are to be made available to each transitional-assistance eligible Medicare beneficiary electing to participate in the program.
Uses and Use Restrictions
Credits will be administered through private discount card sponsors in accordance with the requirements of 42 CFR 403.806, 403.808, and 403.816 for the transitional assistance benefit.
Eligibility Requirements
Applicant Eligibility
A non-governmental, single legal entity doing business in the United States; having three years of private sector experience in the United States in pharmacy benefit management; and at the time of application for Medicare endorsement, it or a subcontractor, operates a pharmacy benefit program, a prescription drug discount card program, a low-income drug assistance program, or a similar program that serves at least one million covered lives and meets the requirements in 42 CFR 403.804 and 42 CFR 403.806.
Beneficiary Eligibility
Individuals who are Medicare beneficiaries, and whose income is not more than 135 percent of the poverty line. To qualify, beneficiaries must not receive outpatient drug coverage from other sources, including Medicaid, TRICARE, group health insurance or Federal Employee Health Benefit Plans (FEHBP), except if the drug coverage is through a Part C Medicare+Choice plan or a Medigap plan. Individuals must have been enrolled in the program by December 31, 2005.
Credentials/Documentation
None.
Aplication and Award Process
Preapplication Coordination
None.
This program is excluded from coverage under E.O.
12372.
Application Procedures
Potential sponsors apply to CMS to become an approved drug discount card sponsor, to administer transitional assistance funds. Beneficiaries complete an enrollment form, which includes eligibility information, and submit it to an approved sponsor. The sponsor forwards the enrollment and eligibility information to CMS, which verifies eligibility for the card and for transitional assistance.
Award Procedures
Transitional assistance funds are drawn down by sponsors through the CMS payments management system on behalf of their transitional assistance enrollees, as the $600 credit is used by beneficiaries to pay for covered discount card drugs.
Deadlines
No further funds are available after the date on which the beneficiary enrolls in the new Medicare Part D drug benefit (first available on January 1, 2006), and in any case not beyond May 15, 2006 (for the beneficiary who does not enroll in Part D by the end of its initial enrollment period).
Authorization
Authorized under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 108-73, Section 1860D-31 of the Social Security Act (the Act).
Range of Approval/Disapproval Time
19 months.
Appeals
Sponsors whose applications to become an approved discount card sponsor are rejected have the right to a reconsideration process. Beneficiaries who are found by CMS to be ineligible for transitional assistance have the option of filing for reconsideration in accordance with 42 CFR 403.810(g).
Renewals
None.
Assistance Considerations
Formula and Matching Requirements
This program has no matching requirements.
Length and Time Phasing of Assistance
Project Period: May 3, 2004 through May 15, 2006.
Post Assistance Requirements
Reports
Periodic reports are due to CMS is accordance with the timeframes established by CMS.
Audits
Payment transactions may be audited by the Secretary or his agent.
Records
Financial records, supporting documents, statistical records, and all other records pertinent to the project shall be retained for at least three years or until resolution of any audit questions.
Financial Information
Account Identification
75-8307-0-7-571.
Obigations
(Benefit Outlays)FY 07 $9,815,000; FY 08 est $0; FY 09 est $0. (Last program benefit adjustments were made in FY 07; program is shut down; no further benefits).
Range and Average of Financial Assistance
Up to $600 in 2004 and 2005 per transitional-assistance eligible Medicare beneficiary electing to participate in the program.
Regulations, Guidelines, and Literature
Regulations governing this program were authorized under Section 1860D-31 of the Social Security Act, as enacted under Public Law 108-73, and were published on December 15, 2003.
Information Contacts
Regional or Local Office
None.
Headquarters Office
Program Contact: Cynthia Moreno, Center for Beneficiary Choices, Health Plan Benefits Group, 7500 Security Boulevard, Baltimore, MD 21244; Telephone: (410) 786-1164.
Criteria for Selecting Proposals
None.
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