1.Short title; table of
contents
(a)This Act may be cited as the Requiring Emergency Pharmaceutical Access for Individual
Relief (REPAIR) Act of 2006
.
(b)The table of
contents of this Act is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Transition requirements.
Sec. 3. Federal fallback for full-benefit dual eligible
individuals for 2006.
Sec. 4. Identifying full-benefit dual eligible individuals in
data records.
Sec. 5. Prohibition on conditioning Medicaid eligibility for
individuals enrolled in certain creditable prescription drug coverage on
enrollment in the Medicare part D drug program.
Sec. 6. Ensuring that full-benefit dual eligible individuals
are not overcharged.
Sec. 7. Reimbursement of States for 2006 transition
costs.
Sec. 8. Facilitation of identification and enrollment through
pharmacies of full-benefit dual eligible individuals in the Medicare part
D drug program.
Sec. 9. State health insurance program assistance regarding the
new Medicare prescription drug benefit.
Sec. 10. Additional Medicare part D informational
resources.
Sec. 11. GAO study and report on the imposition of co-payments
under part D for full-benefit dual eligible individuals residing in a long-term
care facility.
Sec. 12. State coverage of non-formulary prescription drugs for
full-benefit dual eligible individuals during 2006.
Sec. 13. Protection for full-benefit dual eligible individuals
from plan termination prior to receiving functioning access in a new part D
plan.
2.
(a)
(1)Section 1860D–4(b) of the Social Security Act (42 U.S.C.
1395w–104(b)) is amended by adding at the end the following new
paragraph:
(4)The sponsor of a prescription drug plan is required to
provide at least a 30-day supply of any drug that a new enrollee in the plan
was taking prior to enrolling in such plan. For individuals residing in a
long-term care setting, the sponsor of a prescription drug plan is required to
provide at least a 90-day supply of any drug such individual was taking prior
to enrolling in such plan. A formulary transition supply provided under this
section shall be made by the sponsor of a prescription drug plan without
imposing any prior authorization requirements or other access restrictions for
individuals stabilized on a course of treatment and at the dosage previously
prescribed by a physician or recommended by a physician going forward.
(5)The sponsor of a prescription drug plan is required to
provide—
(A)accessible and
trained customer service representatives available for full business hours from
coast to coast to provide knowledgeable assistance to individuals seeking help
with Medicare Part D including, but not limited to, beneficiaries, caseworkers,
SHIP counselors, pharmacists, doctors, and caregivers;
(B)at least one
dedicated phone line for pharmacists with sufficient staff to reduce wait times
for pharmacists seeking Medicare Part D assistance to no more than 20 minutes;
and
(C)sufficient staff
to reduce wait times for all Medicare Part D-related calls to plan phone lines
to no more than 20
minutes.
.
(2)The
requirements under paragraphs (4) and (5) of section 1860D–4(b) of the Social
Security Act (42 U.S.C. 1395w–104(b)), as added by subsection (a), shall apply
to the plan serving as the national point of sale contractor under part D of
title XVIII of such Act.
(b)Effective Date
and Enforcement
(1)The amendment made by subsection (a) shall take effect on
the date of enactment of this Act.
(2)The
Secretary may impose a civil monetary penalty in an amount not to exceed
$15,000 for conduct that a sponsor of a prescription drug plan or an
organization offering an MA–PD plan knows or should know is a violation of the
provisions of paragraph (4) or (5) of section 1860D–4(b) of the Social Security
Act (42 U.S.C. 1395w–104(b)), as added by subsection (a). The provisions of
section 1128A of the Social Security Act (42 U.S.C. a–7a), other than
subsections (a) and (b) and the second sentence of subsection (f), shall apply
to a civil monetary penalty under the previous sentence in the same manner as
such provisions apply to a penalty or proceeding under subsection (a) of such
section 1128A(a).
3.Federal fallback
for full-benefit dual eligible individuals for 2006
(a)
(1)If a full-benefit dual eligible individual (as defined in
section 1935(c)(6) of the Social Security Act (42 U.S.C. 1396u–5(c)(6))), or an
individual who is presumed to be such an individual pursuant to subsection (b),
presents a prescription for a covered part D drug (as defined in section
1860D–2(e) of such Act (42 U.S.C. 1395w–102(e))) at a pharmacy in 2006 and the
pharmacy is unable to locate or verify the individual's enrollment through a
reasonable effort, including the use of the pharmacy billing system or by
calling an official Medicare hotline, or to bill for the prescription through
the plan serving as the national point of sale contractor, the pharmacy may
provide a 30-day supply of the drug to the individual.
(2)The
pharmacy may provide an additional 30-day supply of a drug if the pharmacy
continues to be unable to locate the individual's enrollment through such
reasonable efforts or to bill for the prescription through the plan serving as
the national point of sale contractor when a prescription is presented on or
after the date that a prescription refill is appropriate, but in no case after
December 31, 2006.
(3)The
cost-sharing for a prescription filled pursuant to this subsection shall be
cost-sharing provided for under section 1860D–14(a) of the Social Security Act
(42 U.S.C. 1395w–114(a)).
(b)An individual shall be presumed to be a full-benefit
dual eligible individual (as so defined) if the individual presents at the
pharmacy with—
(1)a government
issued picture identification card;
(2)reliable evidence
of Medicaid enrollment, such as a Medicaid card, recent history of Medicaid
billing in the pharmacy patient profile, or a copy of a current Medicaid award
letter; and
(3)reliable evidence
of Medicare enrollment, such as a Medicare identification card, a Medicare
enrollment approval letter, a Medicare Summary Notice, or confirmation from an
official Medicare hotline.
(c)
(1)The Secretary of Health and Human Services shall
reimburse pharmacists, to the extent that such pharmacists are not otherwise
reimbursed by States or plans, for the costs incurred in complying with the
requirements under subsection (a), including acquisition costs, dispensing
costs, and other overhead costs. Such payments shall be made in a timely manner
from the Medicare Prescription Drug Account under section 1860D–16 of the
Social Security Act (42 U.S.C. 1395w–116) and shall be deemed to be payments
from such Account under subsection (b) of such section.
(2)Retroactive
application to beginning of 2006The costs incurred by a pharmacy
which may be reimbursed under paragraph (1) shall include costs incurred during
the period beginning on January 1, 2006, and before the date of enactment of
this Act.
(d)Recovery of
costs from plans by Secretary not PharmaciesThe Secretary of Health and Human Services
shall establish a process for recovering the costs described in subsection
(c)(1) from prescription drug plans (as defined in section 1860D–1(a)(3)(C) of
the Social Security Act (42 U.S.C. 1394w–101(a)(3)(C))) and MA–PD plans (as
defined in section 1860D–41(a)(14) of such Act (42 U.S.C. 1395w–151(a)(14))) if
the Secretary determines that such plans should have incurred such costs.
Amounts recovered pursuant to the preceding sentence shall be deposited in the
Medicare Prescription Drug Account described in subsection (c)(1).
4.Identifying
full-benefit dual eligible individuals in data records
(a)The Secretary of Health and Human Services and a
prescription drug plan or an MA–PD plan shall clearly identify all full-benefit
dual eligible individuals (as defined in section 1935(c)(6) of the Social
Security Act (42 U.S.C. 1396u–5(c)(6))) and reflect the low-income subsidy
status of such individual for each calender year (beginning with 2006) in every
data record file used to enroll or adjudicate claims for such
individuals.
(b)For
each calendar year (beginning with 2006) and for each Medicaid beneficiary who
is a full-benefit dual eligible individual (as so defined), the Secretary of
Health and Human Services shall—
(1)identify in the
Medicare enrollment database that such individual has dual eligible status that
has been verified with a State or the District of Columbia; and
(2)ensure that such
dual eligible status is reflected in each data file necessary to ensure that
such status is transmitted to a prescription drug plan or an MA–PD plan when
the Secretary certifies the enrollment of such an individual in a plan.
(c)Definition of
MA–PD plan and prescription drug planFor purposes of this
section, the terms MA–PD plan
and prescription drug
plan
have the meaning given such terms in sections 1860D–1(a)(3)(C) and
1860D–41(a)(14) of the Social Security Act (42 U.S.C. 1395w–101(a)(3)(C);
1395w–151(a)(14)), respectively.
5.Prohibition on
conditioning Medicaid eligibility for individuals enrolled in certain
creditable prescription drug coverage on enrollment in the Medicare part D drug
program
(a)Section 1935 of the
Social Security Act (42 U.S.C. 1396v) is amended by adding at the end the
following:
(f)Prohibition on
conditioning eligibility for medical assistance for individuals enrolled in
certain creditable prescription drug coverage on enrollment in medicare
prescription drug benefit
(1)A State shall not condition eligibility for medical
assistance under the State plan for a part D eligible individual (as defined in
section 1860D–1(a)(3)(A)) who is enrolled in creditable prescription drug
coverage described in any of subparagraphs (C) through (H) of section
1860D–13(b)(4) on the individual's enrollment in a prescription drug plan under
part D of title XVIII or an MA–PD plan under part C of such title.
(2)Coordination of
benefits with part D for other individualsNothing in this
subsection shall be construed as prohibiting a State from coordinating medical
assistance under the State plan with benefits under part D of title XVIII for
individuals not described in paragraph
(1).
.
(b)Nullification
of state plan amendments, redetermination of eligibilityIn the
case of a State that, as of the date of enactment of this Act, has an approved
amendment to its State plan under title XIX of the Social Security Act with a
provision that conflicts with section 1935(f) of such Act (as added by
subsection (a)), such provision is, as of such date of enactment, null and
void. The State shall redetermine any applications for medical assistance that
have been denied solely on the basis of the application of such a State plan
amendment not later than 90 days after the date of enactment of this
Act.
6.Ensuring that
full-benefit dual eligible individuals are not overcharged
(a)Section 1860D–14 of the Social Security Act (42 U.S.C.
1395w–114) is amended—
(1)by redesignating
subsection (d) as subsection (e); and
(2)by inserting
after subsection (c) the following new subsection:
(d)Ensuring
full-benefit dual eligible individuals are not overcharged
(1)The Secretary shall, as soon a possible after the date of
enactment of this subsection, establish processes for the following:
(A)Tracking
inappropriate paymentsThe Secretary shall track full-benefit
dual eligible individuals enrolled in a prescription drug plan or an MA–PD plan
to determine whether such individuals were inappropriately subject under the
plan to a deductible or cost-sharing that is greater than is required under
section 1860D–14.
(B)Reduction in
payments to plans and refunds to individualsIf the Secretary
determines under subparagraph (A) that an individual was overcharged, the
Secretary shall—
(i)reduce payments
to the sponsor of the prescription drug plan under section 1860D–15 or to the
organization offering the MA–PD plan under section 1853 that inappropriately
charged the individual by an amount equal to the inappropriate charges;
and
(ii)refund such
amount to the individual within 60 days of the determination that the
individual was inappropriately charged.
If the
Secretary does not provide for the refund under clause (i) within the 60 days
provided for under such clause, interest at the rate established under section
6621(a)(1) of the Internal Revenue Code of 1986 shall be payable from the end
of such 60-day period until the date of the refund.(2)The
processes established under paragraph (1) shall provide for the ability of an
individual to notify the Secretary if the individual believes that they were
inappropriately subject under the plan to a deductible or cost-sharing that is
greater than is required under section
1860D–14.
.
(b)Not later than January 1, 2007, the Secretary of Health
and Human Services shall submit a report to Congress on the implementation of
the processes established under subsection (d) of section 1860D–14 of the
Social Security Act (42 U.S.C. 1395w–114), as added by subsection (a).
7.Reimbursement of
States for 2006 transition costs
(a)
(1)Notwithstanding
section 1935(d) of the Social Security Act (42 U.S.C. 1396u–5(d) or any other
provision of law, the Secretary of Health and Human Services shall reimburse
States for 100 percent of the costs incurred by the State during 2006 for
covered part D drugs (as defined in section 1860D–2(e) of such Act (42 U.S.C.
1395w–102(e))) for part D eligible individuals (as defined in section
1860D–1(a)(3)(A) of the Social Security Act (42 U.S.C. 1394w–101(a)(3)(A)))
which the State reasonably expected would have been covered under such part but
were not because the individual was unable to access on a timely basis
prescription drug benefits to which they were entitled under such part. Such
payments shall be made from the Medicare Prescription Drug Account under
section 1860D–16 of the Social Security Act (42 U.S.C. 1395w–116) and shall be
deemed to be payments from such Account under subsection (b) of such
section.
(2)Retroactive
application to beginning of 2006The costs incurred by a State
which may be reimbursed under paragraph (1) shall include costs incurred during
the period beginning on January 1, 2006, and before the date of enactment of
this Act.
(b)Recovery of
costs from plans by Secretary not StatesThe Secretary of Health and Human Services
shall establish a process for recovering the costs described in subsection
(a)(1) from prescription drug plans (as defined in section 1860D–1(a)(3)(C) of
the Social Security Act (42 U.S.C. 1394w–101(a)(3)(C))) and MA–PD plans (as
defined in section 1860D–41(a)(14) of such Act (42 U.S.C. 1395w–151(a)(14))) if
the Secretary determines that such plans should have incurred such costs.
Amounts recovered pursuant to the preceding sentence shall be deposited in the
Medicare Prescription Drug Account described in subsection (a)(1).
(c)For
purposes of this section, the term State
includes the District
of Columbia.
8.Facilitation of
identification and enrollment through pharmacies of full-benefit dual eligible
individuals in the Medicare part D drug
program
(a)The Secretary of Health and Human Services shall provide
for outreach and education to every pharmacy that has participated in the
Medicaid program under title XIV of the Social
Security Act, particularly independent pharmacies, on the
following:
(1)The needs of
full-benefit dual eligible individuals and the challenges of meeting those
needs.
(2)The processes for
the transition from Medicaid prescription drug coverage to coverage under such
part D for such individuals.
(3)The processes
established by the Secretary to facilitate, at point of sale, identification of
drug plan assignment of such population or enrollment of previously
unidentified or new full-benefit dual eligible individuals into Medicare part D
prescription drug coverage, including how pharmacies can use such processes to
help ensure that such population makes a successful transition to Medicare part
D without a lapse in prescription drug coverage.
(b)Holding
Pharmacies Harmless for Certain Costs
(1)The Secretary of Health and Human Services shall provide
for such payments to pharmacies as may be necessary to reimburse pharmacies
fully for—
(A)transaction fees
associated with the point-of-sale facilitated identification and enrollment
processes referred to in subsection (a)(3); and
(B)costs associated
with technology or software upgrades necessary to make any identification and
enrollment inquiries as part of the processes under subsection (a)(3).
(2)Payments
under paragraph (1) shall be made with respect to fees and costs incurred
during the period beginning on December 1, 2005, and ending on June 1,
2006.
(3)Payments under paragraph (1) shall be made from the
Medicare Prescription Drug Account under section 1860D–16 of the Social
Security Act (42 U.S.C. 1395w–116) and shall be deemed to be payments from such
Account under subsection (b) of such section.
9.State health
insurance program assistance regarding the new Medicare prescription drug
benefitDuring the period
beginning on the date that is 7 days after the date of enactment of this Act
and ending on May 15, 2006 (or a later date if determined appropriate by the
Secretary of Health and Human Services), the Secretary shall ensure that an
employee of the Centers for Medicare & Medicaid Services is stationed at
each State health insurance counseling program (receiving funding under section
4360 of the Omnibus Budget Reconciliation Act of 1990) in order to—
(1)assist Medicare
beneficiaries and counselors under such program in better understanding the
Medicare prescription drug benefit under part D of title XVIII of the
Social Security Act; and
(2)act as a liaison
to the Secretary and the Administrator of the Centers for Medicare &
Medicaid Services regarding issues related to oversight and enforcement of
provisions under the Medicare prescription drug benefit.
10.Additional
Medicare part D informational resources
(a)The
Secretary of Health and Human Services shall increase the number of trained
employees staffing the toll-free telephone number 1–800–MEDICARE in order to
ensure that the average wait time for a caller does not exceed 20
minutes.
(b)The Secretary of Health and Human Services shall—
(1)establish a
toll-free telephone number that is dedicated to providing information regarding
the Medicare prescription drug benefit under title XVIII of the Social Security
Act to pharmacists; and
(2)staff such
telephone number in order to ensure that the average wait time for a caller
does not exceed 20 minutes.
(c)State health
insurance program hotlineThe Secretary of Health and Human
Services shall—
(1)establish a
toll-free telephone number that is dedicated to providing information regarding
the Medicare prescription drug benefit under title XVIII of the Social Security
Act to counselors working in State health insurance counseling programs
(receiving funding under section 4360 of the Omnibus Budget Reconciliation Act
of 1990); and
(2)staff such
telephone number in order to ensure that the average wait time for a caller
does not exceed 20 minutes.
11.GAO study and
report on the imposition of co-payments under part D for full-benefit dual
eligible individuals residing in a long-term care facility
(a)The
Comptroller General of the United States shall conduct a study on how mental
health patients who are full-benefit dual eligible individuals (as defined in
section 1935(c)(6) of the Social Security Act (42 U.S.C. 1396u–5(c)(6))) and
who reside in long-term care facilities, including licensed assisted living
facilities, will be affected by the imposition of co-payments for covered part
D drugs under part D of title XVIII of such Act. Such study shall include a
review of issues that relate to the potential harm of displacement due to an
inability to access needed medications because of such co-payments.
(b)Not
later than 6 months after the date of enactment of this Act, the Comptroller
General of the United States shall submit a report to Congress on the study
conducted under subsection (a) together with recommendations for such
legislation as the Comptroller General determines is appropriate.
12.State coverage
of non-formulary prescription drugs for full-benefit dual eligible individuals
during 2006
(a)State coverage
of non-formulary prescription drugs for full-benefit dual eligible individuals
during 2006For prescriptions
filled during 2006, notwithstanding section 1935(d) of the Social Security Act
(42 U.S.C. 1396v(d)), a State (as defined for purposes of title XIX of such
Act) may provide (and receive Federal financial participation for) medical
assistance under such title with respect to prescription drugs provided to a
full-benefit dual eligible individual (as defined in section 1935(c)(6) of such
Act (42 U.S.C. 1396v(c)(6)) that are not on the formulary of the prescription
drug plan under part D or the MA–PD plan under part C of title XVIII of such
Act in which such individual is enrolled.
(b)
(1)Medicare as
primary payerNothing in
subsection (a) shall be construed as changing or affecting the primary payer
status of a prescription drug plan under part D or an MA–PD plan under part C
of title XVIII of the Social Security Act with respect to prescription drugs
furnished to any full-benefit dual eligible individual (as defined in
section
1935(c)(6) of such Act
(42 U.S.C. 1396v(c)(6)) during 2006.
(2)Nothing in
subsection (a) shall be construed as limiting the authority or responsibility
of a State under section 1902(a)(25) of the Social Security Act (42 U.S.C.
1396a(a)(25)) to seek reimbursement from a prescription drug plan, an MA–PD
plan, or any other third party, of the costs incurred by the State in providing
prescription drug coverage during 2006.
13.Protection for
full-benefit dual eligible individuals from plan termination prior to receiving
functioning access in a new part D plan
(a)Notwithstanding any other provision of law, the Secretary
of Health and Human Services shall not terminate coverage of a full-benefit
dual eligible individual (as defined in section 1935(c)(6) of the Social
Security Act (42 U.S.C. 1396v(c)(6)) unless such individual has functioning
access to a prescription drug plan under part D or an MA–PD plan under part C
of title XVIII of such Act. Such access shall include entry of the individual
into the computer system of such plan and an acknowledgment by the plan that
the individual is eligible for a full premium subsidy under section 1860D–14 of
such Act (42 U.S.C. 1395w–114).
(b)This section shall take effect on the date of enactment of
this Act.