[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5182 Introduced in House (IH)]








109th CONGRESS
  2d Session
                                H. R. 5182

To amend title XVIII of the Social Security Act to require the sponsor 
 of a prescription drug plan or an organization offering an MA-PD plan 
 to promptly pay claims submitted under part D, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             April 25, 2006

 Mr. Jones of North Carolina (for himself, Mr. Berry, Mr. Rangel, Mr. 
 Moran of Kansas, Mr. Weiner, Mr. Marshall, Mr. Taylor of Mississippi, 
  Mr. Jefferson, Mr. Etheridge, Mr. Wicker, Mr. Ross, Mr. Wexler, Mr. 
    Holden, Mr. Doyle, Mr. Moore of Kansas, Mr. Brown of Ohio, Mr. 
 Abercrombie, and Mr. Allen) 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 require the sponsor 
 of a prescription drug plan or an organization offering an MA-PD plan 
 to promptly pay claims submitted under part D, 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.

    This Act may be cited as the ``Fair and Speedy Treatment (FAST) of 
Medicare Prescription Drug Claims Act of 2006''.

SEC. 2. 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)) is amended by adding 
at the end the following new paragraph:
            ``(4) 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)(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 of the 
enactment of this Act.

SEC. 3. 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. 4. 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) Minimum dispensing fees for generic covered 
                part d drugs.--
                            ``(i) In general.--Each PDP sponsor under 
                        this subsection with respect to a prescription 
                        drug plan offered by such sponsor shall provide 
                        that the amount of a dispensing fee paid to a 
                        participating pharmacy for 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 the 
                        pharmacy, shall be an amount that is not less 
                        than the minimum generic drug dispensing fee 
                        specified under clause (ii).
                            ``(ii) Minimum generic drug dispensing fee 
                        specified.--The minimum generic drug dispensing 
                        fee specified under this clause for generic 
                        covered part D drugs dispensed--
                                    ``(I) in calendar year 2006, is 
                                $14; and
                                    ``(II) in subsequent calendar 
                                years, is the minimum generic drug 
                                dispensing fee under this clause for 
                                the previous year increased by the 
                                annual percentage increase in the 
                                consumer price index (all items; U.S. 
                                city average) as of July of such 
                                previous year.
                        Any amount established under subclause (II), 
                        that is based on an increase of $1 or $3, that 
                        is not a multiple of 5 cents or 10 cents, 
                        respectively, shall be rounded to the nearest 
                        multiple of 5 cents or 10 cents, 
                        respectively.''.
    (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. 5. 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.''.
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