[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3799 Introduced in House (IH)]

111th CONGRESS
  1st Session
                                H. R. 3799

To amend title XVIII of the Social Security Act to improve prescription 
  drug coverage under Medicare part D and to amend the Public Health 
 Service Act, the Employee Retirement Income Security Act of 1974, and 
    the Internal Revenue Code of 1986, to improve prescription drug 
    coverage under private health insurance, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                            October 13, 2009

Mr. Johnson of Georgia (for himself, Ms. Kilroy, Mr. Carnahan, Mr. Ryan 
 of Ohio, Ms. Lee of California, Mr. Ellison, Mr. Doggett, Ms. Fudge, 
 and Mr. Kennedy) introduced the following bill; which was referred to 
the Committee on Energy and Commerce, and in addition to the Committees 
     on Ways and Means and Education and Labor, 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 improve prescription 
  drug coverage under Medicare part D and to amend the Public Health 
 Service Act, the Employee Retirement Income Security Act of 1974, and 
    the Internal Revenue Code of 1986, to improve prescription drug 
    coverage under private health insurance, 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 ``Affordable Access to Prescription 
Medications Act of 2009''.

SEC. 2. MEDICARE PART D PRESCRIPTION DRUG PLANS.

    (a) In General.--Section 1860D-2(b)(4) of the Social Security Act 
(42 U.S.C. 1395w-102(b)(4)) is amended by adding at the end the 
following new subparagraph:
                    ``(E) Additional protections.--
                            ``(i) In general.--Notwithstanding any 
                        other provision of this part, effective for 
                        plan years beginning on or after January 1, 
                        2011, a PDP sponsor of a prescription drug plan 
                        and an MA organization offering an MA-PD plan 
                        shall, with respect to any co-payment or 
                        coinsurance requirements applicable to covered 
                        part D drugs under the plan, ensure that--
                                    ``(I) such required co-payment or 
                                coinsurance does not exceed the base 
                                cost of the covered part D drug (as 
                                determined by the Secretary);
                                    ``(II) such required co-payment or 
                                coinsurance does not exceed $200 per 
                                month for any single covered part D 
                                drug (30-day supply); and
                                    ``(III) such required co-payment or 
                                coinsurance does not exceed, in the 
                                aggregate for all covered part D drugs, 
                                $500 per month.
                            ``(ii) Adjustments.--The amounts described 
                        in clauses (II) and (III) of clause (i) shall 
                        be annually adjusted to reflect the average of 
                        the percentage increase or decrease in the 
                        Consumer Price Index for all urban consumers 
                        (U.S. city average) and the percentage increase 
                        or decrease in the medical care component of 
                        such Consumer Price Index during the calendar 
                        year preceding the year for which the 
                        adjustment is being made.''.
    (b) Expansion of Exceptions Process.--Effective for plan years 
beginning on or after January 1, 2011, the Secretary shall expand the 
formulary tier exception request process under sections 423.560 through 
423.636 of title 42, Code of Federal Regulations (as in effect on the 
date of enactment of this Act), to allow individuals enrolled in a 
prescription drug plan under part D of title XVIII of the Social 
Security Act or an MA-PD plan under part C of such title to request an 
exception for a specialty prescription drug to a plan's designation of 
a covered part D drug (as defined in section 1860D-2(e) of such Act (42 
U.S.C. 1395w-102(e)) as a non-preferred prescription drug.
    (c) MedPAC Studies and Reports.--
            (1) Study and report on the medicare part d anti-
        discrimination clause.--
                    (A) Study.--The Medicare Payment Advisory 
                Commission shall conduct a study on various aspects of 
                the prescription drug program under part D of title 
                XVIII of the Social Security Act and, to the greatest 
                extent practicable, the interaction of such program 
                with Medicare beneficiary access to covered drugs under 
                part B of such title. Such study shall include the 
                following:
                            (i) An analysis of--
                                    (I) the use of specialty tiers for 
                                covered part D drugs under prescription 
                                drug plans and MA-PD plans; and
                                    (II) the effect of such specialty 
                                tiers on access to care for Medicare 
                                beneficiaries.
                            (ii) Consideration of the mechanisms 
                        described in subparagraph (B) in the context of 
                        the provisions of section 1860D-11(e)(2)(D) of 
                        the Social Security Act (42 U.S.C. 1395w-
                        111(e)(2)(D)) (in this paragraph referred to as 
                        the ``Medicare part D anti-discrimination 
                        clause'').
                    (B) Mechanisms described.--The following mechanisms 
                are described in this subparagraph:
                            (i) The use of specialty tiers for covered 
                        part D drugs under prescription drug plans and 
                        MA-PD plans.
                            (ii) The application of segmented 
                        coinsurance or copayment structures to covered 
                        part D drugs based on certain categories of 
                        such drugs or diagnoses.
                            (iii) The utilization of other differential 
                        benefit structures based on certain conditions 
                        and Medicare beneficiaries under prescription 
                        drug plans and MA-PD plans, including an 
                        analysis of the interaction between such 
                        utilization and the effects of such utilization 
                        with the Medicare part D anti-discrimination 
                        clause.
                    (C) Report.--Not later than 1 year after the date 
                of enactment of this Act, the Medicare Payment Advisory 
                Commission shall submit to Congress a report containing 
                the results of the study conducted under subparagraph 
                (A), together with recommendations for such legislation 
                and administrative action as the Commission determines 
                appropriate.
                    (D) Revised guidance.--Based on the results of the 
                study conducted under subparagraph (A), the Secretary 
                shall issue revised guidance regarding the use of 
                mechanisms described in subparagraph (B) to all PDP 
                sponsors offering prescription drug plans under part D 
                of title XVIII of the Social Security Act and Medicare 
                Advantage organizations offering MA-PD plans under part 
                C of such title.
            (2) Study and report on cost-sharing for prescription drugs 
        under parts b and d.--
                    (A) Study.--The Medicare Payment Advisory 
                Commission shall conduct a study on cost-sharing for 
                prescription drugs under parts B and D of title XVIII 
                of the Social Security Act. Such study shall include an 
                analysis of the impact of eliminating cost-sharing for 
                covered part D drugs for Medicare beneficiaries who--
                            (i) incur annual out-of-pocket cost-sharing 
                        after the initial coverage limit under section 
                        1860D-2(b)(3) of such Act (42 U.S.C. 1395w-102) 
                        that exceeds 5 percent of the income of the 
                        beneficiary (as determined under section 1860D-
                        14(a)(3)(C) of such Act (42 U.S.C. 1395w-
                        114(a)(3)(C)); and
                            (ii) do not otherwise qualify for an 
                        income-related subsidy under section 1860D-
                        14(a) of such Act (42 U.S.C. 1395w-114(a)) or 
                        other extra help or cost-sharing relief.
                    (B) Report.--Not later than 6 months after the date 
                of enactment of this Act, the Medicare Payment Advisory 
                Commission shall submit to Congress a report containing 
                the results of the study conducted under subparagraph 
                (A), together with recommendations for such legislation 
                and administrative action as the Commission determines 
                appropriate.
            (3) Definitions.--In this section:
                    (A) Covered part d drug.--The term ``covered part D 
                drug'' has the meaning given such term in section 
                1860D-2(e) of the Social Security Act (42 U.S.C. 1395w-
                102(e)).
                    (B) MA-PD plan.--The term ``MA-PD'' plan has the 
                meaning given such term in paragraph (9) of section 
                1860D-41(a) of such Act (42 U.S.C. 1395w-151(a)).
                    (C) Medicare advantage organization.--The term 
                ``Medicare Advantage organization'' has the meaning 
                given such term in section 1859(a)(1) of such Act (42 
                U.S.C. 1395w-28(a)(1)).
                    (D) Pdp sponsor.--The term ``PDP sponsor'' has the 
                meaning given such term in paragraph (13) of such 
                section 1860D-41(a).
                    (E) Prescription drug plan.--The term 
                ``prescription drug plan'' has the meaning given such 
                term in paragraph (14) of such section.

SEC. 3. PRIVATE HEALTH INSURANCE.

    (a) Group Health Plans.--
            (1) Public health service act amendments.--
                    (A) In general.--Subpart 2 of part A of title XXVII 
                of the Public Health Service Act is amended by adding 
                at the end the following new section:

``SEC. 2708. PROVISIONS RELATING TO PRESCRIPTION DRUGS.

    ``(a) In General.--A group health plan, and a health insurance 
issuer offering group health insurance coverage, that provides coverage 
for prescription drugs shall, with respect to any co-payment or 
coinsurance requirements applicable to such drug coverage, ensure 
that--
            ``(1) such required co-payment or coinsurance does not 
        exceed the base cost of the prescription drug (as determined by 
        the Secretary);
            ``(2) such required co-payment or coinsurance does not 
        exceed $200 per month for any single prescription drug (30-day 
        supply); and
            ``(3) such required co-payment or coinsurance does not 
        exceed, in the aggregate for all prescription drugs, $500 per 
        month.
    ``(b) Adjustments.--The amounts described in paragraphs (2) and (3) 
of subsection (a) shall be annually adjusted to reflect the average of 
the percentage increase or decrease in the Consumer Price Index for all 
urban consumers (U.S. city average) and the percentage increase or 
decrease in the medical care component of such Consumer Price Index 
during the calendar year preceding the year for which the adjustment is 
being made.
    ``(c) Notice.--A group health plan under this part shall comply 
with the notice requirement under section 714(b) of the Employee 
Retirement Income Security Act of 1974 with respect to the requirements 
of this section as if such section applied to such plan.''.
                    (B) Conforming amendment.--Section 2723(c) of such 
                Act (42 U.S.C. 300gg-23(c)) is amended by striking 
                ``section 2704'' and inserting ``sections 2704 and 
                2708''.
            (2) Erisa amendments.--
                    (A) In general.--Subpart B of part 7 of subtitle B 
                of title I of the Employee Retirement Income Security 
                Act of 1974 is amended by adding at the end the 
                following new section:

``SEC. 715. PROVISIONS RELATING TO PRESCRIPTION DRUGS.

    ``(a) In General.--A group health plan, and a health insurance 
issuer offering group health insurance coverage, that provides coverage 
for prescription drugs shall, with respect to any co-payment or 
coinsurance requirements applicable to such drug coverage, ensure 
that--
            ``(1) such required co-payment or coinsurance does not 
        exceed the base cost of the prescription drug (as determined by 
        the Secretary of Health and Human Services);
            ``(2) such required co-payment or coinsurance does not 
        exceed $200 per month for any single prescription drug (30-day 
        supply); and
            ``(3) such required co-payment or coinsurance does not 
        exceed, in the aggregate for all prescription drugs, $500 per 
        month.
    ``(b) Adjustments.--The amounts described in paragraphs (2) and (3) 
of subsection (a) shall be annually adjusted to reflect the average of 
the percentage increase or decrease in the Consumer Price Index for all 
urban consumers (U.S. city average) and the percentage increase or 
decrease in the medical care component of such Consumer Price Index 
during the calendar year preceding the year for which the adjustment is 
being made.
    ``(c) Notice.--A group health plan under this part shall comply 
with the notice requirement under section 714(b) with respect to the 
requirements of this section as if such section applied to such 
plan.''.
                    (B) Table of contents.--The table of contents in 
                section 1 of such Act is amended by inserting after the 
                item relating to section 714 the following new item:

``Sec. 715. Provisions relating to prescription drugs.''.
            (3) Internal revenue code amendments.--
                    (A) In general.--Subchapter B of chapter 100 of the 
                Internal Revenue Code of 1986 is amended by adding at 
                the end the following new section:

``SEC. 9813. PROVISIONS RELATING TO PRESCRIPTION DRUGS.

    ``(a) In General.--A group health plan, and a health insurance 
issuer offering group health insurance coverage, that provides coverage 
for prescription drugs shall, with respect to any co-payment or 
coinsurance requirements applicable to such drug coverage, ensure 
that--
            ``(1) such required co-payment or coinsurance does not 
        exceed the base cost of the prescription drug (as determined by 
        the Secretary of Health and Human Services);
            ``(2) such required co-payment or coinsurance does not 
        exceed $200 per month for any single prescription drug (30-day 
        supply); and
            ``(3) such required co-payment or coinsurance does not 
        exceed, in the aggregate for all prescription drugs, $500 per 
        month.
    ``(b) Adjustments.--The amounts described in paragraphs (2) and (3) 
of subsection (a) shall be annually adjusted to reflect the average of 
the percentage increase or decrease in the Consumer Price Index for all 
urban consumers (U.S. city average) and the percentage increase or 
decrease in the medical care component of such Consumer Price Index 
during the calendar year preceding the year for which the adjustment is 
being made.
    ``(c) Notice.--A group health plan under this part shall comply 
with the notice requirement under section 714(b) of the Employee 
Retirement Income Security Act of 1974 with respect to the requirements 
of this section as if such section applied to such plan.''.
                    (B) Clerical amendment.--The table of sections for 
                such subchapter is amended by adding at the end the 
                following new item:

``Sec. 9813. Provisions relating to prescription drugs.''.
    (b) Individual Health Insurance.--
            (1) In general.--Part B of title XXVII of the Public Health 
        Service Act is amended by inserting after section 2752 the 
        following new section:

``SEC. 2754. PROVISIONS RELATING TO PRESCRIPTION DRUGS.

    ``The provisions of section 2708 shall apply to health insurance 
coverage offered by a health insurance issuer in the individual market 
in the same manner as they apply to health insurance coverage offered 
by a health insurance issuer in connection with a group health plan in 
the small or large group market.''.
            (2) Conforming amendment.--Section 2762(b)(2) of such Act 
        (42 U.S.C. 300gg-62(b)(2)) is amended by striking ``section 
        2751'' and inserting ``sections 2751 and 2754''.
    (c) Application to FEHBP.--The amendments made by this section 
shall apply to the administration of chapter 89 of title 5, United 
States Code.
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