US · guidance
CMS Pub. 100-11, ch. 13, § 30.5
Medicare Part D Payment
In order for PACE organizations to continue to meet the statutory requirement of
providing prescription drug coverage to their enrollees, and to ensure that they receive
adequate payment for the provision of Part D drugs, beginning January 1, 2006, PACE
organizations began to offer qualified prescription drug coverage to their enrollees who
are Part D eligible individuals. The MMA did not impact the manner in which PACE
organizations are paid for the provision of outpatient prescription drugs to non-part D
eligible PACE participants.
PACE organizations are required to annually submit two Part D bids: one for a Plan
Benefit Package (PBP) for dually eligible enrollees and one for a PBP for Medicare-only
enrollees. The Part D payment to PACE organizations comprises several pieces,
including the direct subsidy, reinsurance payments, and risk sharing. Payments for
eligible enrollees of either PBP will include a low-income premium subsidy and a low-income cost-sharing subsidy for basic Part D benefits. Payments for dually eligible
enrollees will also include an additional amount to cover nominal cost sharing amounts
(“2% capitation”), and an additional premium payment in situations where the PACE
plan’s basic Part D beneficiary premium is greater than the regional low-income premium
subsidy amount.
[PACE Program Agreement Appendix M: Medicare and Medicaid Payment Amounts]
History
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
bf35458fc87c7247c3b8825988a238b82832ade8be782cd474c2e39a001a28cd
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