C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 423—VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT › Subpart G—Payments to Part D Plan Sponsors For Qualified Prescription Drug Coverage

42 C.F.R. § 423.315

General payment provisions

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Link to an amendment published at 91 FR 17589, Apr. 6, 2026.

(a) Source of payments. CMS payments under this section are made from the Medicare Prescription Drug Account.

(b) Monthly payments. CMS provides a direct subsidy in the form of advance monthly payments equal to the Part D plan's standardized bid, risk adjusted for health status as provided in § 423.329(b), minus the monthly beneficiary premium as determined in § 423.286.

(c) Reinsurance subsidies. CMS provides reinsurance subsidy payments described in § 423.329(c) on a monthly basis during a year based on either estimated or incurred allowable reinsurance costs as provided under § 423.329(c)(2)(i), and final reconciliation to actual allowable reinsurance costs as provided in § 423.343(c).

(d) Low-income subsidies. CMS makes payments for premium and cost sharing subsidies, including additional coverage above the initial coverage limit, on behalf of certain subsidy-eligible individuals as provided in §§ 423.780 and 423.782. CMS provides low-income cost-sharing subsidy payments described in § 423.782 through interim payments of amounts as provided under § 423.329(d)(2)(i) and reconciliation to actual allowable reinsurance costs as provided in § 423.343(d).

(e) Risk-sharing arrangements. CMS may issue lump-sum payments or adjust monthly payments in the following payment year based on the relationship of the Part D plan's adjusted allowable risk corridor costs to predetermined risk corridor thresholds in the coverage year as provided in § 423.336.

(f) Retroactive adjustments and reconciliations. CMS reconciles payment year disbursements with updated enrollment and health status data, actual low-income cost-sharing costs and actual allowable reinsurance costs as provided in § 423.343.

(g) Special rules for private fee-for-service plans—(1) Application of reinsurance. For private fee-for-service plans (as defined by § 422.4(a)(3) of this chapter) offering qualified prescription drug coverage, CMS determines the amount of reinsurance payments as provided under § 423.329(c)(3).

(2) Exemption from risk corridor provisions. The provisions of § 423.336 regarding risk sharing do not apply.

Notes of Decisions
Cited in 3 cases (2 in the last 5 years), 2013–2023 · leading case: United States ex rel. Schutte v. Supervalu Inc.
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United States ex rel. Schutte v. Supervalu Inc. (2023) scotus “§ 1395w–115; 42 CFR §§ 423.315 , 423.329. Those plan sponsors, in turn, enter contracts with pharma- Cite as: 598 U.”
United States ex rel. Schutte v. Supervalu Inc. (2023) scotus “§1395w–115; 42 CFR §§423.315 , 423.329. Those plan sponsors, in turn, enter contracts with pharma- cies (sometimes through middlemen called pharmacy bene- fit managers).”
Fox Insurance Company, Inc. v. Centers for Medicare and Medic (2013) ca9 · cites it 2× “42 C.F.R. §§ 423.315 ; 423.329. The payments are calculated on the basis of an estimate by CMS of the prospective monthly costs of the plan sponsor, after the plan sponsor submits a bid.”
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