Part D Rules for MA Plans

10.15 – Part D Rules for MA Plans (Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16) As provided at 42 CFR §422.4(c), an MAO cannot offer an MA coordinated care plan in an area unless that plan or another plan offered by the MAO in that same service area includes Part D prescription drug coverage. Table II provides a summary of the basic requirements for Part D coverage by MA plans. For complete information, please rely on the Part D prescription drug coverage information provided in chapter 5 of the Prescription Drug Benefit Manual. Regardless of whether an MAO offers a coordinated care plan in the area with Part D benefits, all Special Needs plans (SNPs) are required to include Part D prescription drug coverage (see the definition of SNPs at 42 CFR §422.2). Note that Over-the-Counter (OTC) drug benefits are not classified as Part D prescription drug benefits. Table II: Part D Prescription Drug Coverage by Plan Type Plan Type Regional or Local MA Plan? Must offer Part D? Can an enrollee elect a PDP? MA Coordinated Care Plan (CCP) HMO, Point of Service (HMOPOS), Provider Sponsored Organization (PSO) Local Yes, unless another non-SNP MA plan offered by the same organization in the same service area includes required prescription drug coverage under Part D (42 CFR 422.4(c))1. No PPO Either Yes, unless another non-SNP MA plan offered by the same organization in the same service area includes required prescription drug coverage under Part D (42 CFR 422.4(c)). No Special Needs Plan (SNP) Either Yes, required. 42 CFR 422.2 (definition of SNP) No Private Fee-for-Service (PFFS) plan Local No Yes, provided the PFFS plan does not offer Part D coverage. MA Medical Savings Account (MSA) Plan Local Not permitted Yes Section 1876 Cost Plans Cost plan offering qualified Part D prescription drug coverage NA No, but Part D coverage may be offered as an optional supplemental benefit Yes Cost plan offering non-qualified prescription drug coverage NA No. The cost plan cannot offer both Part D coverage and non-qualified prescription drug coverage. Yes Section 1833 HCPP (Health Care Pre-payment Plan) NA No Yes PACE Programs (Program for the All-inclusive Care of the Elderly) NA Yes2 No Notes to Table II: 1. See chapter 5 of the Prescription Drug Benefit manual located at http://www.cms.gov/Medicare/Prescription-Drug- Coverage/PrescriptionDrugCovContra/PartDManuals.html for the definition of required drug coverage. 2. Program for the All-Inclusive Care of the Elderly (PACE) organizations offering PACE Programs, as defined in section 1894 of the Act generally have elected to provide Part D coverage in order to receive payment for the prescription drug coverage that they are statutorily required to provide.