Medicare Prescription Drug Savings for Our Seniors (Medicare Prescription Drug SOS) Act of 2006 - Amends part D (Voluntary Prescription Drug Benefit Program) of title XVIII (Medicare) of the Social Security Act (SSA) to direct the Secretary of Health and Human Services to: (1) offer one or more Medicare operated prescription drug plans (PDPs) with a service area consisting of the entire United States; and (2) negotiate with pharmaceutical manufacturers to reduce the purchase cost of covered part D drugs. Requires the monthly beneficiary premium for qualified prescription drug coverage and access to negotiated prices to be uniform nationally.
Provides for auto-enrollment of subsidy eligible individuals in Medicare operated PDPs.
Amends SSA title XIX (Medicaid) to provide for the use of 2005 as base in computing the state clawback provision.
Amends SSA title XVIII (Medicare) to: (1) eliminate cost-sharing for certain full-benefit dual eligibles, and the indexing on the price sharing for dual-eligibles and qualifying low income beneficiaries; (2) expedite low-income subsidies under the Medicare PDP; (3) increase permitted resources to obtain low-income subsidies; and (4) waive the late enrollment penalty for subsidy eligible individuals for first 24 months of non-enrollment.
Sets forth anti-fraud and abuse provisions.
Provides for protection of Social Security benefits against a decrease owing to part D Medicare premium increases.
Extends the annual enrollment periods of the Medicare PDP.
Prohibits a PDP sponsor from removing a covered part D drug from the plan formulary, or otherwise introduce a barrier to access to covered part D drugs, without advance notice.
Directs the Secretary to review benzodiazepine prescription policies to assure appropriateness and avoid abuse.
Eliminates the MA Regional Stabilization Fund and certain Medicare Advantage overpayments.
Requires prompt payment of clean claims by Medicare and Medicare Advantage PDPs.
Prohibits co-branding.
Provides for the: (1) payment of minimum dispensing fees to encourage use of generic drugs; and (2) provision of medication therapy management services.
[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[H.R. 6281 Introduced in House (IH)]
109th CONGRESS
2d Session
H. R. 6281
To amend title XVIII of the Social Security Act to provide
comprehensive improvements to the Medicare prescription drug program,
and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
September 29, 2006
Mr. Doggett (for himself, Mr. Rangel, Mr. Stark, Mr. McDermott, Mr.
Lewis of Georgia, Mr. Neal of Massachusetts, Mr. McNulty, Mr. Becerra,
Mrs. Jones of Ohio, Mr. Larson of Connecticut, Mr. Emanuel, Mr. Allen,
Mrs. Capps, Mrs. Davis of California, Ms. DeLauro, Mr. Frank of
Massachusetts, Mr. Al Green of Texas, Mr. Gene Green of Texas, Mr.
Grijalva, Mr. Hinchey, Ms. Jackson-Lee of Texas, Ms. Eddie Bernice
Johnson of Texas, Ms. Kaptur, Mr. Kennedy of Rhode Island, Ms.
Kilpatrick of Michigan, Mr. Langevin, Mrs. Lowey, Mrs. Maloney, Ms.
McCollum of Minnesota, Mr. McGovern, Mr. Meehan, Ms. Moore of
Wisconsin, Mr. Moran of Virginia, Mr. Nadler, Mr. Oberstar, Mr. Ortiz,
Mr. Reyes, Ms. Schakowsky, Mr. Waxman, Mr. Weiner, and Ms. Woolsey)
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
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to provide
comprehensive improvements to the Medicare prescription drug program,
and for other purposes.
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
Prescription Drug Savings for Our Seniors (Medicare Prescription Drug
SOS) Act of 2006''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--MEDICARE OPERATED PRESCRIPTION DRUG PLAN OPTION
Sec. 101. Establishment of medicare operated prescription drug plan
option.
TITLE II--MEDICAID AND LOW-INCOME IMPROVEMENTS
Sec. 201. Change in base used in computing State clawback provision.
Sec. 202. Elimination of cost-sharing for certain full-benefit dual
eligibles.
Sec. 203. Elimination of the indexing on the price-sharing for dual-
eligibles and qualifying low income
beneficiaries.
Sec. 204. Expediting low-income subsidies under the Medicare
prescription drug program.
Sec. 205. Increase in permitted resources to obtain low-income
subsidies.
Sec. 206. Waiver of late enrollment penalty for subsidy eligible
individuals for first 24 months of non-
enrollment.
TITLE III--FRAUD AND ABUSE PROVISIONS
Sec. 301. Criminal penalty for fraud in connection with enrollment
under an MA plan or prescription drug plan.
Sec. 302. Recourse for slamming practices.
Sec. 303. Protection from loss of employment-based retiree health
coverage upon enrollment for medicare
prescription drug benefit during 2006.
Sec. 304. Required application of intermediate sanctions to protect
against fraud and abuse.
Sec. 305. Repeal of special waiver authority for State licensure.
TITLE IV--RELATION TO SOCIAL SECURITY BENEFITS
Sec. 401. Protection of Social Security benefits against decrease due
to part D medicare premium increases.
TITLE V--BENEFICIARY PROTECTION PROVISIONS
Sec. 501. Extension of open enrollment period; suspension of late
enrollment penalties; allowing one-time
change in plan during first year of
enrollment.
Sec. 502. Counting expenditures under State drug assistance programs
against true out-of-pocket costs.
Sec. 503. Price disclosure.
Sec. 504. Removal of covered part D drugs from the prescription drug
plan formulary.
Sec. 505. Codification of requirement for coverage of all or
substantially all of drugs within six
categories of drugs.
Sec. 506. Removal of exclusion of benzodiazepines from required
coverage under the medicare prescription
drug program.
Sec. 507. Standardized forms and procedures for reconsiderations and
appeals.
Sec. 508. Elimination of MA Regional Stabilization Fund (Slush Fund);
elimination of certain MA overpayments.
TITLE VI--FAIR AND SPEEDY TREATMENT OF MEDICARE PRESCRIPTION DRUG
CLAIMS
Sec. 601. Prompt payment by Medicare prescription drug plans and MA-PD
plans under part D.
Sec. 602. Restriction on co-branding.
Sec. 603. Minimum dispensing fees for generic covered part D drugs.
Sec. 604. Provision of medication therapy management services under
part D.
TITLE I--MEDICARE OPERATED PRESCRIPTION DRUG PLAN OPTION
SEC. 101. ESTABLISHMENT OF MEDICARE OPERATED PRESCRIPTION DRUG PLAN
OPTION.
(a) In General.--Subpart 2 of part D of the Social Security Act is
amended by inserting after section 1860D-11 the following new section:
``medicare operated prescription drug plan option
``Sec. 1860D-11A. (a) In General.--Notwithstanding any other
provision of this part, for each year (beginning with 2007), in
addition to any plans offered under section 1860D-11, the Secretary
shall offer one or more medicare operated prescription drug plans (as
defined in subsection (c)) with a service area that consists of the
entire United States and shall enter into negotiations with
pharmaceutical manufacturers to reduce the purchase cost of covered
part D drugs for eligible part D individuals in accordance with
subsection (b).
``(b) Negotiations.--
``(1) In general.--Notwithstanding section 1860D-11(i), for
purposes of offering a medicare operated prescription drug plan
under this section, the Secretary shall negotiate with
pharmaceutical manufacturers with respect to the purchase price
of covered part D drugs and shall encourage the use of more
affordable therapeutic equivalents to the extent such practices
do not override medical necessity as determined by the
prescribing physician. To the extent practicable and consistent
with the previous sentence, the Secretary shall implement
strategies similar to those used by other Federal purchasers of
prescription drugs, and other strategies, to reduce the
purchase cost of covered part D drugs.
``(2) Permitting application of some or all of savings to
reduction in coverage gap.--Notwithstanding any other provision
of this part, the Secretary may increase the initial coverage
limit under section 1860D-2(b)(3) for a year, but only with
respect to the medicare operated prescription drug plan, by an
amount not to exceed the actuarial value of the reductions in
expenditures during such year resulting from the application of
paragraph (1).
``(c) Medicare Operated Prescription Drug Plan Defined.--For
purposes of this part, the term `medicare operated prescription drug
plan' means a prescription drug plan that offers qualified prescription
drug coverage and access to negotiated prices described in section
1860D-2(a)(1)(A). Such a plan may offer supplemental prescription drug
coverage in the same manner as other qualified prescription drug
coverage offered by other prescription drug plans.
``(d) Monthly Beneficiary Premium.--
``(1) Qualified prescription drug coverage.--The monthly
beneficiary premium for qualified prescription drug coverage
and access to negotiated prices described in section 1860D-
2(a)(1)(A) to be charged under a medicare operated prescription
drug plan shall be uniform nationally. Such premium for months
in a year shall be based on the average monthly per capita
actuarial cost of offering the medicare operated prescription
drug plan for the year involved, including administrative
expenses, as determined by the Secretary and as certified by
the chief actuary of the Centers for Medicare & Medicaid
Services.
``(2) Supplemental prescription drug coverage.--Insofar as
a medicare operated prescription drug plan offers supplemental
prescription drug coverage, the Secretary may adjust the amount
of the premium charged under paragraph (1).''.
(b) Auto-Enrollment of Subsidy Eligible Individuals in Medicare
Operated Prescription Drug Plan.--Section 1860D-1(b)(1)(C) of such Act
(42 U.S.C. 1395w-101(b)(1)(C)) is amended--
(1) by designating the matter beginning with ``The process
established'' as a clause (i) with the heading ``Auto-
enrollment for dual eligibles and certain other subsidy
eligible individuals'';
(2) by inserting ``or who is a subsidy eligible individual
described in section 1860D-14(a)(1)'' after ``section
1935(c)(6))'';
(3) by striking ``for the enrollment in'' and all that
follows through ``in the PDP region.'' and inserting ``for the
enrollment in the medicare operated prescription drug plan (as
defined in section 1860D-11A(c)).''; and
(4) by adding at the end the following new clauses:
``(ii) Application in case of premium
increases or plan discontinuation.--The process
under subparagraph (A) shall also provide for
enrollment described in clause (i) in the case
of such an individual who is enrolled in a
prescription drug plan that has a monthly
beneficiary premium that does not exceed the
premium assistance available under section
1860D-14(a)(1)(A)) if such plan is discontinued
or the premium under such plan is increased so
it exceeds such available premium assistance.
``(iii) Notice.--
``(I) In general.--The Secretary
shall provide for notice to each
individual auto-enrolled under clause
(i) or (ii) that the individual has the
right and the opportunity to select
another prescription drug plan (or MA-
PD plan) through which to obtain
prescription drug coverage.
``(II) Additional notice.--In the
case of an individual described in
clause (ii), both the sponsor of the
plan in which the individual is
enrolled and the Secretary shall
provide notice to the individual that
enrollment in the plan will be
discontinued or have a premium above
the benchmark and, as a result, the
individual will be enrolled in the
medicare operated prescription drug
plan for the following year unless the
individual affirmatively acts
otherwise.''.
(c) Application of Monthly Premium for Premium Subsidy Purposes.--
Section 1860D-14(b)(1) of such Act (42 U.S.C. 1395ww-114(b)(1)) is
amended by striking ``the amount specified in paragraph (3)'' and
inserting ``the greater of the amount specified in paragraph (3) or the
monthly premium amount specified in section 1860D-11A(d)(1)''.
(d) Conforming Amendments, Including Elimination of Unnecessary
Plan Requirement and Fallback Plan Provisions.--
(1) Section 1860D-3 of such Act (42 U.S.C. 1395w-103) is
repealed.
(2) Section 1860D-11 of such Act (42 U.S.C. 1395w-111) is
amended--
(A) by striking subsection (f), (g), and (h); and
(B) in subsection (i), by inserting ``except as
provided in section 1860D-11A(b),'' after ``in carrying
out this part,''.
(3) Section 1860D-12(b) of such Act (42 U.S.C. 1395w-
112(b)) is amended by striking paragraph (2).
(4) Section 1860D-13(c) of such Act (42 U.S.C. 1395w-
113(c)) is amended by striking paragraph (3).
(5) Section 1860D-15 of such Act (42 U.S.C. 1395w-115) is
amended by striking subsection (g).
(6) Section 1860D-16(b)(1) of such Act (42 U.S.C. 1395w-
116(b)(1)) is amended by striking subparagraph (B) and
inserting the following:
``(B) payments for expenses incurred with respect
to the operation of medicare operated prescription drug
plans under section 1860D-11A.''.
(7) Section 1860D-41(a) of such Act (42 U.S.C. 1395ww-
141(a)) is amended by striking paragraph (5) and inserting the
following:
``(5) Medicare operated prescription drug plan.--The term
`medicare operated prescription drug plan' has the meaning
given such term in section 1860D-11A(c).''.
(8) Section 1860D-42(a) of such Act (42 U.S.C. 1395w-
142(a)) is amended by striking ``, including section 1860D-
3(a)(1),''.
(e) Effective Date.--The amendments made by this section shall take
effect as if included in the enactment of section 101 of the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003 (Public
Law 108-173; 117 Stat. 2071).
TITLE II--MEDICAID AND LOW-INCOME IMPROVEMENTS
SEC. 201. CHANGE IN BASE USED IN COMPUTING STATE CLAWBACK PROVISION.
(a) In General.--Section 1935(c) of the Social Security Act (42
U.S.C. 1936u-5(c)) is amended--
(1) in paragraph (2)(A)(ii), by inserting ``, subject to
paragraph (7),'' after ``increased for each year ('';
(2) in paragraph (3), by inserting ``Subject to paragraph
(7)--'' after ``dual eligible individuals.--'' in the matter
before subparagraph (A); and
(3) by adding at the end the following new paragraph:
``(7) Use of 2005 as base.--This subsection shall be
applied by substituting `2005' for `2003' each place it appears
in paragraph (3) if such substitution results in a reduced
amount under paragraph (1)(A) of this subsection and, in the
case of such substitution, the reference in paragraph
(2)(A)(ii) to `2004' is deemed a reference to `2006.'''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to payments for calendar quarters beginning on or after January
1, 2007.
SEC. 202. ELIMINATION OF COST-SHARING FOR CERTAIN FULL-BENEFIT DUAL
ELIGIBLES.
(a) In General.--Section 1860D-14(a)(1)(D)(i) of the Social
Security Act (42 U.S.C. 1395w-114(a)(1)(D)(i)) is amended--
(1) in the heading, by striking ``Institutionalized
individuals.--In'' and inserting ``Elimination of cost-sharing
for certain full-benefit dual eligible individuals.--'' and the
following:
``(I) Institutionalized
individuals.--In''; and
(2) by adding at the end the following new subclauses:
``(II) Certain other individuals.--
In the case of an individual who is a
full-benefit dual eligible individual
and who receives services from a
facility or program described in
subclause (III), the elimination of any
beneficiary coinsurance described in
section 1860D-2(b)(2) (for all amounts
through the total amount of
expenditures at which benefits are
available under section 1860D-2(b)(4)).
``(III) Facility described.--For
purposes of subclause (II), a facility
or program described in this subclause
is a custodial care facility or group
home (as such terms are defined by the
Secretary) or any other facility or
program that the Secretary determines
provides services without which the
individual would require long-term care
in a medical or mental health
institution or nursing facility.''.
(b) Effective Date.--
(1) In general.--The amendments made by subsection (a)
shall take effect as if included in the enactment of section
101 of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (Public Law 108-173).
(2) Reimbursement of cost-sharing payments.--The Secretary
shall provide for reimbursement of any beneficiary coinsurance
described in section 1860D-2(b)(2) of the Social Security Act
(42 U.S.C. 1395w-102(b)(2)) paid by or on behalf of an
individual described in section 1860D-14(a)(1)(D)(i)(II) of
such Act, as added by subsection (a), during the period
beginning on January 1, 2006, and ending on the date of
enactment of this Act.
SEC. 203. ELIMINATION OF THE INDEXING ON THE PRICE-SHARING FOR DUAL-
ELIGIBLES AND QUALIFYING LOW INCOME BENEFICIARIES.
(a) In General.--Section 1860D-14(a) of the Social Security Act (42
U.S.C. 1395w-114(a)) is amended by striking paragraph (4).
(b) Effective Date.--The amendment made by subsection (a) shall
take effect on enactment and apply to cost-sharing incurred on or after
January 1, 2007.
SEC. 204. EXPEDITING LOW-INCOME SUBSIDIES UNDER THE MEDICARE
PRESCRIPTION DRUG PROGRAM.
(a) In General.--Section 1860D-14 of the Social Security Act (42
U.S.C. 1395w-114) is amended by adding at the end the following new
subsection:
``(e) Expedited Application and Eligibility Process.--
``(1) Expedited process.--
``(A) In general.--The Secretary shall provide for
an expedited process under this subsection for the
qualification for low-income assistance under this
section through a request by the Secretary to the
Secretary of the Treasury as provided in subparagraphs
(B) and (C) for information sufficient to identify
whether the individual involved is likely eligible for
subsidies under this section based on such information
and the amount of premium and cost-sharing subsidies
for which they would qualify based on such information.
Such process shall be conducted in cooperation with the
Commissioner of Social Security.
``(B) Opt in for newly eligible individuals.--Not
later than 60 days after the date of the enactment of
this subsection, the Secretary shall ensure that, as
part of the Medicare enrollment process, enrolling
individuals--
``(i) receive information describing the
low-income subsidy provided under this section;
and
``(ii) are provided the opportunity to opt-
in to the expedited process described in this
subsection by giving consent for the Secretary
to screen the beneficiary for eligibility for
such subsidy through a request to the Secretary
of the Treasury under section 6103(l)(7) of the
Internal Revenue Code of 1986.
``(C) Transition for currently eligible
individuals.--In the case of any part D eligible
individual to which subparagraph (B) did not apply at
the time of such individual's enrollment, the Secretary
shall, as soon as practicable after implementation of
subparagraph (B), request in writing that the Secretary
of the Treasury disclose, pursuant to section
6103(l)(21) of the Internal Revenue Code of 1986,
whether such individual has either filed no income tax
return or whether such individual's income tax return
indicates likely eligibility for the low-income subsidy
provided under this section.
``(2) Notification of potentially eligible individuals.--
Under such process, in the case of each individual identified
under paragraph (1) who has not otherwise applied for, or been
determined eligible for, benefits under this section (or who
has applied for and been determined ineligible for such
benefits based only on excess resources), the Secretary shall
send them a letter (using basic, uncomplicated language)
containing the following:
``(A) Eligibility.--A statement that, based on the
information obtained under paragraph (1), the
individual is likely eligible for low-income subsidies
under this section.
``(B) Amount of subsidies.--A description of the
amount of premium and cost-sharing subsidies under this
section for which the individual would likely be
eligible based on such information.
``(C) Enrollment opportunity.--In case the
individual is not enrolled in a prescription drug plan
or MA-PD plan--
``(i) a statement that--
``(I) the individual has the
opportunity to enroll in a prescription
drug plan or MA-PD plan for benefits
under this part, but is not required to
be so enrolled; and
``(II) if the individual has
creditable prescription drug coverage,
the individual need not so enroll;
``(ii) a list of the prescription drug
plans and MA-PD plans in which the individual
is eligible to enroll;
``(iii) an enrollment form that may be used
to enroll in such a plan by mail and that
provides that if the individual wishes to
enroll but does not designate a plan, the
Secretary is authorized to enroll the
individual in the medicare operated
prescription drug plan in accordance with
section 1860D-1(b)(1)(C); and
``(iv) a statement that the individual may
also enroll online or by telephone, but, in
order to qualify for low-income subsidies, the
individual must complete the attestation
described in subparagraph (D) or otherwise
apply for such subsidies.
``(D) Attestation.--A one-page application form
that provides for a signed attestation, under penalty
of law, as to the amount of income and assets of the
individual and constitutes an application for the low-
income subsidies described in subparagraph (B). Such
form--
``(i) shall not require the submittal of
additional documentation regarding income or
assets;
``(ii) shall permit the appointment of a
personal representative described in paragraph
(6); and
``(iii) may provide for the specification
of a language (other than English) that is
preferred for subsequent communications with
respect to the individual under this part.
``(E) Information on ship.--Information on how the
individual may contact the State Health Insurance
Assistance Program (SHIP) for the State in which the
individual is located in order to obtain assistance
regarding enrollment and benefits under this part.
If a State is doing its own outreach to low-income seniors
regarding enrollment and low-income subsidies under this part,
such process shall be coordinated with the State's outreach
effort.
``(3) Follow-up communications.--If the individual does not
respond to the letter described in paragraph (2) either by
making an enrollment described in paragraph (2)(C), completing
an attestation described in paragraph (2)(D), or declining
either or both, the Secretary shall make additional attempts to
contact the individual to obtain such an affirmative response.
``(4) Hold-harmless.--Under such process, if an individual
in good faith and the absence of fraud executes an attestation
described in paragraph (2)(D) and is provided low-income
subsidies under this section on the basis of such attestation,
if the individual is subsequently found not eligible for such
subsidies, there shall be no recovery made against the
individual because of such subsidies improperly paid.
``(5) Use of authorized representative.--Under such
process, with proper authorization (which may be part of the
attestation form described in paragraph (2)(D)), an individual
may authorize another individual to act as the individual's
personal representative with respect to communications under
this part and the enrollment of the individual under a
prescription drug plan (or MA-PD plan) and for low-income
subsidies under this section.
``(6) Use of preferred language in subsequent
communications.--In the case an attestation described in
paragraph (2)(D) is completed and in which a language other
than English is specified under clause (iii) of such paragraph,
the Secretary shall provide that subsequent communications to
the individual under this part shall be in such language.
``(7) Construction.--Nothing in this subsection shall be
construed as precluding the Secretary from taking additional
outreach efforts to enroll eligible individuals under this part
and to provide low-income subsidies to eligible individuals.''.
(b) Transitional Disclosure of Return Information for Purposes of
Providing Low-Income Subsidies Under Medicare.--
(1) In general.--Subsection (l) of section 6103 of the
Internal Revenue Code of 1986 is amended by adding at the end
the following new paragraph:
``(21) Transitional disclosure of return information for
purposes of providing low-income subsidies under medicare.--
``(A) In general.--The Secretary, upon written
request from the Secretary of Health and Human Services
under section 1860D-14(e)(1) of the Social Security Act
for an individual described in subparagraph (C) of such
section, shall disclose to officers and employees of
the Department of Health and Human Services and the
Social Security Administration with respect to a
taxpayer for the applicable year--
``(i)(I) whether the adjusted gross income,
as modified in accordance with specifications
of the Secretary of Health and Human Services
for purposes of carrying out such section, of
such taxpayer and, if applicable, such
taxpayer's spouse, for the applicable year,
exceeds the amounts specified by the Secretary
of Health and Human Services as indicating
likely eligibility for the low-income subsidy
provided under section 1860D-14 of such Act,
``(II) whether the return was a joint
return, and
``(III) the applicable year, or
``(ii) if applicable, the fact that there
is no return filed for such taxpayer for the
applicable year.
``(B) Definition of applicable year.--For the
purposes of this paragraph, the term `applicable year'
means the most recent taxable year for which
information is available in the Internal Revenue
Service's taxpayer data information systems, or, if
there is no return filed for such taxpayer for such
year, the prior taxable year.
``(C) Restriction on use of disclosed
information.--Return information disclosed under this
paragraph may be used only for the purposes of
identifying eligible individuals for, and
administering--
``(i) low-income subsidies under section
1860D-14 of the Social Security Act, and
``(ii) the Medicare Savings Program
implemented under clauses (i), (iii), and (iv)
of section 1902(a)(10)(E) of such Act.
``(D) Termination.--Return information may not be
disclosed under this paragraph after the date that is
one year after the date of the enactment of this
paragraph.''.
(2) Confidentiality.--Paragraph (3) of section 6103(a) of
such Code is amended by striking ``or (20)'' and inserting
``(20), or (21)''.
(3) Procedures and recordkeeping related to disclosures.--
Paragraph (4) of section 6103(p) of such Code is amended by
striking ``or (20)'' each place it appears and inserting
``(20), or (21)''.
(4) Unauthorized disclosure or inspection.--Paragraph (2)
of section 7213(a) of such Code is amended by striking ``or
(20)'' and inserting ``(20), or (21)''.
SEC. 205. INCREASE IN PERMITTED RESOURCES TO OBTAIN LOW-INCOME
SUBSIDIES.
(a) Increase in Resource Limits.--Subparagraph (E)(i) of section
1860D-14(a)(3) of the Social Security Act (42 U.S.C. 1395ww-114(a)(3))
is amended--
(1) in subclause (I), by striking ``for 2006'' and
inserting ``for months in 2006 before the first day of the
first month beginning after the date of the enactment of the
Medicare Prescription Drug Savings for Our Seniors (Medicare
Prescription Drug SOS) Act of 2006'' and by striking ``and'' at
the end;
(2) by redesignating subclause (II) as subclause (III);
(3) by inserting after subclause (I) the following new
subclause:
``(II) for months in 2006 beginning
with the first month that begins after
the date of the enactment of the
Medicare Prescription Drug Savings for
Our Seniors (Medicare Prescription Drug
SOS) Act of 2006, $50,000 (or $100,000
in the case of the combined value of
the individual's assets or resources
and the assets or resources of the
individual's spouse); and''; and
(4) in the last sentence, by striking ``subclause (II)''
and inserting ``subclause (III)''.
(b) Not Counting Value of Life Insurance as Resource.--Such section
is further amended--
(1) in subparagraphs (D) and (E), by inserting ``, except
as provided in subparagraph (G)'' after ``supplemental security
income program''; and
(2) by adding at the end the following new subparagraph:
``(G) Exclusion of life insurance in resources.--
For purposes of subparagraphs (D) and (E), the value of
a life insurance policy shall not be counted as a
resource for months beginning after the date of the
enactment of this subparagraph.''.
SEC. 206. WAIVER OF LATE ENROLLMENT PENALTY FOR SUBSIDY ELIGIBLE
INDIVIDUALS FOR FIRST 24 MONTHS OF NON-ENROLLMENT.
Section 1860D-13(b)(3)(B) of the Social Security Act (42 U.S.C.
1395w-113(b)(3)(B)) is amended by inserting before the period at the
end the following: ``, except that in the case of a subsidy eligible
individual (as defined in section 1860D-14(a)(3)(A)) the first 24
uncovered months shall not be counted''.
TITLE III--FRAUD AND ABUSE PROVISIONS
SEC. 301. CRIMINAL PENALTY FOR FRAUD IN CONNECTION WITH ENROLLMENT
UNDER AN MA PLAN OR PRESCRIPTION DRUG PLAN.
(a) In General.--Section 1857 of the Social Security Act (42 U.S.C.
1395w-27) is amended by adding at the end the following new subsection:
``(j) Criminal Penalty for Fraud in Connection With Enrollment
Under an MA Plan or Prescription Drug Plan.--Whoever knowingly and
willfully--
``(1) defrauds an individual in connection with the
enrollment (or nonenrollment) of the individual with a Medicare
Advantage plan under this part or a prescription drug plan
under part D; or
``(2) fraudulently or falsely represents an entity to be
such a plan for purposes of inducing enrollment in such entity;
shall be fined under title 18, United States Code, or imprisoned not
less than 3 years and not more than 10 years, or both.''.
(b) Conforming Reference in Part D.--Section 1860D-12(b) of such
Act (42 U.S.C. 1395w-112(b)) is amended by adding at the end the
following new paragraph:
``(4) Reference to penalty for fraud in connection with
enrollment under a prescription drug plan.--For provision
imposing a criminal penalty for defrauding an individual in
connection with the enrollment of such individual under a
prescription drug plan, see section 1857(j).''.
(c) Effective Date.--The amendment made by subsection (a) shall
apply to fraudulent acts and to fraudulent or false representations
made on or after the date of the enactment of this Act.
SEC. 302. RECOURSE FOR SLAMMING PRACTICES.
Section 1851 of the Social Security Act (42 U.S.C. 1395w-21) is
amended by adding at the end the following new subsection:
``(j) Sanctions Against Slamming Practices.--
``(1) In general.--The Secretary shall establish
procedures, consistent with this subsection and the complaint
processes otherwise available, under which Medicare Advantage
eligible individuals who have been enrolled into an MA-PD plan
without their informed consent may file a complaint with the
Secretary regarding such enrollment. Such a complaint shall be
signed and shall attest, under penalty of perjury, as to the
accuracy of the statements therein.
``(2) Response to the complaint.--If the Secretary finds
that the complaint is justified by the facts in the case, the
Secretary shall permit the individual to be enrolled under the
original medicare fee-for-service program and the medicare
operated prescription drug plan or under another MA plan in
which the individual was previously enrolled. An individual who
is dissatisfied with the Secretary's decision on the complaint
may have a hearing on the complaint before an administrative
law judge in a manner similar to the manner in which such a
hearing is permitted under this title with respect to other
determinations under this title.''.
SEC. 303. PROTECTION FROM LOSS OF EMPLOYMENT-BASED RETIREE HEALTH
COVERAGE UPON ENROLLMENT FOR MEDICARE PRESCRIPTION DRUG
BENEFIT DURING 2006.
Section 1860D-22(a)(2) of the Social Security Act (42 U.S.C. 1395w-
132(a)(2)) is amended by adding at the end the following new
subparagraph:
``(D) Protection from loss of employment-based
coverage.--The sponsor of the plan may not
involuntarily discontinue coverage of an individual
under a group health plan before January 1, 2008, based
upon the individual's decision to enroll in a
prescription drug plan or an MA-PD plan under this
part.''.
SEC. 304. REQUIRED APPLICATION OF INTERMEDIATE SANCTIONS TO PROTECT
AGAINST FRAUD AND ABUSE.
(a) In General.--Section 1860D-12(b)(3)(E) of the Social Security
Act (42 U.S.C. 1395w-112(b)(3)(E)) is amended by inserting ``and the
reference to `may provide' in section 1857(g)(1) is deemed a reference
to `shall provide''' after ``this part''.
(b) Application to MA-PD Plans.--Section 1857(g)(1) of such Act (42
U.S.C. 1395w-27(g)(1)) is amended by inserting ``(or in the case of an
MA-PD plan or a prescription drug plan under part D, the Secretary
shall provide)'' after ``may provide''.
SEC. 305. REPEAL OF SPECIAL WAIVER AUTHORITY FOR STATE LICENSURE.
Subsection (d) of section 423.410 of title 42, Code of Federal
Regulations, is repealed, and the Secretary of Health and Human
Services has no authority to provide for a waiver of a State licensure
requirement described in such subsection except pursuant to section
1855(a)(2)(B) of the Social Security Act (42 U.S.C. 1395w-25(a)(2)(B)).
TITLE IV--RELATION TO SOCIAL SECURITY BENEFITS
SEC. 401. PROTECTION OF SOCIAL SECURITY BENEFITS AGAINST DECREASE DUE
TO PART D MEDICARE PREMIUM INCREASES.
(a) Protection Against Decrease in Social Security Benefits.--
(1) Application to enrollees in prescription drug plans.--
Section 1860D-13(a)(1) of the Social Security Act (42 U.S.C.
1395ww-113(a)(1)) is amended--
(A) in subparagraph (F), by striking ``(D) and
(E),'' and inserting ``(D), (E), and (F),'';
(B) by redesignating subparagraph (F) as
subparagraph (G); and
(C) by inserting after subparagraph (E) the
following new subparagraph:
``(F) Protection of social security benefits.--For
any calendar year, if an individual is entitled to
monthly benefits under section 202 or 223 or to a
monthly annuity under section 3(a), 4(a), or 4(f) of
the Railroad Retirement Act of 1974 for November and
December of the preceding year and was enrolled under a
prescription drug plan or MA-PD plan for such months,
the base beneficiary premium otherwise applied under
this paragraph for the individual for months in that
year shall be decreased by the amount (if any) by which
the sum of the amounts described in the following
clauses (i) and (ii) exceeds the amount of the increase
in such monthly benefits for that individual
attributable to section 215(i):
``(i) Part d premium increase factor.--
``(I) In general.--Except as
provided in this clause, the amount of
the increase (if any) in the adjusted
national average monthly bid amount (as
determined under subparagraph (B)(iii))
for a month in the year over such
amount for a month in the preceding
year.
``(II) No application to full
premium subsidy individuals.--In the
case of an individual enrolled for a
premium subsidy under section 1860D-
14(a)(1), zero.
``(III) Special rule for partial
premium subsidy individuals.--In the
case of an individual enrolled for a
premium subsidy under section 1860D-
14(a)(2), a percent of the increase
described in subclause (I) equal to 100
percent minus the percent applied based
on the linear scale under such section.
``(ii) Part b premium increase factor.--If
the individual is enrolled for such months
under part B--
``(I) In general.--Except as
provided in subclause (II), the amount
of the annual increase in premium
effective for such year resulting from
the application of section 1839(a)(3),
as reduced (if any) under section
1839(f).
``(II) No application to
individuals participating in medicare
savings program.--In the case of an
individual who is enrolled for medical
assistance under title XIX for medicare
cost-sharing described in section
1905(p)(3)(A)(ii), zero.''.
(2) Application under medicare advantage program.--Section
1854(b)(2)(B) of such Act (42 U.S.C. 1395w-24(b)(2)(B)), as in
effect as of January 1, 2006, relating to MA monthly
prescription drug beneficiary premium, is amended by inserting
after ``as adjusted under section 1860D-13(a)(1)(B)'' the
following: ``and section 1860D-13(a)(1)(F)''.
(3) Payment from medicare prescription drug account.--
Section 1860D-16(b) of such Act (42 U.S.C. 1395w-116(b)) is
amended--
(A) in paragraph (1), as amended by section
101(c)(5)--
(i) by striking ``and'' at the end of
subparagraph (D);
(ii) by striking the period at the end of
subparagraph (E) and inserting ``; and''; and
(iii) by adding at the end the following
new subparagraph:
``(F) payment under paragraph (5) of premium
reductions effected under section 1860D-13(a)(1)(F).'';
and
(B) by adding at the end the following new
paragraph:
``(5) Payment for social security benefit protection
premium reductions.--
``(A) In general.--In addition to payments provided
under section 1860D-15 to a PDP sponsor or an MA
organization, in the case of each part D eligible
individual who is enrolled in a prescription drug plan
offered by such sponsor or an MA-PD plan offered by
such organization and who has a premium reduced under
section 1860D-13(a)(1)(F), the Secretary shall provide
for payment to such sponsor or organization of an
amount equivalent to the amount of such premium
reduction.
``(B) Application of provisions.--The provisions of
subsections (d) and (f) of section 1860D-15 (relating
to payment methods and disclosure of information) shall
apply to payment under subparagraph (A) in the same
manner as they apply to payments under such section.''.
(b) Disregard of Premium Reductions in Determining Dedicated
Revenues Under MMA Cost Containment.--Section 801(c)(3)(D) of the
Medicare Prescription Drug, Improvement, and Modernization Act of 2003
(Public Law 108-173) is amended by adding at the end the following:
``Such premiums shall also be determined without regard to any
reductions effected under section 1839(f) or 1860D-13(a)(1)(F) of such
title.''.
(c) Effective Dates.--
(1) Part d premium.--The amendments made by subsection (a)
apply to premiums for months beginning with January 2007.
(2) MMA provision.--The amendment made by subsection (b)
shall take effect on the date of the enactment of this Act.
TITLE V--BENEFICIARY PROTECTION PROVISIONS
SEC. 501. EXTENSION OF OPEN ENROLLMENT PERIOD; SUSPENSION OF LATE
ENROLLMENT PENALTIES; ALLOWING ONE-TIME CHANGE IN PLAN
DURING FIRST YEAR OF ENROLLMENT.
(a) Extension of Open Enrollment Period for 2006.--Section
1851(e)(3)(B) of the Social Security Act (42 U.S.C. 1395w-21(e)(3)(B))
is amended in clause (iii) by striking ``May 15, 2006'' and inserting
``November 14, 2006''.
(b) No Late Enrollment Penalties for Months Before January 2008.--
Section 1860D-13(b)(3)(B) of such Act (42 U.S.C. 1395w-113(b)(3)(B)) is
amended by inserting ``(after December 2007)'' after ``any month''.
(c) Change in Plan During First Year of Enrollment.--Section 1860D-
1(b)(1) of such Act (42 U.S.C. 1395w-101(b)(1)) is amended by adding at
the end the following new subparagraph:
``(D) Change in prescription drug plan allowed
during first year of enrollment.--
``(i) In general.--Subject to clause (ii),
at any time during the 12-month period
beginning with the first month in which a part
D eligible individual is enrolled in a
prescription drug plan under this part, the
individual may change the prescription drug
plan in which the individual is enrolled.
``(ii) Limitation of one change during
period.--An individual may exercise the right
under clause (i) only once during such 12-month
period and the exercise of such right shall be
in addition to the exercise of any other rights
to change such an enrollment during such
period.''.
SEC. 502. COUNTING EXPENDITURES UNDER STATE DRUG ASSISTANCE PROGRAMS
AGAINST TRUE OUT-OF-POCKET COSTS.
Section 1860D-2(b)(4)(C)(ii) of the Social Security Act (42 U.S.C.
1395w-102(b)(4)(C)(ii)) is amended by inserting ``, AIDS Drug
Assistance Program, or other State drug assistance program'' after
``State Pharmaceutical Assistance Program''.
SEC. 503. PRICE DISCLOSURE.
(a) In General.--Section 1860D-2(d)(2) of the Social Security Act
(42 U.S.C. 1395w-102(d)(2)) is amended--
(1) in the first sentence, by striking ``which are passed
through'' and all that follows through ``other dispensers'';
(2) in the second sentence, by inserting ``do not'' before
``apply''; and
(3) in the second sentence, by inserting before the period
at the end the following: ``and the Secretary shall make the
information described in the previous sentence available to the
public''.
(b) Conforming Amendment.--Section 1927(b)(3)(D) of such Act (42
U.S.C. 1396r-8(b)(3)(D)) is amended by striking the last sentence.
SEC. 504. REMOVAL OF COVERED PART D DRUGS FROM THE PRESCRIPTION DRUG
PLAN FORMULARY.
Section 1860D-4(b)(3)(E) of the Social Security Act (42 U.S.C.
1395w-104(b)(3)(E)) is amended to read as follows:
``(E) Removing drug from formulary or changing
preferred or tier status of drug.--
``(i) Limitation on removal or change.--
Beginning with 2006, except as provided in
clause (iii), the PDP sponsor of a prescription
drug plan may not--
``(I) remove a covered part D drug
from the plan formulary;
``(II) change the preferred or
tiered cost-sharing status of such a
drug to a status less favorable to an
enrollee; or
``(III) introduce a barrier, such
as step therapy, prior authorization,
or quantity limitation, to access to
covered part D drugs,
unless advance notice under clause (ii) of such
removal, change, or introduction has been
provided and unless such removal, change, or
introduction is only effective beginning on
January 1 of the year following the year in
which such notice is provided.
``(ii) Notice.--The notice under this
clause is an appropriate notice (such as under
subsection (a)(3)) to the Secretary, affected
enrollees, physicians, pharmacies, and
pharmacists during the period beginning on
September 1 and ending on October 31 of a year.
Such notice shall ensure that such information
is made available prior to the annual,
coordinated open election period described in
section 1851(e)(3)(B)(iii), as applied under
section 1860D-1(b)(1)(B)(iii).
``(iii) Exception.--Clause (i) shall not
apply to a covered part D drug--
``(I) if it has been determined to
be unsafe by the Food and Drug
Administration; and
``(II) if, during a plan year, the
drug changes from being a single source
drug to a multiple source drug (as
defined in section 1927(k)), and the
prescription drug plan covers another
bioequivalent multiple source drug at
the same or lower cost-sharing to
enrolled individuals.''.
SEC. 505. CODIFICATION OF REQUIREMENT FOR COVERAGE OF ALL OR
SUBSTANTIALLY ALL OF DRUGS WITHIN SIX CATEGORIES OF
DRUGS.
(a) In General.--Section 1860D-4(b)(3) of the Social Security Act
(42 U.S.C. 1395w-104(b)(3)) is amended--
(1) in subparagraph (C)(i), by striking ``The formulary''
and inserting ``Subject to subparagraph (G), the formulary'';
and
(2) by inserting after subparagraph (F) the following new
subparagraph:
``(G) Required inclusion of drugs in certain
categories and classes.--
``(i) In general.--The formulary must
include all or substantially all drugs in the
following categories that are available as of
April 17 of the prior year and shall include at
least some drugs from each category without
restrictions or limitations on coverage (such
as through the application of a less-preferred
cost-sharing tier or status, usage restriction,
step therapy, prior authorization, or a
quantity limitation):
``(I) Immunosuppressant.
``(II) Antidepressant.
``(III) Antipsychotic.
``(IV) Anticonvulsant.
``(V) Antiretroviral.
``(VI) Antineoplastic.
``(ii) Substantially all defined.--For
purposes of clause (i), the term `substantially
all' means all drugs and unique dosage forms in
the categories described in such clause, except
for--
``(I) multi-source brands of the
identical molecular structure;
``(II) extended release products
when the immediate-release product is
included on the formulary;
``(III) products that have the same
active ingredient; and
``(IV) dosage forms that do not
provide a unique route of
administration, such as tablets and
capsules.''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to contract years beginning on or after January 1, 2007.
SEC. 506. REMOVAL OF EXCLUSION OF BENZODIAZEPINES FROM REQUIRED
COVERAGE UNDER THE MEDICARE PRESCRIPTION DRUG PROGRAM.
(a) In General.--Section 1860D-2(e)(2) of the Social Security Act
(42 U.S.C. 1395w-102(e)(2)) is amended--
(1) by striking ``subparagraph (E)'' and inserting
``subparagraphs (E) and (J)''; and
(2) by inserting ``and benzodiazepines'' after ``smoking
cessation agents''.
(b) Review of Benzodiazepine Prescription Policies to Assure
Appropriateness and to Avoid Abuse.--The Secretary of Health and Human
Services shall review the policies of medicare prescription drug plans
(and MA-PD plans) under parts C and D of title XVIII of the Social
Security Act regarding the filling of prescriptions for benzodiazepine
to ensure that these policies are consistent with accepted clinical
guidelines, are appropriate to individual health histories, and are
designed to minimize long term use, guard against over-prescribing, and
prevent patient abuse.
(c) Development by Medicare Quality Improvement Organizations of
Educational Guidelines for Physicians Regarding Prescribing of
Benzodiazepines.--The Secretary of Health and Human Services shall
provide, in contracts entered into with medicare quality improvement
organizations under part B of title XI of the Social Security Act, for
the development by such organizations of appropriate educational
guidelines for physicians regarding the prescribing of benzodiazepines.
(d) Effective Date.--The amendments made by this section shall be
effective as if included in the enactment of the Medicare Prescription
Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173).
SEC. 507. STANDARDIZED FORMS AND PROCEDURES FOR RECONSIDERATIONS AND
APPEALS.
(a) In General.--Section 1860D-4 of the Social Security Act (42
U.S.C. 1395w-104) is amended by adding at the end the following new
subsection:
``(l) Standardized Forms and Procedures for Reconsiderations and
Appeals.--
``(1) Standard enrollee notice.--The Secretary shall
develop a standard notice to be distributed by a prescription
drug plan (or an MA-PD plan) to an enrollee when a covered part
D drug prescribed for the enrollee is not covered, or the
coverage of such drug is otherwise restricted, by the plan.
``(2) Standardized process for reconsiderations and
appeals.--The Secretary shall require prescription drug plans
and MA-PD plans to follow the same standardized process for
reconsiderations and redeterminations under subsections (g) and
(h). Such process shall require that determinations regarding
medical necessity are based on professional medical judgement,
the medical condition of the enrollee, the treating physician's
recommendation, and other medical evidence.''.
(b) Effective Date.--The Secretary of Health and Human Services
shall provide for the standard notice and the standardized process, and
the application of such notice and process, under the amendment made by
subsection (a) by not later than January 1, 2007.
SEC. 508. ELIMINATION OF MA REGIONAL STABILIZATION FUND (SLUSH FUND);
ELIMINATION OF CERTAIN MA OVERPAYMENTS.
(a) Elimination of Slush Fund.--
(1) In general.--Subsection (e) of section 1858 of the
Social Security Act (42 U.S.C. 1395w-27a) is repealed.
(2) Conforming amendment.--Section 1858(f)(1) of the Social
Security Act (42 U.S.C. 1395w-27a(f)(1)) is amended by striking
``subject to subsection (e),''.
(3) Effective date.--The amendments made by this subsection
shall take effect as if included in the enactment of section
221(c) of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (Public Law 108-173; 117 Stat. 2181).
(b) Elimination of Certain Medicare Advantage Overpayments.--
(1) In general.--Section 1853(a)(1)(C)(ii) of the Social
Security Act (42 U.S.C. 1395w-23(a)(1)(C)(ii)), as added by
section 5301 of the Deficit Reduction Act of 2005, is amended--
(A) in the heading, by striking ``during phase-out
of budget neutrality factor'';
(B) in the matter preceding subclause (I), by
striking ``through 2010'' and inserting ``and
subsequent years''; and
(C) in subclause (II), by striking ``only for 2008,
2009, and 2010'' and inserting ``for 2008 and
subsequent years''.
(2) Effective date.--The amendments made by this subsection
shall take effect as if included in the enactment of section
5301 of the Deficit Reduction Act of 2005.
TITLE VI--FAIR AND SPEEDY TREATMENT OF MEDICARE PRESCRIPTION DRUG
CLAIMS
SEC. 601. PROMPT PAYMENT BY MEDICARE PRESCRIPTION DRUG PLANS AND MA-PD
PLANS UNDER PART D.
(a) Application to Prescription Drug Plans.--Section 1860D-12(b) of
the Social Security Act (42 U.S.C. 1395w-112 (b)), as amended by
section 301(b), is amended by adding at the end the following new
paragraph:
``(5) Prompt payment of clean claims.--
``(A) Prompt payment.--Each contract entered into
with a PDP sponsor under this subsection with respect
to a prescription drug plan offered by such sponsor
shall provide that payment shall be issued, mailed, or
otherwise transmitted with respect to all clean claims
submitted under this part within the applicable number
of calendar days after the date on which the claim is
received.
``(B) Definitions.--In this paragraph:
``(i) Clean claim.--The term `clean claim'
means a claim, with respect to a covered part D
drug, that has no apparent defect or
impropriety (including any lack of any required
substantiating documentation) or particular
circumstance requiring special treatment that
prevents timely payment from being made on the
claim under this part.
``(ii) Applicable number of calendar
days.--The term `applicable number of calendar
days' means--
``(I) with respect to claims
submitted electronically, 14 calendar
days; and
``(II) with respect to claims
submitted otherwise, 30 calendar days.
``(C) Interest payment.--If payment is not issued,
mailed, or otherwise transmitted within the applicable
number of calendar days (as defined in subparagraph
(B)) after a clean claim is received, interest shall be
paid at a rate used for purposes of section 3902(a) of
title 31, United States Code (relating to interest
penalties for failure to make prompt payments), for the
period beginning on the day after the required payment
date and ending on the date on which payment is made.
``(D) Procedures involving claims.--
``(i) Claims deemed to be clean claims.--
``(I) In general.--A claim for a
covered part D drug shall be deemed to
be a clean claim for purposes of this
paragraph if the PDP sponsor involved
does not provide a notification of
deficiency to the claimant by the 10th
day that begins after the date on which
the claim is submitted.
``(II) Notification of
deficiency.--For purposes of subclause
(II), the term `notification of
deficiency' means a notification that
specifies all defects or improprieties
in the claim involved and that lists
all additional information or documents
necessary for the proper processing and
payment of the claim.
``(ii) Payment of clean portions of
claims.--A PDP sponsor shall, as appropriate,
pay any portion of a claim for a covered part D
drug that would be a clean claim but for a
defect or impropriety in a separate portion of
the claim in accordance with subparagraph (A).
``(iii) Obligation to pay.--A claim for a
covered part D drug submitted to a PDP sponsor
that is not paid or contested by the provider
within the applicable number of calendar days
(as defined in subparagraph (B)) shall be
deemed to be a clean claim and shall be paid by
the PDP sponsor in accordance with subparagraph
(A).
``(iv) Date of payment of claim.--Payment
of a clean claim under subparagraph (A) is
considered to have been made on the date on
which full payment is received by the provider.
``(E) Electronic transfer of funds.--A PDP sponsor
shall pay all clean claims submitted electronically by
an electronic funds transfer mechanism.''.
(b) Application to MA-PD Plans.--Section 1857(f) of such Act (42
U.S.C. 1395w-27) is amended by adding at the end the following new
paragraph:
``(3) Incorporation of certain prescription drug plan
contract requirements.--The provisions of section 1860D-
12(b)(5) shall apply to contracts with a Medicare Advantage
organization in the same manner as they apply to contracts with
a PDP sponsor offering a prescription drug plan under part
D.''.
(c) Effective Date.--The amendments made by this section shall
apply to contracts entered into or renewed on or after the date of the
enactment of this Act.
SEC. 602. RESTRICTION ON CO-BRANDING.
(a) In General.--Section 1860D-4(b)(2)(A) of the Social Security
Act (42 U.S.C. 1395w-104(b)(2)(A)) is amended by adding at the end the
following new sentences: ``It is unlawful for a PDP sponsor of a
prescription drug plan to display on such a card the name, brand, or
trademark of any pharmacy.''
(b) Effective Date.--With respect to cards dispensed before, on, or
after the date of the enactment of this Act, the amendment made by this
section shall apply to such cards on and after the date that is 90 days
after such date of enactment. Any card dispensed before such date that
is 90 days after the date of enactment that violates the second
sentence of section 1860D-4(b)(2)(A) of the Social Security Act, as
added by subsection (a), shall be reissued by such 90-day date.
SEC. 603. MINIMUM DISPENSING FEES FOR GENERIC COVERED PART D DRUGS.
(a) In General.--Section 1860D-4(b)(1) of the Social Security Act
(42 U.S.C. 1395w-104(b)(1)) is amended by adding at the end the
following new subparagraph:
``(F) Payment of minimum dispensing fees to
encourage use of generic drugs.--
``(i) In general.--Subject to clauses (ii)
and (iii), with respect to a generic covered
part D drug that is therapeutically equivalent
and bioequivalent to a brand name drug that is
a covered part D drug dispensed through a
participating pharmacy, the amount of the
dispensing fee paid to the pharmacy for the
generic covered part D drug shall be an amount
that is at least the greater of--
``(I) 50 percent greater than the
amount of the dispensing fee for the
brand name drug; or
``(II) $10.
``(ii) Safe harbor for brand name drug
dispensing fee amounts.--
``(I) In general.--For purposes of
clause (i) and subject to subclause
(II), a prescription drug plan under
this section shall not decrease the
amount of the dispensing fee paid by
the plan to a participating pharmacy
for a brand name drug described in such
clause to an amount that is less than
the amount of the dispensing fee paid
by such plan to such pharmacy for such
drug on the date of the enactment of
this subparagraph.
``(II) Exception.--The Secretary
may waive the prohibition under
subclause (I) with respect to a
dispensing fee paid by a prescription
drug plan for a brand name drug, as the
Secretary determines appropriate.''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to prescriptions filled on or after the date that is the first
day of the first contract year after the date of the enactment of this
Act.
SEC. 604. PROVISION OF MEDICATION THERAPY MANAGEMENT SERVICES UNDER
PART D.
(a) Provision of Medication Therapy Management Services Under Part
D.--
(1) In general.--Section 1860D-4(c)(2) of the Social
Security Act (42 U.S.C.1395w-104(c)(2)) is amended--
(A) in subparagraph (A)--
(i) in clause (i)--
(I) by inserting ``or other health
care provider with advanced training in
medication management'' after
``furnished by a pharmacist''; and
(II) by striking ``targeted
beneficiaries described in clause
(ii)'' and inserting ``targeted
beneficiaries specified under clause
(ii)''
(ii) by striking clause (ii) and inserting
the following:
``(ii) Targeted beneficiaries.--The
Secretary shall specify the population of part
D eligible individuals appropriate for services
under a medication therapy management program
based on the following characteristics:
``(I) Having a disease state in
which evidence-based medicine has
demonstrated the benefit of medication
therapy management intervention based
on objective outcome measures.
``(II) Taking multiple covered part
D drugs or having a disease state in
which a complex combination medication
regimen is utilized.
``(III) Being identified as likely
to incur annual costs for covered part
D drugs that exceed a level specified
by the Secretary or where acute or
chronic decompensation of disease would
likely increase expenditures under the
Federal Hospital Insurance Trust Fund
or the Federal Supplementary Medical
Insurance Trust Fund under sections
1817 and 1841, respectively, such as
through the requirement of emergency
care or acute hospitalization.'';
(B) by striking subparagraph (B) and inserting the
following:
``(B) Elements.--
``(i) Minimum defined package of
services.--The Secretary shall specify a
minimum defined package of medication therapy
management services that shall be provided to
each enrollee. Such package shall be based on
the following considerations:
``(I) Performing necessary
assessments of the health status of
each enrollee.
``(II) Providing medication therapy
review to identify, resolve, and
prevent medication-related problems,
including adverse events.
``(III) Increasing enrollee
understanding to promote the
appropriate use of medications by
enrollees and to reduce the risk of
potential adverse events associated
with medications, through beneficiary
and family education, counseling, and
other appropriate means.
``(IV) Increasing enrollee
adherence with prescription medication
regimens through medication refill
reminders, special packaging, and other
compliance programs and other
appropriate means.
``(V) Promoting detection of
adverse drug events and patterns of
overuse and underuse of prescription
drugs.
``(VI) Developing a medication
action plan which may alter the
medication regimen, when permitted by
the State licensing authority. This
information should be provided to, or
accessible by, the primary health care
provider of the enrollee.
``(VII) Monitoring and evaluating
the response to therapy and evaluating
the safety and effectiveness of the
therapy, which may include laboratory
assessment.
``(VIII) Providing disease-specific
medication therapy management services
when appropriate.
``(IX) Coordinating and integrating
medication therapy management services
within the broader scope of health care
management services being provided to
each enrollee.
``(ii) Delivery of services.--
``(I) Personal delivery.--To the
extent feasible, face-to-face
interaction shall be the preferred
method of delivery of medication
therapy management services.
``(II) Individualized.--Such
services shall be patient-specific and
individualized and shall be provided
directly to the patient by a pharmacist
or other health care provider with
advanced training in medication
management.
``(III) Distinct from other
activities.--Such services shall be
distinct from any activities related to
formulary development and use,
generalized patient education and
information activities, and any
population-focused quality assurance
measures for medication use.
``(iii) Opportunity to identify patients in
need of medication therapy management
services.--The program shall provide
opportunities for health care providers to
identify patients who should receive medication
therapy management services.'';
(C) by striking subparagraph (E) and inserting the
following:
``(E) Pharmacy fees.--
``(i) In general.--The PDP sponsor of a
prescription drug plan shall pay pharmacists
and others providing services under the
medication therapy management program under
this paragraph based on the time and intensity
of services provided to enrollees.
``(ii) Submission along with plan
information.--Each such sponsor shall disclose
to the Secretary upon request the amount of any
such payments and shall submit a description of
how such payments are calculated along with the
information submitted under section 1860D-
11(b). Such description shall be submitted at
the same time and in a similar manner to the
manner in which the information described in
paragraph (2) of such section is submitted.'';
and
(D) by adding at the end the following new
subparagraph:
``(F) Pharmacy access requirements.--The PDP
sponsor of a prescription drug plan shall secure the
participation in its network of a sufficient number of
retail pharmacies to assure that enrollees have the
option of obtaining services under the medication
therapy management program under this paragraph
directly from community-based retail pharmacies.''.
(2) Effective date.--The amendments made by this subsection
shall apply to medication therapy management services provided
on or after January 1, 2008.
(b) Medication Therapy Management Demonstration Program.--Section
1860D-4(c) of the Social Security Act (42 U.S.C.1395w-104(c)) is
amended by adding at the end the following new paragraph:
``(3) Community-based medication therapy management
demonstration program.--
``(A) Establishment.--
``(i) In general.--By not later than
January 1, 2008, the Secretary shall establish
a 2-year demonstration program, based on the
recommendations of the Best Practices
Commission established under subparagraph (B),
with both PDP sponsors of prescription drug
plans and Medicare Advantage Organizations
offering MA-PD plans, to examine the impact of
medication therapy management furnished by a
pharmacist in a community-based or ambulatory-
based setting on quality of care, spending
under this part, and patient health.
``(ii) Sites.--
``(I) In general.--Subject to
subclause (II), the Secretary shall
designate not less than 10 PDP sponsors
of prescription drug plans or Medicare
Advantage organizations offering MA-PD
plans, none of which provide
prescription drug coverage under such
plans in the same PDP or MA region,
respectively, to conduct the
demonstration program under this
paragraph.
``(II) Designation consistent with
recommendations of best practices
commission.--The Secretary shall ensure
that the designation of sites under
subclause (I) is consistent with the
recommendations of the Best Practices
Commission under subparagraph (B)(ii).
``(B) Best practices commission.--
``(i) Establishment.--The Secretary shall
establish a Best Practices Commission composed
of representatives from pharmacy organizations,
health care organizations, beneficiary
advocates, chronic disease groups, and other
stakeholders (as determined appropriate by the
Secretary) for the purpose of developing a best
practices model for medication therapy
management.
``(ii) Recommendations.--The Commission
shall submit to the Secretary recommendations
on the following:
``(I) The minimum number of
enrollees that should be included in
the demonstration program, and at each
demonstration program site, to
determine the impact of medication
therapy management furnished by a
pharmacist in a community-based setting
on quality of care, spending under this
part, and patient health.
``(II) The number of urban and
rural sites that should be included in
the demonstration program to ensure
that prescription drug plans and MA-PD
plans offered in urban and rural areas
are adequately represented.
``(III) A best practices model for
medication therapy management to be
implemented under the demonstration
program under this paragraph.
``(C) Reports.--
``(i) Interim report.--Not later than 1
year after the commencement of the
demonstration program, the Secretary shall
submit to Congress an interim report on such
program.
``(ii) Final report.--Not later than 6
months after the completion of the
demonstration program, the Secretary shall
submit to Congress a final report on such
program, together with recommendations for such
legislation and administrative action as the
Secretary determines appropriate.
``(D) Waiver authority.--The Secretary may waive
such requirements of titles XI and XVIII as may be
necessary for the purpose of carrying out the
demonstration program under this paragraph.''.
<all>
Introduced in House
Introduced in House
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.
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.
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.
Referred to the Subcommittee on Health.
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