[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4946 Introduced in House (IH)]
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116th CONGRESS
1st Session
H. R. 4946
To amend title XVIII of the Social Security Act to ensure equal access
of Medicare beneficiaries to community pharmacies in underserved areas
as network pharmacies under Medicare prescription drug coverage, and
for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
October 31, 2019
Mr. Welch (for himself, Mr. Griffith, Mr. Loebsack, Mr. Carter of
Georgia, Mr. Gonzalez of Texas, Mr. Crawford, Mr. Westerman, Mr. David
P. Roe of Tennessee, Mrs. Rodgers of Washington, Mrs. Axne, Mr. Allen,
and Mr. Peterson) introduced the following bill; which was referred to
the Committee on Energy and Commerce, and in addition to the Committee
on Ways and Means, 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 ensure equal access
of Medicare beneficiaries to community pharmacies in underserved areas
as network pharmacies under Medicare prescription drug coverage, 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 ``Ensuring Seniors Access to Local
Pharmacies Act of 2019''.
SEC. 2. ALLOWING ANY STATE LICENSED PHARMACY SERVING AN UNDERSERVED
AREA TO BECOME A NETWORK PHARMACY UNDER MEDICARE
PRESCRIPTION DRUG COVERAGE.
(a) In General.--Section 1860D-4(b)(1)(B) of the Social Security
Act (42 U.S.C. 1395w-104(b)(1)(B)) is amended--
(1) by striking ``Discounts allowed for network
pharmacies.--For'' and inserting the following: ``Discounts
allowed for network pharmacies.--
``(i) In general.--For''; and
(2) by adding at the end the following new clause:
``(ii) Inclusion of pharmacies located in
underserved areas in networks.--For plan years
beginning on or after January 1, 2020, in the
case of a prescription drug plan that has, in
its network of pharmacies, one or more
pharmacies located in a health professional
shortage area (as defined in section
332(a)(1)(A) of the Public Health Service Act),
in a medically underserved area (according to a
designation under section 330(b)(3)(A) of the
Public Health Service Act), among a medically
underserved population (as defined in such
section 330(b)(3)(A) of such Act), or in a
rural area (as defined by the Federal Office of
Rural Health Policy), and that provides a
reduction in coinsurance or copayments
described in clause (i) for covered part D
drugs dispensed through such pharmacies, such
plan shall extend to any pharmacy located in
such area or among such population the option
to be an in-network pharmacy with respect to
such plan under terms and conditions (including
the reductions described in clause (i))
comparable to those the plan has agreed upon
with other in-network pharmacies located in
such area or among such population.''.
SEC. 3. REASONABLE REIMBURSEMENT REQUIREMENTS.
Section 1860D-2(d)(1)(B) of the Social Security Act (42 U.S.C.
1395w-102(d)(1)(B)) is amended--
(1) by striking ``Prices.--For purposes'' and inserting
``Prices.--
``(i) In general.--For purposes''; and
(2) by adding at the end the following new clauses:
``(ii) Reasonable reimbursement.--For plan
years beginning on or after January 1, 2020, a
PDP sponsor and a Medicare Advantage
organization shall ensure that--
``(I) each prescription drug plan
or MA-PD plan offered by the sponsor or
organization does not reimburse a
pharmacy or pharmacist an amount less
than the amount that the pharmacy
benefits manager reimburses a pharmacy
benefits manager affiliate (as defined
in clause (iv)) providing the same
pharmacist services; and
``(II) in no case may the
negotiated price for a covered part D
drug furnished by a pharmacy under a
prescription drug plan or MA-PD plan
offered by the sponsor or organization,
be less than such pharmacy's cost of
purchasing and dispensing such drug and
providing such other services
associated with furnishing such drug as
may be specified by the Secretary.
``(iii) Claim reimbursement disclosure
requirements.--With respect to payment made by
a PDP sponsor or a Medicare Advantage
organization to a pharmacy for a covered part D
drug furnished by such pharmacy during a plan
year beginning on or after January 1, 2020,
such sponsor or organization shall promptly
furnish all pricing components including the
Network Reimbursement ID used to price the
claim, any fees, pharmacy price concessions,
discounts, subsidies, rebates, incentives, or
any other forms of direct or indirect
remuneration that affect payment and pricing of
the claim as part of the claim adjudication
response at the point-of sale. All pricing
components described in the preceding sentence
shall each be identified in a predetermined
line item in the remittance advice that is
standard across the industry. The PDP sponsor
or Medicare Advantage organization shall
include suitable claim-level detail on the
electronic remittance advice that accompanies
each payment. This claim-level detail shall
include, in an industry standardized format,
all fields needed to properly identify the
claim, including the Claim Authorization
Number, date of service, date of payment
remittance, ingredient cost reimbursed,
dispensing fee reimbursed, payment amounts
including the Network ID used to price the
claim, the specific dollar amounts and the
appropriate qualifier codes for each payment
adjustment including fees, pharmacy price
concessions, or incentives.
``(iv) Pharmacy benefits manager affiliate
defined.--For purposes of clause (ii), the term
`pharmacy benefits manager affiliate' means a
pharmacy or pharmacist that directly or
indirectly, through one or more intermediaries,
owns or controls, is owned or controlled by, or
is under common ownership or control with a
pharmacy benefits manager.''.
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