To amend title XVIII of the Social Security Act to provide for a voluntary program for limiting maximum out-of-pocket expenditures for beneficiaries under the Medicare Program.

May 21, 2003

Mr. STARK introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned

To amend title XVIII of the Social Security Act to provide for a voluntary program for limiting maximum out-of-pocket expenditures for beneficiaries under the Medicare Program.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

(a) SHORT TITLE- This Act may be cited as the `Medicare Out-of-Pocket Spending Limit Act of 2003'.

(b) TABLE OF CONTENTS- The table of contents of this Act is as follows:

Sec. 1. Short title; table of contents.

Sec. 2. Establishment of medicare voluntary catastrophic coverage program.

`Part D--Voluntary Catastrophic Benefit Program

`Sec. 1860. Establishment of program.

`Sec. 1860A. Scope of benefits.

`Sec. 1860B. Eligibility and enrollment.

`Sec. 1860C. Monthly premium; collection of premiums.

`Sec. 1860E. Federal Catastrophic Insurance Account.

`Sec. 1860F. Appropriations to cover Government contributions.

Sec. 3. Medicaid buy-in of medicare catastrophic coverage for certain low-income individuals.

`Sec. 1860D. Special eligibility, enrollment, and copayment rules for low-income individuals.

SEC. 2. ESTABLISHMENT OF MEDICARE VOLUNTARY CATASTROPHIC COVERAGE PROGRAM.

(a) IN GENERAL- Title XVIII of the Social Security Act is amended--

(1) by redesignating part D as part E; and

(2) by inserting after part C the following new part:

`Part D--Voluntary Catastrophic Benefit Program

`ESTABLISHMENT OF PROGRAM

`SEC. 1860. There is established as a part of the medicare program under this title a voluntary program to cover catastrophic out-of-pocket costs incurred under parts A and B.

`SCOPE OF BENEFITS

`SEC. 1860A. (a) IN GENERAL- The benefits provided to an individual enrolled in the insurance program under this part shall consist of elimination of further cost-sharing (described in subsection (b)) for expenses incurred during a year after the individual has incurred cost-sharing totaling the catastrophic limit specified in subsection (c).

`(b) COST-SHARING COVERED-

`(1) IN GENERAL- For purposes of this part, the term `cost-sharing' means costs incurred by an individual that are attributable to the following:

`(A) INPATIENT HOSPITAL DEDUCTIBLE AND HOSPITAL COINSURANCE- Costs incurred for the deductible and coinsurance described in section 1813(a)(1).

`(2) BLOOD DEDUCTIBLE- The deduction described in section 1813(a)(2).

`(C) SNF COINSURANCE- Coinsurance described in section 1813(a)(3).

`(D) HOSPICE COINSURANCE- Hospice coinsurance under section 1813(a)(4).

`(E) PART B DEDUCTIBLE AND COINSURANCE- Amounts charged as the deductible or coinsurance or copayments under part B, but not including any amounts owed in excess of the full payment rate recognized under this title with respect to the items or services involved.

`(2) TREATMENT OF INCURRED COSTS- For purposes of this part, costs shall be treated as incurred only if they were incurred during an individual's coverage period under this part and only if they were billed and owed, regardless of whether payment was or was not made by the individual or by another party (including by a group health plan, by a medicare supplemental health insurance policy, under title XIX, or otherwise).

`(c) CATASTROPHIC LIMIT-

`(1) IN GENERAL- The catastrophic limit under this subsection is equal to--

`(A) for 2006, $2000; or

`(B) for a subsequent year, is equal to $2,000 increased the percentage by which the average expenditures per full-year enrollee under this part for that subsequent year will exceed such average for 2006.

`(2) ROUNDING- Any amount computed under paragraph (1)(B) shall be rounded to the nearest $50.

`(3) PROMULGATION- Not later than September 1 of each year (beginning with 2006) the Secretary shall determine the catastrophic limit under this subsection for the following year.

`(d) ADMINISTRATION OF BENEFITS- The Secretary shall establish a method for the administration of this part through fiscal intermediaries and carriers under parts A and B in coordination with the payment of benefits under those parts. In carrying out this part--

`(1) to the maximum extent feasible, the Secretary shall provide for timely determination of eligibility and benefits so as to permit the adjustment of the amount of payments made to providers under such parts to take into account the catastrophic benefits provided under this part and to avoid the need for payment of covered cost-sharing by beneficiaries;

`(2) the Secretary shall develop a method for the reimbursement of individuals (or other parties) in cases in which they make payment for costs for which benefits are available under this part; and

`(3) the Secretary may enter into contracts with other parties to administer and facilitate administration of this part.

`(e) SOURCE OF PAYMENT- Payment of benefits under this part shall be made from the Federal Catastrophic Insurance Account within the Federal Supplementary Medical Insurance Trust Fund and shall be transferred (in a manner specified by the Secretary) to the Federal Hospital Insurance Trust Fund.

`ELIGIBILITY AND ENROLLMENT

`SEC. 1860B. (a) ELIGIBILITY- Every individual who, in or after 2006, is entitled to hospital insurance benefits under part A and is enrolled in the medical insurance program under part B is eligible to enroll in the insurance program under this part, during an enrollment period prescribed in or under this section, in such manner and form as may be prescribed by regulations.

`(b) ENROLLMENT-

`(1) IN GENERAL- Each individual who satisfies subsection (a) shall be enrolled (or eligible to enroll) in the program under this part in accordance with the provisions of section 1837 (other than subsection (f)), as if that section applied to this part, except as otherwise explicitly provided in this part.

`(2) PENALTY FOR LATE ENROLLMENT- Except as provided in subsection (d), section 1860D(b) (relating to loss of coverage under the medicaid program) or as otherwise explicitly provided, no individual shall be entitled to enroll in the program under this part at any time after the initial enrollment period without penalty, and in the case of all other late enrollments, the Secretary shall develop and apply a late enrollment penalty for the individual that is similar to the late enrollment penalty described in section 1839(b).

`(3) SPECIAL ENROLLMENT PERIOD IN 2005-

`(A) IN GENERAL- In the case of an individual who first satisfies subsection (a) on or before October 1, 2005, there shall be an initial general enrollment period beginning on such date and ending on March 31, 2006, during which the individual may enroll under this part.

`(B) EFFECTIVE DATE OF COVERAGE- An individual who enrolls under the program under this part pursuant to subparagraph (A) shall be entitled to benefits under this part beginning on the first day of the month following the month in which such enrollment occurs, but in no case earlier than January 1, 2006.

`(c) PERIOD OF COVERAGE-

`(1) IN GENERAL- Except as otherwise provided in this part, an individual's coverage under the program under this part shall be effective for the period provided in section 1838, as if that section applied to the program under this part.

`(2) PART D COVERAGE TERMINATED BY TERMINATION OF COVERAGE UNDER PART A OR PART B- In addition to the causes of termination specified in section 1838, an individual's coverage under this part shall be terminated when the individual terminates coverage under either part A or part B, effective on the effective date of the earlier termination of coverage under either such part.

`(d) ENROLLMENT FOR INDIVIDUALS WHOSE GROUP HEALTH PLAN COVERAGE ENDS- The provisions of section 1837(i) shall apply with respect to enrollment under this part in the same manner as such section applies with respect to enrollment under part B.

`MONTHLY PREMIUM; COLLECTION OF PREMIUMS

`SEC. 1860C. (a) MONTHLY PREMIUM BASED ON PART B METHODOLOGY-

`(1) DETERMINATION OF MONTHLY ACTUARIAL RATE AND MONTHLY PREMIUM- The Secretary shall compute, with respect to this part and the Federal Catastrophic Insurance Account, a monthly actuarial rate and a monthly premium in the same manner as such a rate and premium is computed under section 1839(a) with respect to part B and the Federal Supplementary Medical Insurance Trust Fund.

`(2) APPLICATION OF PART B LATE ENROLLMENT PENALTY AND RELATED PROVISIONS- The provisions of subsections (b), (d), and (e) of section 1839 shall apply with respect to enrollment under this part and the premium established under paragraph (1) in the same manner as such provisions apply to enrollment under part B and the premium established under section 1839(a).

`(3) TREATMENT AS PART OF CONSOLIDATED PREMIUM- The provisions of section 1839(f) shall be applied (after the first year in which this part is in effect) as if the premium established under this section were included as part of the premium under section 1839.

`(b) PAYMENT OF PREMIUMS-

`(1) GENERALLY THROUGH DEDUCTION FROM SOCIAL SECURITY, RAILROAD RETIREMENT BENEFITS, OR BENEFITS ADMINISTERED BY OPM-

`(A) IN GENERAL- In the case of an individual who is entitled to or receiving benefits as described in subsection (a), (b), or (d) of section 1840, premiums payable under this part shall be collected by deduction from such benefits at the same time and in the same manner

as premiums payable under part B are collected pursuant to section 1840.

`(B) TRANSFERS OF DEDUCTION TO ACCOUNT- The Secretary of the Treasury shall, from time to time, but not less often than quarterly, transfer premiums collected pursuant to subparagraph (A) to the Federal Catastrophic Insurance Account from the appropriate funds and accounts described in subsections (a)(2), (b)(2), and (d)(2) of section 1840, on the basis of the certifications described in such subsections. The amounts of such transfers shall be appropriately adjusted to the extent that prior transfers were too great or too small.

`(2) OTHERWISE THROUGH DIRECT PAYMENTS BY ENROLLEE TO SECRETARY-

`(A) IN THE CASE OF INADEQUATE DEDUCTION- An individual to whom paragraph (1) applies (other than an individual receiving benefits as described in section 1840(d)) and who estimates that the amount that will be available for deduction under such paragraph for any premium payment period will be less than the amount of the monthly premiums for such period may (under regulations) pay to the Secretary the estimated balance, or such greater portion of the monthly premium as the individual chooses.

`(B) OTHER CASES- An individual enrolled in the insurance program under this part with respect to whom none of the preceding provisions of this subsection applies (or to whom section 1840(c) applies) shall pay premiums to the Secretary at such times and in such manner as the Secretary shall by regulations prescribe.

`(C) DEPOSIT OF PREMIUMS IN ACCOUNT- Amounts paid to the Secretary under this paragraph shall be deposited in the Treasury to the credit of the Federal Catastrophic Insurance Account in the Federal Supplementary Medical Insurance Trust Fund.

`SPECIAL ELIGIBILITY, ENROLLMENT, AND COPAYMENT RULES FOR LOW-INCOME INDIVIDUALS

`SEC. 1860D. (a) STATE OPTIONS FOR COVERAGE: CONTINUATION OF MEDICAID COVERAGE OR ENROLLMENT UNDER THIS PART-

`(1) IN GENERAL- The Secretary shall, at the request of a State, enter into an agreement with the State under which all individuals described in paragraph (2) are enrolled in the program under this part, without regard to whether any such individual has previously declined the opportunity to enroll in such program.

`(2) ELIGIBILITY GROUPS- The individuals described in this paragraph, for purposes of paragraph (1), are individuals who satisfy section 1860B(a) and who are--

`(A) in a coverage group or groups permitted under section 1843 (as selected by the State and specified in the agreement); or

`(B) qualified medicare catastrophic beneficiaries (as defined in section 1905(x)(1)).

`(3) COVERAGE PERIOD- The period of coverage under this part of an individual enrolled under an agreement under this subsection shall be as follows:

`(A) INDIVIDUALS ELIGIBLE (AT STATE OPTION) FOR PART B BUY-IN- In the case of an individual described in subsection (a)(2)(A), the coverage period shall be the same period that applies (or would apply) pursuant to section 1843(d).

`(B) QUALIFIED MEDICARE CATASTROPHIC BENEFICIARIES- In the case of an individual described in subsection (a)(2)(B)--

`(i) the coverage period shall begin on the latest of--

`(I) January 1, 2006;

`(II) the first day of the third month following the month in which the State agreement is entered into; or

`(III) the first day of the first month following the month in which the individual satisfies section 1860B(a); and

`(ii) the coverage period shall end on the last day of the month in which the individual is determined by the State to have become ineligible for medicare catastrophic coverage benefits.

`(4) ENROLLMENT FOR LOW-INCOME SUBSIDY THROUGH OTHER MEANS-

`(A) FLEXIBILITY IN ENROLLMENT PROCESS- With respect to low-income individuals residing in a State enrolling under this part on or after January 1, 2006, the Secretary shall provide for determinations of whether the individual is eligible for a subsidy and the amount of such individual's income to be made under arrangements with appropriate entities other than State medicaid agencies.

`(B) USE OF CERTAIN INFORMATION- Arrangements with entities under subparagraph (A) shall provide for --

`(i) the use of existing Federal government databases to identify eligibility; and

`(ii) the use of information obtained under section 154 of the Social Security Act Amendments of 1994 for newly eligible medicare beneficiaries, and the application of such information with respect to other medicare beneficiaries.

`(b) SPECIAL PART D ENROLLMENT OPPORTUNITY FOR INDIVIDUALS LOSING MEDICAID ELIGIBILITY-

`(1) IN GENERAL- In the case of an individual who--

`(A) satisfies section 1860B(a); and

`(B) loses eligibility for benefits under the State plan under title XIX after having been enrolled under such plan or having been determined eligible for such benefits;

the Secretary shall provide an opportunity for enrollment under the program under this part during the

period that begins on the date that such individual loses such eligibility and ends on the date specified by the Secretary.

`(2) REFERENCE TO WAIVER OF LATE ENROLLMENT PENALTY- For provision waiving imposition of late enrollment penalty in the case of an enrollment of an individual under this part by reason of paragraph (1), see section 1860B(b)(2).

`(c) DEFINITION- For purposes of this section, the term `State' has the meaning given such term under section 1101(a) for purposes of title XIX.

`FEDERAL CATASTROPHIC INSURANCE ACCOUNT

`SEC. 1860E. (a) ESTABLISHMENT- There is created within the Federal Supplementary Medical Insurance Trust Fund established by section 1841 an account to be known as the `Federal Catastrophic Insurance Account' (in this section referred to as the `Account').

`(b) AMOUNTS IN ACCOUNT-

`(1) IN GENERAL- The Account shall consist of--

`(A) such amounts as may be deposited in, or appropriated to, such fund as provided in this part; and

`(B) such gifts and bequests as may be made as provided in section 201(i)(1).

`(2) SEPARATION OF FUNDS- Funds provided under this part to the Account shall be kept separate from all other funds within the Federal Supplementary Medical Insurance Trust Fund.

`(c) PAYMENTS FROM ACCOUNT-

`(1) IN GENERAL- The Managing Trustee shall pay from time to time from the Account such amounts as the Secretary certifies are necessary to make the payments provided for by this part, and the payments with respect to administrative expenses in accordance with section 201(g).

`(2) TREATMENT IN RELATION TO PART B PREMIUM- Amounts payable from the Account shall not be taken into account in computing actuarial rates or premium amounts under section 1839.

`APPROPRIATIONS TO COVER GOVERNMENT CONTRIBUTIONS

`SEC. 1860F. There are authorized to be appropriated from time to time, out of any moneys in the Treasury not otherwise appropriated, to the Federal Catastrophic Insurance Account, a Government contribution computed in the same manner as the Government contributions are computed under section 1844(a)(1), except that any reference to part B or a provision in section 1839(a) is deemed to be a reference to this part and the corresponding provision in section 1860C.'.

(b) CATASTROPHIC COVERAGE OPTION UNDER MEDICARE+CHOICE PLANS-

(1) ELIGIBILITY, ELECTION, AND ENROLLMENT- Section 1851 of the Social Security Act (42 U.S.C. 1395w-21) is amended--

(A) in subsection (a)(1)(A), by striking `parts A and B' inserting `parts A, B, and D'; and

(B) in subsection (i)(1), by striking `parts A and B' and inserting `parts A, B, and D'.

(2) VOLUNTARY BENEFICIARY ENROLLMENT FOR CATASTROPHIC COVERAGE- Section 1852(a)(1)(A) of such Act (42 U.S.C. 1395w-22(a)(1)(A)) is amended by inserting `(and under part D to individuals also enrolled under that part)' after `parts A and B'.

(3) PAYMENTS TO ORGANIZATIONS- Section 1853(a)(1)(A) of such Act (42 U.S.C. 1395w-23(a)(1)(A)) is amended--

(A) by inserting `determined separately for benefits under parts A and B and under part D (for individuals enrolled under that part)' after `as calculated under subsection (c)';

(B) by striking `that area, adjusted for such risk factors' and inserting `that area. In the case of payment for benefits under parts A and B, such payment shall be adjusted for such risk factors as'; and

(C) by inserting before the last sentence the following: `In the case of the payments for benefits under part D, such payment shall be adjusted for the risk factors of each enrollee as the Secretary determines to be feasible and appropriate.'.

(4) CALCULATION OF ANNUAL MEDICARE+CHOICE CAPITATION RATES- Section 1853(c) of such Act (42 U.S.C. 1395w-23(c)) is amended--

(A) in paragraph (1), in the matter preceding subparagraph (A), by inserting `for benefits under parts A and B' after `capitation rate';

(B) in paragraph (6)(A), by striking `rate of growth in expenditures under this title' and inserting `rate of growth in expenditures for benefits available under parts A and B'; and

(C) by adding at the end the following new paragraph:

`(8) PAYMENT FOR CATASTROPHIC COVERAGE- The Secretary shall determine a capitation rate for catastrophic coverage described in part D--

`(A) for 2006, which is based on the projected national per capita costs for coverage under part D and associated claims processing costs for beneficiaries under the original medicare fee-for-service program; and

`(B) for each subsequent year, which shall be equal to the rate for the previous year updated by the Secretary's estimate of the projected per capita rate of growth in expenditures under this title for such coverage for an individual enrolled under part D.

The Secretary shall provide for an appropriate geographic adjustment in such capitation rate to reflect differences (other than those reflected in the health status adjustments) in the average per capita expenditures under part D in the different geographic areas.'.

(5) REQUIREMENT FOR ADDITIONAL BENEFITS- Section 1854(f)(1) of such Act (42 U.S.C. 1395w-24(f)(1)) is amended by adding at the end the following new sentence: `Such determination shall be made separately for benefits under parts A

and B and for catastrophic coverage benefits under part D.'.

(c) CONFORMING REVISION OF MEDIGAP STANDARDS- The provisions of section 1882(p)(1)(E) of the Social Security Act (42 U.S.C. 1395ss(p)(1)(E)) shall apply to the benefit changes effected by this section and the standards for benefit packages previously established under section 1882(p) of such Act shall be revised to avoid duplication with the benefits provided under part D of title XVIII of such Act (as inserted by subsection (a)).

(d) CONFORMING AMENDMENTS TO FEDERAL SUPPLEMENTARY HEALTH INSURANCE TRUST FUND- Section 1841 of the Social Security Act (42 U.S.C. 1395t) is amended--

(1) in the last sentence of subsection (a)--

(A) by striking `and' after `section 201(i)(1)'; and

(B) by inserting before the period the following: `, and such amounts as may be deposited in, or appropriated to, the Federal Catastrophic Insurance Account established by section 1860E';

(2) in subsection (g), by inserting after `by this part,' the following: `the payments provided for under part D (in which case the payments shall come from the Federal Catastrophic Insurance Account in the Federal Supplementary Medical Insurance Trust Fund),';

(3) in the first sentence of subsection (h), by inserting before the period the following: `and section 1860C(b)(1)(A) (in which case the payments shall come from the Federal Catastrophic Insurance Account in the Federal Supplementary Medical Insurance Trust Fund)'; and

(4) in the first sentence of subsection (i)--

(A) by striking `and' after `section 1840(b)(1)'; and

(B) by inserting before the period the following: `, section 1860D(b)(1)(A) (in which case the payments shall come from the Federal Catastrophic Insurance Account in the Federal Supplementary Medical Insurance Trust Fund)'.

(e) APPLYING EXCLUSIONS FROM COVERAGE- Section 1862(a) of such Act (42 U.S.C. 1395y(a)) is amended in the matter preceding paragraph (1) by striking `part A or part B' and inserting `part A, B, or D'.

SEC. 3. MEDICAID BUY-IN OF MEDICARE CATASTROPHIC COVERAGE FOR CERTAIN LOW-INCOME INDIVIDUALS.

(a) STATE OPTION TO BUY-IN LOW-INCOME INDIVIDUALS-

(1) IN GENERAL- Section 1902(a)(10)(E) of the Social Security Act (42 U.S.C. 1396a(a)(10)(E)) is amended--

(A) by striking `and' at the end of clause (iii);

(B) by adding `and' at the end of clause (iv); and

(C) by adding at the end the following new clause:

`(v) at the option of a State, for making medical assistance available for medicare catastrophic cost-sharing for qualified medicare catastrophic beneficiaries (as defined in subsection (x)(1)), regardless of whether or not such beneficiaries are otherwise eligible for medical assistance under this title;'.

(2) CONSTRUCTION- Nothing in this section shall be construed as reducing the amount of medical assistance otherwise available to medicare beneficiaries under the medicaid program.

(b) ADDITIONAL FUNDS FOR TERRITORIES- Section 1108 of the Social Security Act (42 U.S.C. 1308) is amended--

(1) in subsection (f), by striking `subsection (g),' and inserting `subsections (g) and (h)'; and

(2) by adding at the end the following new subsection:

`(h) ADDITIONAL MEDICAID PAYMENTS TO TERRITORIES FOR MEDICARE CATASTROPHIC COVERAGE- .

`(1) IN GENERAL- In the case of a territory that develops and implements a plan described in paragraph (2) (for providing medical assistance with respect to the provision of catastrophic coverage to medicare beneficiaries), the amount otherwise determined under subsection (f) (as increased under subsection (g)) for the State shall be increased by the amount specified in paragraph (3).

`(2) PLAN- The plan described in this paragraph is a plan that--

`(A) provides medical assistance with respect to the provision of some or all medicare catastrophic coverage described in part D of title XVIII to low-income medicare beneficiaries; and

`(B) assures that additional amounts received by the State that are attributable to the operation of this subsection are used only for such assistance.

`(3) INCREASED AMOUNT-

`(A) IN GENERAL- The amount specified in this paragraph for a State for a year is equal to the product of--

`(i) the aggregate amount specified in subparagraph (B); and

`(ii) the amount specified in subsection (g)(1) for that State, divided by the sum of the amounts specified in such section for all such States.

`(B) AGGREGATE AMOUNT- The aggregate amount specified in this subparagraph for--

`(i) 2006, is equal to $15,000,000; or

`(ii) a subsequent year, is equal to $15,000,000 multiplied by the percentage described in section 1860A(c)(1)(B) for that subsequent year.'.

(c) DEFINITIONS OF ELIGIBLE BENEFICIARIES AND COVERAGE- Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended by adding at the end the following new subsection:

`(x)(1) The term `qualified medicare catastrophic beneficiary' means an individual--

`(A) who is enrolled or enrolling under part D of title XVIII; and

`(B) whose income (as determined under section 1612 for purposes of the supplemental security income program, except as provided in subsection (p)(2)(D)) is below 175 percent of the official poverty line (as referred to in subsection (p)(2)) applicable to a family of the size involved.

`(2) The term `medicare catastrophic cost-sharing' means the following:

`(A) In the case of a qualified medicare catastrophic beneficiary whose income (as determined under paragraph (1)) is less than 150 percent of the official poverty line, premiums under section 1860D.

`(B) In the case of a qualified medicare catastrophic beneficiary whose income (as determined under paragraph (1)) is at least 150 percent but less than 175 percent of the official poverty line, a percentage of premiums under section 1860D, determined on a linear sliding scale ranging from 100 percent for individuals with incomes at 150 percent of such line to 0 percent for individuals with incomes at 175 percent of such line.

`(3) In the case of any State which is providing medical assistance to its residents under a waiver granted under section 1115, the Secretary shall require the State to meet the requirement of section 1902(a)(10)(E) in the same manner as the State would be required to meet such requirement if the State had in effect a plan approved under this title.'.

(d) 100 PERCENT FMAP FOR COST-SHARING- The first sentence of section 1905(b) of such Act (42 U.S.C. 1396d(b)) is amended--

(1) by striking `and' before `(4)'; and

(2) by inserting before the period at the end the following: `, and (5) with respect to the 50 States and the District of Columbia the Federal medical assistance percentage shall be 100 percent with respect to medicare catastrophic cost-sharing (as defined in subsection (x)(2))'.

(e) CONFORMING AMENDMENT- Section 1905(a) of the Social Security Act (42 U.S.C. 1396d) is amended in the second sentence of the flush matter at the end by striking `premiums under part B' the first place it appears and inserting `premiums under parts B and D'.

END