[Congressional Bills 107th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5539 Introduced in House (IH)]







107th CONGRESS
  2d Session
                                H. R. 5539

To amend title XVIII of the Social Security Act to provide for coverage 
 of medication therapy management services, including disease specific 
management services, for certain high-risk patients under the Medicare 
                                Program.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                            October 2, 2002

Mr. Pickering 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 for coverage 
 of medication therapy management services, including disease specific 
management services, for certain high-risk patients 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; PURPOSE.

    (a) Short Title.--This Act may be cited as the ``Medicare 
Medication Therapy Management Services Coverage Act of 2002''.
    (b) Purpose.--The purpose of this Act is to provide coverage of 
medication therapy management services under the medicare program for 
beneficiaries at risk for potential medication problems, such as 
beneficiaries taking multiple medications and beneficiaries with 
complex or chronic medical conditions.

SEC. 2. MEDICARE COVERAGE OF MEDICATION THERAPY MANAGEMENT SERVICES FOR 
              CERTAIN HIGH-RISK PATIENTS.

    (a) In General.--Section 1861 of the Social Security Act (42 U.S.C. 
1395x) is amended--
            (1) in subsection (s)(2)--
                    (A) by striking ``and'' at the end of subparagraph 
                (U);
                    (B) by adding ``and'' at the end of subparagraph 
                (V); and
                    (C) by adding at the end the following new 
                subparagraph:
            ``(W) medication therapy management services (as defined in 
        subsection (ww)(1)(A)) for individuals who are receiving 
        medication for a condition and are otherwise determined to be 
        at high risk (as defined by the Secretary), and including 
        disease specific management services for individuals who are 
        receiving medication for the treatment of asthma or diabetes, 
        lipid reducing medication, anti-coagulation medication, or 
        medication for such other chronic diseases as the Secretary may 
        specify;'';
            (2) by adding at the end the following new subsection:

     ``Medication Therapy Management Services; Qualified Pharmacist

    ``(ww)(1)(A) The term `medication therapy management services' 
means--
            ``(i) services or programs furnished by a qualified 
        pharmacist in an eligible State which are designed--
                    ``(I) to assure that medications are used 
                appropriately by individuals;
                    ``(II) to enhance individuals' understanding of the 
                appropriate use of medications;
                    ``(III) to increase individuals' compliance with 
                prescription medication regimens;
                    ``(IV) to reduce the risk of potential adverse 
                events associated with medications; and
                    ``(V) to reduce the need for other costly medical 
                services through better management of medication 
                therapy; and
            ``(ii) services provided by qualified pharmacists in 
        collaboration with physicians and other health care 
        professionals when necessary, involving case management, 
        disease management, patient training and education, medication 
        refill reminders, medication therapy problem resolution, 
        laboratory testing conducted to monitor medication therapy, 
        other services of qualified pharmacists that enhance the use of 
        prescription medications, and such other professional services 
        of qualified pharmacists, consistent with the scope of the 
        practice of pharmacy as defined by applicable State law or 
        regulation.
    ``(B) The term `disease specific management services' means 
medication therapy management services provided to individuals who are 
receiving medication for the treatment of asthma or diabetes, lipid 
reducing medication, anti-coagulation medication, or medication for 
such other chronic diseases as the Secretary may specify, only pursuant 
to a protocol with the individual's treating physician under which the 
qualified pharmacist may initiate or modify the medication therapy, and 
carry out such additional medication therapy management services as is 
provided under State law or regulation, as permitted under the 
protocol.
    ``(C) Covered medication therapy management services are covered 
under this title only if they are documented and shared with the 
appropriate physician and other health care providers (as established 
under a reporting system developed by State Boards of Pharmacy).
    ``(2) The term `qualified pharmacist' means an individual who--
            ``(A) is a licensed pharmacist in good standing with the 
        State Board of Pharmacy;
            ``(B) with respect only to the provision of disease 
        specific management services, is currently certified by a 
        nationally recognized licensed certification or credentialing 
        program to furnish medication management therapy services for 
        the diseases referred to in paragraph (1)(B); and
            ``(C) has a separate, private consultation area in which to 
        provide covered.
    ``(3) The term `eligible State' means a State that meets such 
criteria as the Secretary may establish for the licensing or 
credentialing of qualified pharmacists for the provision of medication 
therapy management services in the State, and shall include a State 
that is eligible for payments under title XIX for the provision of such 
services under the State plan.''; and
            (3) in subsection (aa)(6), by inserting ``(or, with respect 
        to subsection (ww)(1)(B), a qualified pharmacist)'' after 
        ``nurse practitioner'' and by inserting ``(or pharmacist's)'' 
        after ``practitioner's''.
    (b) Payment.--
            (1) In general.--Section 1833(a)(1) of such Act (42 U.S.C. 
        1395l(a)(1)) is amended--
                    (A) in subsection (a)(1)--
                            (i) by striking ``and'' before ``(U)''; and
                            (ii) by inserting before the semicolon at 
                        the end the following: ``, and (V) with respect 
                        to covered medication therapy management 
                        services (as defined in section 1861(ww)(1)), 
                        the amounts paid shall be 80 percent of the 
                        lesser of the actual charge or the amounts 
                        specified under the fee schedule developed 
                        under subsection (p)''; and
                    (B) by inserting after subsection (o) the following 
                new subsection:
    ``(p) With respect to medication therapy management services (as 
defined in section 1861(ww)(1)), the Secretary shall establish a fee 
schedule--
            ``(1) under which payments are based on an encounter and 
        increase in 15 minute increments; and
            ``(2) in which, in order to be paid for a 15-minute 
        increment, the majority of the time be spent by the qualified 
        pharmacist in providing covered services.''.
            (2) Application of balance billing limitations.--Section 
        1842(b)(18)(C) of such Act (42 U.S.C. 1395u(b)(18)(C)) is 
        amended by adding at the end the following new clause:
            ``(vii) A qualified pharmacist (as defined in section 
        1861(ww)(2)).''.
            (3) Report to congress.--Not later than 3 years after the 
        date of the enactment of this Act, the Secretary of Health and 
        Human Services shall submit to Congress a report on fee 
        schedule developed under section 1834(p) of the Social Security 
        Act (as added by paragraph (1)) for covered medication therapy 
        management services under part B of the medicare program.
    (c) Program Operation.--
            (1) Development in consultation with pharmacy 
        organizations.--The Secretary of Health and Human Services 
        shall carry out the amendments made by this section in 
        cooperation with organizations representing qualified 
        pharmacists, including--
                    (A) identifying medication therapy management 
                services that will be covered; and
                    (B) establishing payment mechanisms for such 
                services.
            (2) Ongoing evaluation.--The Secretary shall provide for an 
        ongoing evaluation and documentation of the provision of 
        medication therapy management services under such amendment in 
        improving quality of care and reducing health care costs.
    (d) Effective Date.--The amendments made by this section shall 
apply to services furnished on or after January 1, 2004.
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