1.
This Act may be cited as the
Medicare Dual Eligible Prescription
Drug Coverage Act of 2005
.
2.
The Senate finds the
following:
(1)
Individuals who are dually
eligible for benefits under the medicare program and full benefits under the
medicaid program—
(A)
are among the most vulnerable
populations in our society; and
(B)
require adequate outreach,
education, and timing in order to adjust to changes in our health care delivery
system.
(2)
The transition of 6,400,000
dual eligibles from prescription drug coverage under the medicaid program to
prescription drug coverage under part D of the medicare program is the largest
transition ever of individuals from one insurance program to another.
(3)
In its June 2004 report to
Congress, the Medicare Payment Advisory Commission (MedPAC) suggested that
large, private employers with 75,000 employees or less need at least 6 months
to transition their employees' drug coverage from one pharmacy benefit
management company to another such company. The States and the Federal
Government are taking on a far more complex task with 6,400,000 dual eligibles
having to make the transition described in paragraph (2).
(4)
Timely access to prescription
drugs leads to higher quality of life and prevents avoidable emergency room
visits, hospitalizations, and premature nursing home placements.
(5)
Since even a short-term gap
in prescription drug coverage could have serious health consequences for dual
eligibles, Congress must work to guarantee as smooth a transition as possible
for dual eligibles so that no dual eligible is without prescription drug
coverage even for one day.
3.
Continuing State coverage of medicaid prescription drug
coverage to medicare dual eligible beneficiaries for 6 months
(a)
For prescriptions filled
during the period beginning on January 1, 2006, and ending on June 30, 2006,
section 1935(d) of the Social Security Act (42 U.S.C. 1396u–5(d)) shall not
apply and, notwithstanding any other provision of law, a State (as defined for
purposes of title XIX of such Act) shall continue to provide (and receive
Federal financial participation for) medical assistance under such title with
respect to prescription drugs as if such section 1935(d) had not been
enacted.
(b)
(1)
Medicare as primary payer
Nothing in subsection (a)
shall be construed as changing or affecting the primary payer status of a
prescription drug plan or an MA–PD plan under part D 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. 1396u–5(c)(6)) during the 6-month period described in such
subsection.
(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 described in such subsection.
4.
Delay in implementation of medicaid clawback payments
Notwithstanding section
1935(c) of the Social Security Act (42 U.S.C. 1396u–5(c)), a State or the
District of Columbia shall not be required to provide for a payment under such
section to the Secretary of Health and human Services for any month prior to
July 1, 2006.
5.
Education and outreach to dual eligibles regarding prescription
drug coverage and monitoring of the transition of dual eligibles to
prescription drug coverage under medicare
(a)
Notwithstanding any other
provision of law, of the amounts appropriated for the Centers for Medicare
& Medicaid Services under section 1015(a)(1) of the Medicare Prescription
Drug, Improvement, and Modernization Act of 2003 (Public Law 108–173; 117 Stat.
2446), the following rules shall apply:
(1)
Education and outreach to duals
$100,000,000 shall be used to
provide education and outreach, including through one-on-one counseling and
application assistance, to 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))) regarding prescription drug coverage
under part D of title XVIII of such Act. Of such amount—
(A)
at least $20,000,000 (but in
no case more than $50,000,000) shall be used to award grants to States under
section 4360 of the Omnibus Budget Reconciliation Act of 1990 (42 U.S.C.
1395b–4) to provide such education and outreach; and
(B)
the remaining amount shall be
used to provide funding to community-based organizations that work with
full-benefit dual eligible individuals (as so defined) in order to provide such
education and outreach.
(2)
Monitoring impact on duals
(A)
$50,000,000 shall be used by
the Centers for Medicare & Medicaid Services, in consultation with the
Centers for Disease Control and Prevention, the Administration on Aging, and
the Social Security Administration, to develop and implement a standardized
protocol to collect data from health departments and other sources in 10
representative urban and rural communities on the impact of the transition of
full benefit dual eligible individuals (as so defined) from prescription drug
coverage under the medicaid program to prescription drug coverage under part D
of the medicare program. Such protocol shall be implemented by not later than
July 1, 2005.
(B)
The protocol developed under
subparagraph (A) shall include for the monitoring of the following information
with respect to such full benefit dual eligible individuals:
(i)
Emergency room visit
rates.
(ii)
Hospitalization rates.
(iii)
Nursing home placement
rates.
(iv)
Deaths.
(C)
Collection by PDPs and MA–PDs
The protocol developed under
subparagraph (A) shall require that such data be collected by the prescription
drug plans and the MA–PDs in which the individuals are enrolled and include
information on race and ethnicity.
(D)
Not later than January 1,
2006, and July 1, 2006, the Administrator of the Centers for Medicare &
Medicaid Services, in consultation with the Centers for Disease Control and
Prevention, the Administration on Aging, and the Social Security
Administration, shall submit a report to Congress on the implementation of the
protocol under subparagraph (A).
(b)
There are appropriated to the
Secretary of Health and Human Services, to be transferred from the Federal
Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance
Trust Fund, for fiscal year 2005 and each subsequent fiscal year, an amount not
to exceed $50,000,000 (or if greater, an amount equal to $1 multiplied by the
number of individuals entitled to benefits under part A of title XVIII of the
Social Security Act or enrolled under part B of such title for the year) in
order award grants to States under section 4360 of the Omnibus Budget
Reconciliation Act of 1990 (42 U.S.C. 1395b–4).
(c)
Extension of availability of amounts appropriated under
MMA
Section 1015(b) of the
Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public
Law 108–173; 117 Stat. 2446) is amended by striking September 30,
2005
and inserting September 30, 2006
.
6.
Collection and sharing of dual eligible drug utilization
data
(a)
Section 1860D–42 of the
Social Security Act (42 U.S.C. 1395w–152) is amended by adding at the end the
following new subsection:
(c)
Collection and sharing of dual eligible drug utilization
data
(1)
A PDP sponsor of a
prescription drug plan and an MA organization offering an MA–PD plan shall
submit to the Secretary such information regarding the drug utilization of
enrollees in such plans who are full-benefit dual eligible individuals (as
defined in section 1935(c)(6)) as the
Secretary determines appropriate to carry out paragraph (2).
(2)
Collection and sharing of data
The Secretary shall collect
data on the drug utilization of full-benefit dual eligible individuals (as so
defined). The Secretary shall share such data with the States and the District
of Columbia in as close to a real-time basis as possible.
.
(b)
The amendment made by
subsection (a) shall take effect as if included in the enactment of section
101(a) of the Medicare Prescription Drug, Improvement, and Modernization Act of
2003 (Public Law 108–173; 117 Stat. 2071).
7.
GAO study on the clawback formula
(a)
(1)
The Comptroller General of
the United States shall conduct a study on the clawback formula contained in
section 1935(c) of the Social Security Act (42 U.S.C. 1396u–5(c)), as added by
section 103(b) of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (Public Law 108–173; 117 Stat. 2155).
(2)
The study conducted under
paragraph (1) shall include a full examination of—
(A)
disincentives for States to
enroll 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))) in the medicaid program or part D of
title XVIII of the Social Security Act;
(B)
the 6-month delay in States
receiving rebate data;
(C)
the prescription drug cost
containment measures implemented by States after 2003; and
(D)
issues relating to States
having to pay more for prescription drug coverage for full benefit dual
eligible individuals (as so defined) than they otherwise would have if the
Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public
Law 108–173; 117 Stat. 2066 et seq.) had not been enacted.
(b)
Not later than April 1, 2006,
the Comptroller General of the United States shall submit to Congress a report
on the study conducted under subsection (a) together with such recommendations
as the Comptroller General determines appropriate.