PUBLIC LAW 108–173—DEC. 8, 2003
117 STAT. 2097
to all fallback service areas in a PDP region for a contract period, an entity that— ‘‘(A) meets the requirements to be a PDP sponsor (or would meet such requirements but for the fact that the entity is not a risk-bearing entity); and ‘‘(B) does not submit a bid under section 1860D–11(b) for any prescription drug plan for any PDP region for the first year of such contract period. For purposes of subparagraph (B), an entity shall be treated as submitting a bid with respect to a prescription drug plan if the entity is acting as a subcontractor of a PDP sponsor that is offering such a plan. The previous sentence shall not apply to entities that are subcontractors of an MA organization except insofar as such organization is acting as a PDP sponsor with respect to a prescription drug plan. ‘‘(3) FALLBACK SERVICE AREA.—For purposes of this subsection, the term ‘fallback service area’ means, for a PDP region with respect to a year, any area within such region for which the Secretary determines before the beginning of the year that the access requirements of the first sentence of section 1860D– 3(a) will not be met for part D eligible individuals residing in the area for the year. ‘‘(4) FALLBACK PRESCRIPTION DRUG PLAN.—For purposes of this part, the term ‘fallback prescription drug plan’ means a prescription drug plan that— ‘‘(A) only offers the standard prescription drug coverage and access to negotiated prices described in section 1860D– 2(a)(1)(A) and does not include any supplemental prescription drug coverage; and ‘‘(B) meets such other requirements as the Secretary may specify. ‘‘(5) PAYMENTS UNDER THE CONTRACT.— ‘‘(A) IN GENERAL.—A contract entered into under this subsection shall provide for— ‘‘(i) payment for the actual costs (taking into account negotiated price concessions described in section 1860D–2(d)(1)(B)) of covered part D drugs provided to part D eligible individuals enrolled in a fallback prescription drug plan offered by the entity; and ‘‘(ii) payment of management fees that are tied to performance measures established by the Secretary for the management, administration, and delivery of the benefits under the contract. ‘‘(B) PERFORMANCE MEASURES.—The performance measures established by the Secretary pursuant to subparagraph (A)(ii) shall include at least measures for each of the following: ‘‘(i) COSTS.—The entity contains costs to the Medicare Prescription Drug Account and to part D eligible individuals enrolled in a fallback prescription drug plan offered by the entity through mechanisms such as generic substitution and price discounts. ‘‘(ii) QUALITY PROGRAMS.—The entity provides such enrollees with quality programs that avoid adverse drug reactions and overutilization and reduce medical errors.
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