Doughnut Hole Provisions

8/9/2019 Doughnut Hole Provisions

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(2) REPEAL OF PROVISION.Section 3315 of1

the Patient Protection and Affordable Care Act (in-2

cluding the amendments made by such section) is re-3

pealed, and any provision of law amended or re-4

pealed by such sections is hereby restored or revived5

as if such section had not been enacted into law.6

(b) CLOSING THE DONUT HOLE.Part D of title7

XVIII of the Social Security Act (42 U.S.C. 1395w1018

et seq.), as amended by section 3301 of the Patient Pro-9

tection and Affordable Care Act, is further amended10

(1) in section 1860D4311

(A) in subsection (b), by striking July 1,12

2010 and inserting January 1, 2011; and13

(B) in subsection (c)(2), by striking July14

1, 2010, and ending on December 31, 2010,15

and inserting January 1, 2011, and December16

31, 2011,;17

(2) in section 1860D14A18

(A) in subsection (a)19

(i) by striking July 1, 2010 and in-20

serting January 1, 2011; and21

(ii) by striking April 1, 2010 and22

inserting 180 days after the date of the23

enactment of this section;24

(B) in subsection (b)(1)(C)25

VerDate Nov 24 2008 12:44 Mar 18, 2010 Jkt 000000 PO 00000 Frm 00021 Fmt 6652 Sfmt 6201 C:\TEMP\HCEARA_001.XML HOLCPCMarch 18, 2010 (12:44 p.m.)

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(i) in the heading, by striking 20101

AND;2

(ii) by striking July 1, 2010 and in-3

serting January 1, 2011; and4

(iii) by striking May 1, 2010 and5

inserting not later than 30 days after the6

date of the establishment of a model agree-7

ment under subsection (a);8

(C) in subsection (c)9

(i) in paragraph (1)(A)(iii), by strik-10

ing July 1, 2010, and ending on Decem-11

ber 31, 2011 and inserting January 1,12

2011, and ending on December 31, 2011;13

and14

(ii) in paragraph (2), by striking15

2010 and inserting 2011;16

(D) in subsection (d)(2)(B), by striking17

July 1, 2010, and ending on December 31,18

2010 and inserting January 1, 2011, and19

ending on December 31, 2011; and20

(E) in subsection (g)(1)21

(i) in the matter before subparagraph22

(A), by striking an applicable drug and23

inserting a covered part D drug;24



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(ii) by adding and at the end of1

subparagraph (C);2

(iii) by striking subparagraph (D);3

and4

(iv) by redesignating subparagraph5

(E) as subparagraph (D); and6

(3) in section 1860D2(b) 7

(A) in paragraph (2)(A), by striking The8

coverage and inserting Subject to subpara-9

graphs (C) and (D), the coverage;10

(B) in paragraph (2)(B), by striking sub-11

paragraph (A)(ii) and inserting subpara-12

graphs (A)(ii), (C), and (D);13

(C) by adding at the end of paragraph (2)14

the following new subparagraphs:15

(C) COVERAGE FOR GENERIC DRUGS IN16

COVERAGE GAP.17

(i) IN GENERAL.Except as pro-18

vided in paragraph (4), the coverage for an19

applicable beneficiary (as defined in section20

1860D14A(g)(1)) has coinsurance (for21

costs above the initial coverage limit under22

paragraph (3) and below the out-of-pocket23

threshold) for covered part D drugs that24



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are not applicable drugs under section1

1860D14A(g)(2) that is2

(I) equal to the generic-gap co-3

insurance percentage (specified in4

clause (ii)) for the year, or5

(II) actuarially equivalent6

(using processes and methods estab-7

lished under section 1860D11(c)) to8

an average expected payment of such9

percentage of such costs for covered10

part D drugs that are not applicable11

drugs under section 1860D12

14A(g)(2).13

(ii) GENERIC-GAP COINSURANCE14

PERCENTAGE.The generic-gap coinsur-15

ance percentage specified in this clause16

for17

(I) 2011 is 93 percent;18

(II) 2012 and each succeeding19

year before 2020 is the generic-gap20

coinsurance percentage under this21

clause for the previous year decreased22

by 7 percentage points; and23

(III) 2020 and each subsequent24

year is 25 percent.25



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(D) COVERAGE FOR APPLICABLE DRUGS1

IN COVERAGE GAP.2

(i) IN GENERAL.Except as pro-3

vided in paragraph (4), the coverage for an4

applicable beneficiary (as defined in section5

1860D14A(g)(1)) has coinsurance (for6

costs above the initial coverage limit under7

paragraph (3) and below the out-of-pocket8

threshold) for the negotiated price (as de-9

fined in section 1860D14A(g)(6)) of cov-10

ered part D drugs that are applicable11

drugs under section 1860D14A(g)(2) that12

is13

(I) equal to the difference be-14

tween the applicable gap percentage15

(specified in clause (ii) for the year)16

and the discount percentage specified17

in section 1860D14A(g)(4)(A) for18

such applicable drugs, or19

(II) actuarially equivalent20

(using processes and methods estab-21

lished under section 1860D11(c)) to22

an average expected payment of such23

percentage of such costs, for covered24

part D drugs that are applicable25



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drugs under section 1860D1

14A(g)(2).2

(ii) APPLICABLE GAP PERCENT-3

AGE.The applicable gap percentage spec-4

ified in this clause for5

(I) 2013 and 2014 is 97.5 per-6

cent;7

(II) 2015 and 2016 is 95 per-8

cent;9

(III) 2017 is 90 percent;10

(IV) 2018 is 85 percent;11

(V) 2019 is 80 percent; and12

(VI) 2020 and each subsequent13

year is 75 percent.;14

(D) in paragraph (3)(A), as restored under15

subsection (a)(2), by striking paragraph (4)16

and inserting paragraphs (2)(C), (2)(D), and17

(4);18

(E) in paragraph (4)(E), by inserting be-19

fore the period at the end the following: , ex-20

cept that incurred costs shall not include the21

portion of the negotiated price that represents22

the reduction in coinsurance resulting from the23

application of paragraph (2)(D); and24



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(4) in section 1860D22(a)(2)(A), by inserting1

before the period at the end the following: , not2

taking into account the value of any discount or cov-3

erage provided during the gap in prescription drug4

coverage that occurs between the initial coverage5

limit under section 1860D2(b)(3) during the year6

and the out-of-pocket threshold specified in section7

1860D2(b)(4)(B).8

(c) CONFORMING AMENDMENT TO AMP UNDER9

MEDICAID.Section 1927(k)(1)(B)(i) of the Social Secu-10

rity Act (42 U.S.C. 1396r8(k)(1)(B)(i)), as amended by11

section 2503(a)(2)(B) of the Patient Protection and Af-12

fordable Care Act, is amended13

(1) by striking and at the end of subclause14

(III);15

(2) by striking the period at the end of sub-16

clause (IV); and17

(3) by adding at the end the following new sub-18

clause:19

(V) discounts provided by man-20

ufacturers under section 1860D21

14A..22

SEC. 1102. MEDICARE ADVANTAGE PAYMENTS.23

(a) REPEAL.Effective as if included in the enact-24

ment of the Patient Protection and Affordable Care Act,25



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Doughnut Hole Provisions

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