42 U.S.C. § 1395cc — Special rules for employer-sponsored programs

**(a) Subsidy payment** (1) **In general** — The Secretary shall provide in accordance with this subsection for payment to the sponsor of a qualified retiree prescription drug plan (as defined in paragraph (2)) of a special subsidy payment equal to the amount specified in paragraph (3) for each qualified covered retiree under the plan (as defined in paragraph (4)). This subsection constitutes budget authority in advance of appropriations Acts and represents the obligation of the Secretary to provide for the payment of amounts provided under this section. (2) **Qualified retiree prescription drug plan defined** — For purposes of this subsection, the term “qualified retiree prescription drug plan” means employment-based retiree health coverage (as defined in subsection (c)(1)) if, with respect to a part D eligible individual who is a participant or beneficiary under such coverage, the following requirements are met: (A) *Attestation of actuarial equivalence to standard coverage* — The sponsor of the plan provides the Secretary, annually or at such other time as the Secretary may require, with an attestation that the actuarial value of prescription drug coverage under the plan (as determined using the processes and methods described in [section 1395w–111(c) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w–111/c&num=0&edition=prelim)) is at least equal to the actuarial value of standard prescription drug coverage, not taking into account the value of— (i) for years prior to 2025, any discount or coverage provided during the gap in prescription drug coverage that occurs between the initial coverage limit under [section 1395w–102(b)(3) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w–102/b/3&num=0&edition=prelim) during the year and the out-of-pocket threshold specified in [section 1395w–102(b)(4)(B) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w–102/b/4/B&num=0&edition=prelim); and (ii) for 2025 and each subsequent year, any discount provided pursuant to [section 1395w–114c of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w-114c&num=0&edition=prelim). (B) *Audits* — The sponsor of the plan, or an administrator of the plan designated by the sponsor, shall maintain (and afford the Secretary access to) such records as the Secretary may require for purposes of audits and other oversight activities necessary to ensure the adequacy of prescription drug coverage and the accuracy of payments made under this section. The provisions of [section 1395w–102(d)(3) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w–102/d/3&num=0&edition=prelim) shall apply to such information under this section (including such actuarial value and attestation) in a manner similar to the manner in which they apply to financial records of PDP sponsors and MA organizations. (C) *Provision of disclosure regarding prescription drug coverage* — The sponsor of the plan shall provide for disclosure of information regarding prescription drug coverage in accordance with [section 1395w–113(b)(6)(B) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w–113/b/6/B&num=0&edition=prelim). (3) **Employer and union special subsidy amounts** (A) *In general* — For purposes of this subsection, the special subsidy payment amount under this paragraph for a qualifying covered retiree for a coverage year enrolled with the sponsor of a qualified retiree prescription drug plan is, for the portion of the retiree’s gross covered retiree plan-related prescription drug costs (as defined in subparagraph (C)(ii)) for such year that exceeds the cost threshold amount specified in subparagraph (B) and does not exceed the cost limit under such subparagraph, an amount equal to 28 percent of the allowable retiree costs (as defined in subparagraph (C)(i)) attributable to such gross covered prescription drug costs. (B) *Cost threshold and cost limit applicable* (i) *In general* — Subject to clause (ii)— (I) the cost threshold under this subparagraph is equal to $250 for plan years that end in 2006; and (II) the cost limit under this subparagraph is equal to $5,000 for plan years that end in 2006. (ii) *Indexing* — The cost threshold and cost limit amounts specified in subclauses (I) and (II) of clause (i) for a plan year that ends after 2006 shall be adjusted in the same manner as the annual deductible and the annual out-of-pocket threshold, respectively, are annually adjusted under paragraphs (1) and (4)(B) of [section 1395w–102(b) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w–102/b&num=0&edition=prelim). (C) *Definitions* — For purposes of this paragraph: (i) *Allowable retiree costs* — The term “allowable retiree costs” means, with respect to gross covered prescription drug costs under a qualified retiree prescription drug plan by a plan sponsor, the part of such costs that are actually paid (net of discounts, chargebacks, and average percentage rebates) by the sponsor or by or on behalf of a qualifying covered retiree under the plan. (ii) *Gross covered retiree plan-related prescription drug costs* — For purposes of this section, the term “gross covered retiree plan-related prescription drug costs” means, with respect to a qualifying covered retiree enrolled in a qualified retiree prescription drug plan during a coverage year, the costs incurred under the plan, not including administrative costs, but including costs directly related to the dispensing of covered part D drugs during the year. Such costs shall be determined whether they are paid by the retiree or under the plan. (iii) *Coverage year* — The term “coverage year” has the meaning given such term in [section 1395w–115(b)(4) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w–115/b/4&num=0&edition=prelim). (4) **Qualifying covered retiree defined** — For purposes of this subsection, the term “qualifying covered retiree” means a part D eligible individual who is not enrolled in a prescription drug plan or an MA–PD plan but is covered under a qualified retiree prescription drug plan. (5) **Payment methods, including provision of necessary information** — The provisions of [section 1395w–115(d) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w–115/d&num=0&edition=prelim) (including paragraph (2), relating to requirement for provision of information) shall apply to payments under this subsection in a manner similar to the manner in which they apply to payment under [section 1395w–115(b) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w–115/b&num=0&edition=prelim). (6) **Construction** — Nothing in this subsection shall be construed as— (A) precluding a part D eligible individual who is covered under employment-based retiree health coverage from enrolling in a prescription drug plan or in an MA–PD plan; (B) precluding such employment-based retiree health coverage or an employer or other person from paying all or any portion of any premium required for coverage under a prescription drug plan or MA–PD plan on behalf of such an individual; (C) preventing such employment-based retiree health coverage from providing coverage— (i) that is better than standard prescription drug coverage to retirees who are covered under a qualified retiree prescription drug plan; or (ii) that is supplemental to the benefits provided under a prescription drug plan or an MA–PD plan, including benefits to retirees who are not covered under a qualified retiree prescription drug plan but who are enrolled in such a prescription drug plan or MA–PD plan; or (D) preventing employers to provide for flexibility in benefit design and pharmacy access provisions, without regard to the requirements for basic prescription drug coverage, so long as the actuarial equivalence requirement of paragraph (2)(A) is met. **(b) Application of MA waiver authority** The provisions of [section 1395w–27(i) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w–27/i&num=0&edition=prelim) shall apply with respect to prescription drug plans in relation to employment-based retiree health coverage in a manner similar to the manner in which they apply to an MA plan in relation to employers, including authorizing the establishment of separate premium amounts for enrollees in a prescription drug plan by reason of such coverage and limitations on enrollment to part D eligible individuals enrolled under such coverage, and shall be applied in a manner to facilitate the offering of prescription drug benefits under a Program plan under [section 8903c of title 5](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section8903c&num=0&edition=prelim), as required under subsection (h)(2) of such section, through employment-based retiree health coverage through— (1) a prescription drug plan; or (2) contracts between such a Program plan and the PDP sponsor of such a prescription drug plan..11 So in original. **(c) Definitions** For purposes of this section: (1) **Employment-based retiree health coverage** — The term “employment-based retiree health coverage” means health insurance or other coverage of health care costs (whether provided by voluntary insurance coverage or pursuant to statutory or contractual obligation) for part D eligible individuals (or for such individuals and their spouses and dependents) under a group health plan based on their status as retired participants in such plan. (2) **Sponsor** — The term “sponsor” means a plan sponsor, as defined in [section 1002(16)(B) of title 29](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title29-section1002/16/B&num=0&edition=prelim), in relation to a group health plan, except that, in the case of a plan maintained jointly by one employer and an employee organization and with respect to which the employer is the primary source of financing, such term means such employer. (3) **Group health plan** — The term “group health plan” includes such a plan as defined in [section 1167(1) of title 29](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title29-section1167/1&num=0&edition=prelim) and also includes the following: (A) *Federal and State governmental plans* — Such a plan established or maintained for its employees by the Government of the United States, by the government of any State or political subdivision thereof, or by any agency or instrumentality of any of the foregoing, including a health benefits plan offered under chapter 89 of title 5. (B) *Collectively bargained plans* — Such a plan established or maintained under or pursuant to one or more collective bargaining agreements. (C) *Church plans* — Such a plan established and maintained for its employees (or their beneficiaries) by a church or by a convention or association of churches which is exempt from tax under section 501 of the Internal Revenue Code of 1986.