1.This Act may be cited as the
Seniors' Medication Copayment
Reduction Act of 2009
.
2.Congress makes the following
findings:
(1)A growing body of evidence demonstrates
that patient-level financial barriers, including copayments and coinsurance for
medications, systematically reduce the use of high value medical
services.
(2)Empirical studies demonstrate that
reductions in cost-sharing can mitigate the adverse health consequences
attributable to cost related decreases in the utilization of prescription
medications and reduce aggregate medical expenditures as a result.
(3)Financial barriers to prescription
medications that are of high value should be reduced or eliminated to increase
adherence to prescribed medication.
(4)Value-Based Insurance Design recognizes
that medical services and prescription medications differ in the clinical
benefit achieved and that patient out-of-pocket costs should be adjusted
according to the value of the services provided.
(5)The current one size fits
all
copayment or coinsurance design for medications provided under the
Medicare program does not recognize the well-established value differences in
health outcomes produced by various medical interventions.
(6)The establishment by Medicare of copayment
and coinsurance requirements for medications using Value-Based Insurance Design
will optimize clinical gains for each dollar spent, which would be a benefit to
seniors and a fiscally responsible use of taxpayer dollars.
3.
(a)Not later than 1 year after the date of
enactment of this Act, the Secretary of Health and Human Services (in this
section referred to as the Secretary
) shall establish a
demonstration program to test Value-Based Insurance Design methodologies for
Medicare beneficiaries with chronic conditions.
(b)Demonstration program design
(1)The Secretary shall select not less than 2
Medicare Advantage plans to participate in this demonstration program under
this section initially.
(2)A plan selected to participate in the
demonstration program under paragraph (1) shall meet the following
requirements:
(A)The plan offers a coordinated Part D drug
benefit.
(B)The plan and organization offering such
plan meet such other criteria as the Secretary determines appropriate.
(c)
(1)Subject to subsection (b), the
demonstration program under this section shall be conducted for a 5-year
period.
(2)Expansion of demonstration program;
implementation of demonstration program results
(A)Expansion of demonstration
programIf the report under
paragraph subsection (e) or (f)(3) contains an evaluation that the
demonstration program under this section—
(i)reduces expenditures under the Medicare
program; or
(ii)does not increase expenditures under the
Medicare program and increases the quality of health care services provided to
Medicare beneficiaries,
then the Secretary shall continue
the existing demonstration program and may expand the demonstration
program.(B)Implementation of demonstration program
resultsIf the report under
subsection (e) or (f)(3) contains an evaluation contained in clause (i) or (ii)
of subparagraph (A), the Secretary may issue regulations to implement, on a
permanent basis, the components of the demonstration program that are
beneficial to the Medicare program.
(d)Value-Based Insurance Design
methodology
(1)Reduction of copayments and
coinsuranceUtilizing
Value-Based Insurance Design methodologies, the Secretary shall identify each
medication for which the amount of the copayment or coinsurance payable should
be reduced or eliminated.
(2)Value-Based Insurance DesignFor purposes of this section,
Value-Based Insurance Design
is a methodology for identifying
specific medications or classes of medications for which copayments or
coinsurance should be reduced or eliminated due to the high value and
effectiveness of such medications when prescribed for particular clinical
conditions.
(3)In identifying medications for purposes of
paragraph (1), the Secretary shall, at a minimum, consider the medications
utilized in the treatment of the following conditions:
(A)Asthma.
(B)Atrial fibrillation.
(C)Deep venous thrombosis.
(D)Chronic obstructive pulmonary
disease.
(E)Chronic renal failure.
(F)Congestive heart failure.
(G)Coronary artery disease.
(H)Myocardial infarction.
(I)Depression.
(J)Epilepsy.
(K)Diabetes mellitus.
(L)Hypertension.
(M)Hypothyroidism.
(N)Schizophrenia.
(O)Tobacco abuse disorder.
(e)
(1)Not later than 1 year after the date of
enactment of this Act, the Secretary shall submit to Congress a report on the
implementation by the Secretary of the demonstration program under this
section.
(2)The report required by paragraph (1) shall
include the following:
(A)A statement setting forth each medication
identified pursuant to subsection (d)(1).
(B)For each such medication, a statement of
the amount of the copayment or coinsurance required to be paid for such
medication and the amount of the reduction from previous levels.
(f)Review and assessment of utilization of
methodologies
(1)The Secretary shall enter into a contract
or agreement with an independent entity having expertise in Value-Based
Insurance Design to review and assess the implementation by the Secretary of
the demonstration program under this section. The review and assessment shall
include the following:
(A)An assessment of the utilization by the
Secretary of the methodologies referred to in subsection (d).
(B)An analysis of whether reducing or
eliminating the copayment or coinsurance for each medication identified by the
Secretary pursuant to subsection (d)(1) resulted in increased adherence to
medication regimens and better health outcomes.
(C)An analysis of the cost savings resulting
from reducing or eliminating the copayment or coinsurance for each medication
so identified.
(D)Such other matters as the Secretary
considers appropriate.
(2)The contract or agreement entered into
under paragraph (1) shall require the entity concerned to submit to the
Secretary a report on the review and assessment conducted by the entity under
that paragraph in time for the inclusion of the results of such report in the
report required by paragraph (3).
(3)Not later than 3 years after the date of
the enactment of this Act, the Secretary shall submit to Congress a report on
the review and assessment conducted under this subsection. The report shall
include the following:
(A)A description of the results of the review
and assessment.
(B)Such recommendations as the Secretary
considers appropriate for enhancing the utilization of the methodologies
referred to in subsection (a)(1) so as to reduce copayments and coinsurance
paid by Medicare beneficiaries for medications furnished under the Medicare
program and to otherwise improve the quality of health care provided under such
Medicare program.
(g)The Secretary may waive such provisions of
titles XI and XVIII of the Social Security Act as may be necessary to carry out
the demonstration program under this section.
(h)For purposes of carrying out the
demonstration program under this section, the Secretary shall provide for the
transfer from the Federal Hospital Insurance Trust Fund under section 1817 of
the Social Security Act (42 U.S.C. 1395i) and the Federal Supplementary
Insurance Trust Fund under section 1841 of the Social Security Act (42 U.S.C.
1395t), including the Medicare Prescription Drug Account in such Trust Fund, in
such proportion as determined appropriate by the Secretary, of such sums as may
be necessary.