[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>