[Code of Federal Regulations]
[Title 42, Volume 3]
[Revised as of October 1, 2006]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR423.343]

[Page 390-391]
 
                         TITLE 42--PUBLIC HEALTH
 
                    CHAPTER IV--CENTERS FOR MEDICARE
                          & MEDICAID SERVICES,
                        DEPARTMENT OF HEALTH AND
                             HUMAN SERVICES
 
PART 423_VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT--Table of Contents
 
 Subpart G_Payments to Part D Plan Sponsors For Qualified Prescription 
                              Drug Coverage
 
Sec.  423.343  Retroactive adjustments and reconciliations.

    (a) Application of enrollee adjustment. The provisions of Sec.  
422.308(f) of this chapter apply to payments to Part D sponsors under 
this section in the same manner as they apply to payments to MA 
organizations under section 1853(a) of the Act.
    (b) Health status. CMS makes adjustments to payments made under 
Sec.  423.329(a)(1) to account for updated health status risk adjustment 
data as provided under Sec.  422.310(g)(2) of this chapter. CMS may 
recover payments associated with health status adjustments if the Part D 
sponsor fails to provide the information described in Sec.  
423.329(b)(3).
    (c) Reinsurance. CMS makes final payment for reinsurance after a 
coverage year after obtaining all of the information necessary to 
determine the amount of payment.
    (1) Submission of cost data. Within 6 months of the end of a 
coverage year,

[[Page 391]]

the Part D sponsor must provide the information that CMS requires.
    (2) Payments. CMS at its discretion either makes lump-sum payments 
or adjusts monthly payments throughout the remainder of the payment year 
following the coverage year based on the difference between monthly 
reinsurance payments made during the coverage year and the amount 
payable in Sec.  423.329(c) for the coverage year. CMS may recover 
payments made through a lump sum recovery or by adjusting monthly 
payments throughout the remainder of the coverage year if the monthly 
reinsurance payments made during the coverage year exceed the amount 
payable under Sec.  423.329(c) or if the Part D sponsor does not provide 
the data in paragraph (c)(1) of this section.
    (d) Low-income cost-sharing subsidy. CMS makes final payment for 
low-income cost-sharing subsidies after a coverage year after obtaining 
all of the information necessary to determine the amount of payment.
    (1) Submission of cost data. Within 6 months of the end of a 
coverage year, the Part D sponsor must provide the information that CMS 
requires.
    (2) Payments. CMS at its discretion either makes lump-sum payments 
or adjusts monthly payments throughout the remainder of the payment year 
following the coverage year based on the difference between interim low-
income cost-sharing subsidy payments and total low-income cost-sharing 
subsidy costs eligible for subsidy under Sec.  423.782 submitted by the 
plan for the coverage year. CMS may recover payments made through a lump 
sum recovery or by adjusting monthly payments throughout the remainder 
of the coverage year if interim low-income cost-sharing subsidy payments 
exceed the amount payable under Sec.  423.782 or if the Part D sponsor 
does not provide the data in paragraph (d)(1) of this section. In the 
event adequate data is not provided for risk corridor costs, CMS assumes 
that the Part D plan's adjusted allowable risk corridor costs are 50 
percent of the target amount.