[Congressional Bills 117th Congress]
[From the U.S. Government Publishing Office]
[S. 5106 Introduced in Senate (IS)]
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117th CONGRESS
2d Session
S. 5106
To amend title XVIII of the Social Security Act to ensure Medicare-only
PACE program enrollees have a choice of prescription drug plans under
Medicare part D.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
November 16, 2022
Mr. Carper (for himself and Mr. Cassidy) 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 ensure Medicare-only
PACE program enrollees have a choice of prescription drug plans under
Medicare part D.
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 ``PACE Part D Choice Act of 2022''.
SEC. 2. ENSURING MEDICARE-ONLY PACE PROGRAM ENROLLEES HAVE A CHOICE OF
PRESCRIPTION DRUG PLANS UNDER MEDICARE PART D.
Section 1860D-21(f) of the Social Security Act (42 U.S.C. 1395w-
131(f)) is amended--
(1) in paragraph (1), by striking ``and (3)'' and inserting
``(3), and (4)''; and
(2) by adding at the end the following new paragraph:
``(4) Ensuring choice of prescription drug plans.--
``(A) In general.--For plan years beginning on or
after January 1, 2023, subject to the succeeding
provisions of this paragraph, an applicable PACE
program enrollee may elect to enroll in a qualified
standalone prescription drug plan, in accordance with
rules established by the Secretary pursuant to this
paragraph, while enrolled under a PACE program.
``(B) Definition of applicable pace program
enrollee; qualified standalone prescription drug
plan.--In this paragraph:
``(i) Applicable pace program enrollee.--
The term `applicable PACE program enrollee'
means a part D eligible individual who--
``(I) is not entitled to medical
assistance under title XIX; and
``(II) is enrolled under a PACE
program offered by a PACE provider.
``(ii) Qualified standalone prescription
drug plan.--The term `qualified standalone
prescription drug plan' means, with respect to
an applicable PACE program enrollee, a
prescription drug plan--
``(I) that is not an MA-PD plan;
``(II) that is not operated by the
PACE program under which the individual
is enrolled; and
``(III) for which the Secretary
determines, with respect to the
applicable PACE program enrollees
enrolled in a PACE program offered by
such PACE provider, that--
``(aa) the estimated
beneficiary out-of-pocket costs
(as defined in clause (iii))
for the plan year for qualified
prescription drug coverage
under the plan is equal to or
less than the estimated out-of-
pocket costs for such coverage
under the prescription drug
plan offered by the PACE
program in which the applicable
PACE program enrollee is
enrolled; and
``(bb) the estimated total
amount of Federal subsidies for
the plan year for qualified
prescription drug coverage
under the plan (which may be
estimated using data from the
previous plan year) is equal to
or less than the estimated
subsidy amount for such
coverage under the prescription
drug plan offered by the PACE
program in which the applicable
PACE program enrollee is
enrolled.
``(iii) Out-of-pocket costs defined.--In
this paragraph, the term `out-of-pocket costs'
includes premiums imposed under a prescription
drug plan and, in the case of coverage under a
qualified standalone prescription drug plan,
deductibles, copayments, coinsurance, and other
cost-sharing.
``(C) Out-of-pocket costs.--In the case where an
applicable PACE program enrollee elects to enroll in a
qualified standalone prescription drug plan pursuant to
this paragraph, the individual shall be responsible for
any out-of-pocket costs imposed under the plan
(including costs for nonformulary drugs) after the
application of any subsidies under section 1860D-14 for
an applicable PACE program enrollee who is a subsidy
eligible individual (as defined in section 1860D-
14(a)(3)).
``(D) Requirements for pace programs.--
``(i) Educating and helping enroll
beneficiaries into a part d plan option.--A
PACE program shall be required to provide--
``(I) information to all applicable
PACE program enrollees who are enrolled
under the PACE program regarding the
option to enroll in a qualified
standalone prescription drug plan under
this paragraph; and
``(II) upon request of an
applicable PACE program enrollee,
counseling and coordination to assist
applicable PACE program enrollees in
making decisions regarding the
selection of qualified standalone
prescription drug plans available to
them.
``(ii) Monitoring drug utilization,
adherence, and spend.--A PACE program shall be
required to monitor drug utilization,
medication adherence, and drug spending
(through claims data shared pursuant to
subparagraph (F) and otherwise) throughout the
year with respect to any applicable PACE
program enrollee who elects to enroll in a
qualified standalone prescription drug plan
under this paragraph in order to coordinate
with the PDP sponsor of such plan regarding the
drug benefits offered by the plan, including
upon request of an applicable PACE program
enrollee the filing of any grievances or
appeals with the plan on behalf of the
applicable PACE program enrollee.
``(E) Disenrollment.--An applicable PACE program
enrollee may disenroll from the qualified standalone
prescription drug plan elected by such applicable PACE
program enrollee under subparagraph (A) if the enrollee
changes medication during the plan year or can
demonstrate an unexpected increase in out-of-pocket
costs post enrollment.
``(F) Claims sharing.--In the case where an
applicable PACE program enrollee enrolls in a qualified
standalone prescription drug plan, the PACE program in
which the individual is enrolled and the PDP sponsor of
the qualified standalone prescription drug plan shall
share claims data with each other with respect to the
applicable PACE program enrollee as needed to support
care management for the applicable PACE program
enrollee (including for purposes of monitoring and
coordination required under subparagraph (D)(ii)) and
for purposes of comprehensive risk adjustment under
section 1894(d). Such data shall be shared without the
need for any formal or informal request of the PACE
program in which the individual is enrolled or the PDP
sponsor of the qualified standalone prescription drug
plan in which the applicable PACE program enrollee is
enrolled.
``(G) Rule of construction.--The authority
established under this paragraph for an applicable PACE
program enrollee to elect to enroll in a qualified
standalone prescription drug plan shall not be
construed as permitting an applicable PACE program
enrollee to enroll in a prescription drug plan that is
not a qualified standalone prescription drug plan.
``(H) Relation to pace statutes.--
``(i) In general.--The authority provided
under this paragraph for an applicable PACE
program enrollee to elect to enroll in a
qualified standalone prescription drug plan
shall apply notwithstanding subsection
(a)(1)(B)(1) of section 1894 and such other
provisions of sections 1894 and 1934 as the
Secretary determines may conflict with the
authority provided for under this paragraph,
including subsections (a)(2)(B), (b)(1)(A)(i),
(b)(1)(C), (f)(2)(B)(ii), and (f)(2)(B)(v) of
such sections.
``(ii) Clarification on payment for part d
drug coverage.--Insofar as an applicable PACE
program enrollee is enrolled in a qualified
standalone prescription drug plan under this
paragraph, the PACE program shall not be
entitled to payment under section 1894(d) for
the provision of qualified prescription drug
coverage under such standalone prescription
drug plan with respect to such applicable PACE
program enrollee.''.
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