Pharmacist Access and Recognition in Medicare (PhARM) Act of 2006 - Amends part D (Voluntary Prescription Drug Benefit Program) of title XVIII (Medicare) of the Social Security Act to require prompt payment of clean claims to pharmacies by prescription drug plans and Medicare Advantage prescription drug plans. Defines prompt payment as within 14 days from submission for claims submitted electronically, and within 30 days for claims submitted otherwise. Requires payment of interest, also, if a payment is not issued, mailed, or otherwise transmitted within the applicable number of calendar days.
Prohibits a Medicare prescription drug card issued by a prescription drug plan sponsor from displaying the name, brand, or trademark (co-branding) of any pharmacy.
Revises requirements for a covered medication therapy management program, allowing it to be furnished by a health care provider, other than a pharmacist, with advanced training in medication management.
Requires the Secretary of Health and Human Services to specify: (1) the population of part D eligible individuals appropriate for services under a medication therapy management program, based on certain characteristics; and (2) a minimum defined package of medication therapy management services that shall be provided to each enrollee.
Revises requirements for pharmacy fees.
Directs the Secretary to establish: (1) a two-year demonstration program 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, and patient health; and (2) a Best Practices Commission to develop a best practices model for medication therapy management.
[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[S. 2563 Introduced in Senate (IS)]
109th CONGRESS
2d Session
S. 2563
To amend title XVIII of the Social Security Act to require prompt
payment to pharmacies under part D, to restrict pharmacy co-branding on
prescription drug cards issued under such part, and to provide
guidelines for Medication Therapy Management Services programs offered
by prescription drug plans and MA-PD plans under such part.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
April 6, 2006
Mr. Cochran (for himself, Mr. Enzi, and Mr. Talent) introduced the
following bill; which was read twice and referred to the Committee on
Finance
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to require prompt
payment to pharmacies under part D, to restrict pharmacy co-branding on
prescription drug cards issued under such part, and to provide
guidelines for Medication Therapy Management Services programs offered
by prescription drug plans and MA-PD plans under such part.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Pharmacist Access and Recognition in
Medicare (PhARM) Act of 2006''.
SEC. 2. PROMPT PAYMENT BY PRESCRIPTION DRUG PLANS AND MA-PD PLANS UNDER
PART D.
(a) Prompt Payment by Prescription Drug Plans.--Section 1860D-12(b)
of the Social Security Act (42 U.S.C. 1395w-112(b)) is amended by
adding at the end the following new paragraph:
``(4) Prompt payment of clean claims.--
``(A) Prompt payment.--
``(i) In general.--Each contract entered
into with a PDP sponsor under this section 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.
``(ii) Clean claim defined.--In this
paragraph, the term `clean claim' means a claim
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.
``(B) Applicable number of calendar days defined.--
In this paragraph, the term `applicable number of
calendar days' means--
``(i) with respect to claims submitted
electronically, 14 days; and
``(ii) with respect to claims submitted
otherwise, 30 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) In general.--A contract entered into
with a PDP sponsor under this section with
respect to a prescription drug plan offered by
such sponsor shall provide that, not later than
10 days after the date on which a clean claim
is submitted, the PDP sponsor shall provide the
claimant with a notice that acknowledges
receipt of the claim by such sponsor. Such
notice shall be considered to have been
provided on the date on which the notice is
mailed or electronically transferred.
``(ii) Claim deemed to be clean.--A claim
is deemed to be a clean claim if the PDP
sponsor involved does not provide notice to the
claimant of any deficiency in the claim within
10 days of the date on which the claim is
submitted.
``(iii) Claim determined to not be a clean
claim.--
``(I) In general.--If a PDP sponsor
determines that a submitted claim is
not a clean claim, the PDP sponsor
shall, not later than the end of the
period described in clause (ii), notify
the claimant of such determination.
Such notification shall specify all
defects or improprieties in the claim
and shall list all additional
information or documents necessary for
the proper processing and payment of
the claim.
``(II) Determination after
submission of additional information.--
A claim is deemed to be a clean claim
under this paragraph if the PDP sponsor
involved does not provide notice to the
claimant of any defect or impropriety
in the claim within 10 days of the date
on which additional information is
received under subclause (I).
``(III) Payment of clean portion of
a claim.--A PDP sponsor shall pay any
portion of a claim that would be a
clean claim but for a defect or
impropriety in a separate portion of
the claim in accordance with
subparagraph (A).
``(iv) Obligation to pay.--A claim
submitted to a PDP sponsor that is not paid or
contested by the provider within the applicable
number of 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).
``(v) Date of payment of claim.--Payment of
a clean claim under such subparagraph 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
electronic transfer of funds.''.
(b) Prompt Payment by MA-PD Plans.--Section 1857(f) of the Social
Security Act (42 U.S.C. 1395w-27(f)) 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)(4) 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 that is
90 days after the date of the enactment of this Act.
SEC. 3. RESTRICTION ON PHARMACY CO-BRANDING ON MEDICARE PRESCRIPTION
DRUG CARDS ISSUED BY PRESCRIPTION DRUG PLANS AND MA-PD
PLANS.
(a) In General.--Section 1860D-4 of the Social Security Act (42
U.S.C. 1395w-104) is amended--
(1) in subsection (b)(2)(A), by striking ``The PDP
sponsor'' and inserting ``Subject to subsection (l), the PDP
sponsor''; and
(2) by adding at the end the following new subsection:
``(l) Co-Branding Prohibited.--A card that is issued under
subsection (b)(2)(A) for use under a prescription drug plan offered by
a PDP sponsor shall not display the name, brand, or trademark of any
pharmacy.''.
(b) Effective Date.--The amendments made by this section shall
apply to cards distributed on or after the date that is 90 days after
the date of enactment of this Act.
SEC. 4. 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 Senate
Sponsor introductory remarks on measure. (CR S3220)
Read twice and referred to the Committee on Finance. (text of measure as introduced: CR S3220-3221)
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