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 S—Special Rules for States-Eligibility Determinations for Subsidies and General Payment Provisions

42 C.F.R. § 423.907

Treatment of territories

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(a) General rules. (1) Low-income Part D eligible individuals who reside in the territories are not eligible to receive premium and cost-sharing subsidies under subpart P of this part.

(2) A territory may submit a plan to the Secretary under which medical assistance is to be provided to low-income individuals for the provision of covered Part D drugs.

(3) Territories with plans approved by the Secretary will receive increased grants under section 1935(e)(3) of the Act as described in paragraph (c) of this section.

(b) Plan requirements. Plans submitted to the Secretary must include the following:

(1) A description of the medical assistance to be provided.

(2) The low-income population (income less than 150 percent of the Federal poverty level) to receive medical assistance.

(3) An assurance that no more than 10 percent of the amount of the increased grant will be used for administrative expenses.

(c) Increased grant amounts. The amount of the grant provided under section 1108 (f) of the Act as increased by section 1108 (g) of the Act for each territory with an approved plan for a year is the amount in paragraph (d) of this section multiplied by the ratio of—

(1) The number of individuals who are entitled to benefits under Part A or enrolled under Part B and who reside in the territory (as determined by the Secretary based on the most recent available data for the beginning of the year); and

(2) The sum of the number of individuals in all territories in paragraph (c)(1) of this section with approved plans.

(d) Total grant amount. The total grant amount is—

(1) For the last three quarters of fiscal year 2006, $28,125,000;

(2) For fiscal year 2007, $37,500,000; and

(3) For each subsequent year, the amount for the prior fiscal year increased by the annual percentage increase described in § 423.104(d)(5)(iv).

Notes of Decisions
Cited in 2 cases, 2005–2007 · leading case: First Med. Health Plan, Inc. v. Vega-Ramos, 479 F.3d 46 (1st Cir. 2007).
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First Med. Health Plan, Inc. v. Vega-Ramos, 479 F.3d 46 (1st Cir. 2007). “See 42 C.F.R. § 423.907 . There is no requirement that a territory use an entity established by the Medicare laws to provide drug coverage for its dual eligible population.”
First Med. Health Plan, Inc. v. Vega, 406 F. Supp. 2d 150 (D.P.R. 2005). · cites it 5× “§ 1396u-5, and 42 C.F.R. § 423.907 . Pursuant to these statutes, low-income Part D eligible beneficiaries who reside in the territories are not eligible to receive premium and cost-sharing subsidies of covered Part D drugs.”
— 42 C.F.R. § 423.907(a)(2) — 1 case
First Med. Health Plan, Inc. v. Vega, 406 F. Supp. 2d 150 (D.P.R. 2005). “§ 1396u-5, and 42 C.F.R. § 423.907 . Pursuant to these statutes, low-income Part D eligible beneficiaries who reside in the territories are not eligible to receive premium and cost-sharing subsidies of covered Part D drugs.”
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