[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5307 Introduced in House (IH)]







109th CONGRESS
  2d Session
                                H. R. 5307

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

                              May 4, 2006

 Mr. Pallone introduced the following bill; which was referred to the 
Committee on Ways and Means, and in addition to the Committee on Energy 
    and Commerce, 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 ``Pharmacists Medicare Relief 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 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 equal to the weighted average of 
                interest on 3-month marketable Treasury securities 
                determined for such period, increased by 0.1 percentage 
                point 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, as 
                                appropriate, 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) Private right of action.--
                            ``(i) In general.--Nothing in this 
                        paragraph shall be construed to prohibit or 
                        limit a claim or action not covered by the 
                        subject matter of this section that any 
                        individual or organization has against a 
                        provider or a PDP sponsor.
                            ``(ii) Anti-retaliation.--Consistent with 
                        applicable Federal or State law, a PDP sponsor 
                        shall not retaliate against an individual or 
                        provider for exercising a right of action under 
                        this subparagraph.''.
    (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 of the 
enactment of this Act.

SEC. 3. RESTRICTION ON CO-BRANDING.

    (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 or an MA-PD plan offered by a Medicare Advantage 
organization and any marketing materials distributed with respect to 
such a plan shall not display the name or brand of any pharmacy.''.
    (b) Penalty.--Section 1128B of the Social Security Act (42 U.S.C. 
1320a-7b) is amended by adding at the end the following new subsection:
    ``(g) Whoever knowingly and willfully engages in co-branding 
prohibited under section 1860D-4(l) with respect to a prescription drug 
plan offered by a PDP sponsor under part D of title XVIII or a Medicare 
Advantage plan offered by a Medicare Advantage organization under part 
C of such title, shall be guilty of a felony and upon conviction 
thereof shall be fined not more than $25,000 or imprisoned for not more 
than five years, or both.''.
    (c) Effective Date.--The amendments made by this section shall 
apply to cards and marketing materials distributed on or after the date 
that is 90 days after the date of the enactment of this Act.
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