Common use of Transitional Assistance Clause in Contracts

Transitional Assistance. The conference agreement provides special provisions for low-income persons. A transitional assistance eligible individual will be entitled to have his or her discount card enrollment fee paid. Those individuals with incomes below 100% of poverty (special transitional assistance eligible individuals) would be liable for coinsurance charges of 5% of incurred costs up to $600 in both 2004 and 2005. Other transitional assistance eligible individuals (those with incomes between 100% and 135% of poverty) would be liable for coinsurance charges of 10 % of incurred costs up to $600 in both 2004 and 2005. Thus, the program will pay 95% of a special transitional eligible individual’s incurred drug costs up to $600 in 2004 and 90% of other transitional eligible individual’s incurred drug costs up to $600 in 2004. Similarly, payment would be made for 95% or 90%, whichever is appropriate, of the individual’s incurred drug costs up to $600 in 2005. In addition, any balance left over from 2004 may be added to the amount available in 2005, except no rollover would be permitted if the individual voluntarily disenrolled from an endorsed plan. No funds will be available under this program for covered discount card drugs dispensed after December 31, 2005. The Secretary will provide a method for the reimbursement of card sponsors for transitional assistance. The $600 annual amount is to be prorated in 2004, for persons not enrolling in an endorsed program and providing self-certification prior to the program’s initial implementation date. For 2005, the amount is to be prorated for persons not enrolling in an endorsed program and providing self-certification prior to February 1, 2005. The conference agreement permits a pharmacy to reduce the coinsurance otherwise applicable. It also permits states to pay some or all of the coinsurance for some or all transitional assistance eligible enrollees. The payment would be made directly by the state to the pharmacy. No federal matching payments would be available for these costs; further they could not be considered as Medicare cost-sharing for purposes of the qualified Medicare beneficiary program. The conference agreement includes provisions to ensure access to transitional assistance for qualified residents of long-tem care facilities and American Indians. It requires the Secretary to establish procedures to ensure such access for qualified residents of long-term care facilities. The Secretary could waive requirements of the new Section 1860D-31, as necessary, to negotiate arrangements with sponsors to provide arrangements with pharmacies that support long-term care facilities. The Secretary is also required to establish procedures to ensure that pharmacies operated by the Indian Health Service, Indian tribes and tribal organizations, and urban Indian organizations have the opportunity to participate in the pharmacy networks of at least two endorsed programs in each of the 50 states and the District of Columbia where such a pharmacy operates. Where necessary, the Secretary could waive requirements of the new Section 1860D- 31. The availability of negotiated prices or transitional assistance could not be taken into account in determining an individual’s eligibility for or benefits under any other Federal program. Any nonuniformity of benefits resulting from the implementation of the new Section 1807 (such as the waiver of an enrollment fee) would not be taken into account in calculations of any required additional benefits under Part C.