[Congressional Record Volume 152, Number 43 (Thursday, April 6, 2006)]
[Senate]
[Pages S3220-S3222]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. COCHRAN (for himself, Mr. Enzi, and Mr. Talent):
  S. 2563. A bill to amend title XVIII of the Social Security Act to 
require prompt payment to pharmacies under part D, to restrict pharmacy 
co-branding on prescription drug cards issued under such part, and to 
provide guidelines for Medication Therapy Management Services programs 
offered by prescription drug plans and MA-PD plans under such part; to 
the Committee on Finance.
  Mr. COCHRAN. Mr. President, The Medicare prescription drug plan is a 
tremendous success with more than 27 million Medicare beneficiaries now 
enrolled in the program. Seniors are realizing significant decreases in 
the cost of their prescription drugs and the savings are even greater 
than expected. The Centers for Medicare and Medicaid Services (CMS) and 
health care providers worked together to plan and implement this 
program. In particular, community pharmacists played an important role 
in making this benefit successful. Prior to the January 1 start of the 
program, pharmacists assisted their Medicare patients in the selection 
and enrollment process. This process was new and challenging, but 
pharmacists were diligent in serving their patients and providing much-
needed medications while the program became functional.
  We are introducing a bill today to assist pharmacists as they 
continue to serve their patients and as they help to continue the 
success of the Medicare drug benefit. This bill will allow pharmacists 
to achieve efficiencies in reimbursement for the products they have 
provided to new beneficiaries. This is especially needed by small, 
rural independent pharmacies. This legislation will also provide 
incentives for pharmacists and other providers to help beneficiaries 
better utilize their medications, adhere to their drug regimens, and 
utilize cost saving medication therapy management programs.
  I am pleased to offer this legislation that will help continue the 
success of the Medicare prescription drug benefit.
  Mr. President, I ask unanimous consent that the text of the bill be 
printed in the Record.
  There being no objection, the text of the bill was ordered to be 
printed in the Record, as follows:

                                S. 2563

       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 ``Pharmacist Access and 
     Recognition in Medicare (PhARM) Act of 2006''.

     SEC. 2. PROMPT PAYMENT BY PRESCRIPTION DRUG PLANS AND MA-PD 
                   PLANS UNDER PART D.

       (a) Prompt Payment by Prescription Drug Plans.--Section 
     1860D-12(b) of the Social Security Act (42 U.S.C. 1395w-
     112(b)) is amended by adding at the end the following new 
     paragraph:
       ``(4) Prompt payment of clean claims.--
       ``(A) Prompt payment.--
       ``(i) In general.--Each contract entered into with a PDP 
     sponsor under this section with respect to a prescription 
     drug plan offered by such sponsor shall provide that payment 
     shall be issued, mailed, or otherwise transmitted with 
     respect to all clean claims submitted under this part within 
     the applicable number of calendar days after the date on 
     which the claim is received.
       ``(ii) Clean claim defined.--In this paragraph, the term 
     `clean claim' means a claim that has no apparent defect or 
     impropriety (including any lack of any required 
     substantiating documentation) or particular circumstance 
     requiring special treatment that prevents timely payment from 
     being made on the claim under this part.
       ``(B) Applicable number of calendar days defined.--In this 
     paragraph, the term `applicable number of calendar days' 
     means--
       ``(i) with respect to claims submitted electronically, 14 
     days; and
       ``(ii) with respect to claims submitted otherwise, 30 days.
       ``(C) Interest payment.--If payment is not issued, mailed, 
     or otherwise transmitted within the applicable number of 
     calendar days (as defined in subparagraph (B)) after a clean 
     claim is received, interest shall be paid at a rate used for 
     purposes of section 3902(a) of title 31, United States Code 
     (relating to interest penalties for failure to make prompt 
     payments), for the period beginning on the day after the 
     required payment date and ending on the date on which payment 
     is made.
       ``(D) Procedures involving claims.--
       ``(i) In general.--A contract entered into with a PDP 
     sponsor under this section with respect to a prescription 
     drug plan offered by such sponsor shall provide that, not 
     later than 10 days after the date on which a clean claim is 
     submitted, the PDP sponsor shall provide the claimant with a 
     notice that acknowledges receipt of the claim by such 
     sponsor. Such notice shall be considered to have been 
     provided on the date on which the notice is mailed or 
     electronically transferred.
       ``(ii) Claim deemed to be clean.--A claim is deemed to be a 
     clean claim if the PDP sponsor involved does not provide 
     notice to the claimant of any deficiency in the claim within 
     10 days of the date on which the claim is submitted.
       ``(iii) Claim determined to not be a clean claim.--

       ``(I) In general.--If a PDP sponsor determines that a 
     submitted claim is not a clean claim, the PDP sponsor shall, 
     not later than the end of the period described in clause 
     (ii), notify the claimant of such determination. Such 
     notification shall specify all defects or improprieties in 
     the claim and shall list all additional information or 
     documents necessary for the proper processing and payment of 
     the claim.
       ``(II) Determination after submission of additional 
     information.--A claim is deemed to be a clean claim under 
     this paragraph if the PDP sponsor involved does not provide 
     notice to the claimant of any defect or impropriety in the 
     claim within 10 days of the date on which additional 
     information is received under subclause (I).
       ``(III) Payment of clean portion of a claim.--A PDP sponsor 
     shall pay any portion of a claim that would be a clean claim 
     but for a defect or impropriety in a separate portion of the 
     claim in accordance with subparagraph (A).

       ``(iv) Obligation to pay.--A claim submitted to a PDP 
     sponsor that is not paid or contested by the provider within 
     the applicable number of days (as defined in subparagraph 
     (B)) shall be deemed to be a clean claim and shall be paid by 
     the PDP sponsor in accordance with subparagraph (A).
       ``(v) Date of payment of claim.--Payment of a clean claim 
     under such subparagraph is considered to have been made on 
     the date on which full payment is received by the provider.
       ``(E) Electronic transfer of funds.--A PDP sponsor shall 
     pay all clean claims submitted electronically by electronic 
     transfer of funds.''.
       (b) Prompt Payment by MA-PD Plans.--Section 1857(f) of the 
     Social Security Act (42 U.S.C. 1395w-27(f)) is amended by 
     adding at the end the following new paragraph:
       ``(3) Incorporation of certain prescription drug plan 
     contract requirements.--The provisions of section 1860D-
     12(b)(4) shall apply to contracts with a Medicare Advantage 
     organization in the same manner as they apply to contracts 
     with a PDP sponsor offering a prescription drug plan under 
     part D.''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to contracts entered into or renewed on or after 
     the date that is 90 days after the date of the enactment of 
     this Act.

[[Page S3221]]

     SEC. 3. RESTRICTION ON PHARMACY CO-BRANDING ON MEDICARE 
                   PRESCRIPTION DRUG CARDS ISSUED BY PRESCRIPTION 
                   DRUG PLANS AND MA-PD PLANS.

       (a) In General.--Section 1860D-4 of the Social Security Act 
     (42 U.S.C. 1395w-104) is amended--
       (1) in subsection (b)(2)(A), by striking ``The PDP 
     sponsor'' and inserting ``Subject to subsection (l), the PDP 
     sponsor''; and
       (2) by adding at the end the following new subsection:
       ``(l) Co-Branding Prohibited.--A card that is issued under 
     subsection (b)(2)(A) for use under a prescription drug plan 
     offered by a PDP sponsor shall not display the name, brand, 
     or trademark of any pharmacy.''.
       (b) Effective Date.--The amendments made by this section 
     shall apply to cards distributed on or after the date that is 
     90 days after the date of enactment of this Act.

     SEC. 4. PROVISION OF MEDICATION THERAPY MANAGEMENT SERVICES 
                   UNDER PART D.

       (a) Provision of Medication Therapy Management Services 
     Under Part D.--
       (1) In general.--Section 1860D-4(c)(2) of the Social 
     Security Act (42 U.S.C.1395w-104(c)(2)) is amended--
       (A) in subparagraph (A)--
       (i) in clause (i)--

       (I) by inserting ``or other health care provider with 
     advanced training in medication management'' after 
     ``furnished by a pharmacist''; and
       (II) by striking ``targeted beneficiaries described in 
     clause (ii)'' and inserting ``targeted beneficiaries 
     specified under clause (ii)''

       (ii) by striking clause (ii) and inserting the following:
       ``(ii) Targeted beneficiaries.--The Secretary shall specify 
     the population of part D eligible individuals appropriate for 
     services under a medication therapy management program based 
     on the following characteristics:

       ``(I) Having a disease state in which evidence-based 
     medicine has demonstrated the benefit of medication therapy 
     management intervention based on objective outcome measures.
       ``(II) Taking multiple covered part D drugs or having a 
     disease state in which a complex combination medication 
     regimen is utilized.
       ``(III) Being identified as likely to incur annual costs 
     for covered part D drugs that exceed a level specified by the 
     Secretary or where acute or chronic decompensation of disease 
     would likely increase expenditures under the Federal Hospital 
     Insurance Trust Fund or the Federal Supplementary Medical 
     Insurance Trust Fund under sections 1817 and 1841, 
     respectively, such as through the requirement of emergency 
     care or acute hospitalization.'';

       (B) by striking subparagraph (B) and inserting the 
     following:
       ``(B) Elements.--
       ``(i) Minimum defined package of services.--The Secretary 
     shall specify a minimum defined package of medication therapy 
     management services that shall be provided to each enrollee. 
     Such package shall be based on the following considerations:

       ``(I) Performing necessary assessments of the health status 
     of each enrollee.
       ``(II) Providing medication therapy review to identify, 
     resolve, and prevent medication-related problems, including 
     adverse events.
       ``(III) Increasing enrollee understanding to promote the 
     appropriate use of medications by enrollees and to reduce the 
     risk of potential adverse events associated with medications, 
     through beneficiary and family education, counseling, and 
     other appropriate means.
       ``(IV) Increasing enrollee adherence with prescription 
     medication regimens through medication refill reminders, 
     special packaging, and other compliance programs and other 
     appropriate means.
       ``(V) Promoting detection of adverse drug events and 
     patterns of overuse and underuse of prescription drugs.
       ``(VI) Developing a medication action plan which may alter 
     the medication regimen, when permitted by the State licensing 
     authority. This information should be provided to, or 
     accessible by, the primary health care provider of the 
     enrollee.
       ``(VII) Monitoring and evaluating the response to therapy 
     and evaluating the safety and effectiveness of the therapy, 
     which may include laboratory assessment.
       ``(VIII) Providing disease-specific medication therapy 
     management services when appropriate.
       ``(IX) Coordinating and integrating medication therapy 
     management services within the broader scope of health care 
     management services being provided to each enrollee.

       ``(ii) Delivery of services.--

       ``(I) Personal delivery.--To the extent feasible, face-to-
     face interaction shall be the preferred method of delivery of 
     medication therapy management services.
       ``(II) Individualized.--Such services shall be patient-
     specific and individualized and shall be provided directly to 
     the patient by a pharmacist or other health care provider 
     with advanced training in medication management.
       ``(III) Distinct from other activities.--Such services 
     shall be distinct from any activities related to formulary 
     development and use, generalized patient education and 
     information activities, and any population-focused quality 
     assurance measures for medication use.

       ``(iii) Opportunity to identify patients in need of 
     medication therapy management services.--The program shall 
     provide opportunities for health care providers to identify 
     patients who should receive medication therapy management 
     services.'';
       (C) by striking subparagraph (E) and inserting the 
     following:
       ``(E) Pharmacy fees.--
       ``(i) In general.--The PDP sponsor of a prescription drug 
     plan shall pay pharmacists and others providing services 
     under the medication therapy management program under this 
     paragraph based on the time and intensity of services 
     provided to enrollees.
       ``(ii) Submission along with plan information.--Each such 
     sponsor shall disclose to the Secretary upon request the 
     amount of any such payments and shall submit a description of 
     how such payments are calculated along with the information 
     submitted under section 1860D-11(b). Such description shall 
     be submitted at the same time and in a similar manner to the 
     manner in which the information described in paragraph (2) of 
     such section is submitted.''; and
       (D) by adding at the end the following new subparagraph:
       ``(F) Pharmacy access requirements.--The PDP sponsor of a 
     prescription drug plan shall secure the participation in its 
     network of a sufficient number of retail pharmacies to assure 
     that enrollees have the option of obtaining services under 
     the medication therapy management program under this 
     paragraph directly from community-based retail pharmacies.''.
       (2) Effective date.--The amendments made by this subsection 
     shall apply to medication therapy management services 
     provided on or after January 1, 2008.
       (b) Medication Therapy Management Demonstration Program.--
     Section 1860D-4(c) of the Social Security Act (42 
     U.S.C.1395w-104(c)) is amended by adding at the end the 
     following new paragraph:
       ``(3) Community-based medication therapy management 
     demonstration program.--
       ``(A) Establishment.--
       ``(i) In general.--By not later than January 1, 2008, the 
     Secretary shall establish a 2-year demonstration program, 
     based on the recommendations of the Best Practices Commission 
     established under subparagraph (B), with both PDP sponsors of 
     prescription drug plans and Medicare Advantage Organizations 
     offering MA-PD plans, to examine the impact of medication 
     therapy management furnished by a pharmacist in a community-
     based or ambulatory-based setting on quality of care, 
     spending under this part, and patient health.
       ``(ii) Sites.--

       ``(I) In general.--Subject to subclause (II), the Secretary 
     shall designate not less than 10 PDP sponsors of prescription 
     drug plans or Medicare Advantage Organizations offering MA-PD 
     plans, none of which provide prescription drug coverage under 
     such plans in the same PDP or MA region, respectively, to 
     conduct the demonstration program under this paragraph.
       ``(II) Designation consistent with recommendations of best 
     practices commission.--The Secretary shall ensure that the 
     designation of sites under subclause (I) is consistent with 
     the recommendations of the Best Practices Commission under 
     subparagraph (B)(ii).

       ``(B) Best practices commission.--
       ``(i) Establishment.--The Secretary shall establish a Best 
     Practices Commission composed of representatives from 
     pharmacy organizations, health care organizations, 
     beneficiary advocates, chronic disease groups, and other 
     stakeholders (as determined appropriate by the Secretary) for 
     the purpose of developing a best practices model for 
     medication therapy management.
       ``(ii) Recommendations.--The Commission shall submit to the 
     Secretary recommendations on the following:

       ``(I) The minimum number of enrollees that should be 
     included in the demonstration program, and at each 
     demonstration program site, to determine the impact of 
     medication therapy management furnished by a pharmacist in a 
     community-based setting on quality of care, spending under 
     this part, and patient health.
       ``(II) The number of urban and rural sites that should be 
     included in the demonstration program to ensure that 
     prescription drug plans and MA-PD plans offered in urban and 
     rural areas are adequately represented.
       ``(III) A best practices model for medication therapy 
     management to be implemented under the demonstration program 
     under this paragraph.

       ``(C) Reports.--
       ``(i) Interim report.--Not later than 1 year after the 
     commencement of the demonstration program, the Secretary 
     shall submit to Congress an interim report on such program.
       ``(ii) Final report.--Not later than 6 months after the 
     completion of the demonstration program, the Secretary shall 
     submit to Congress a final report on such program, together 
     with recommendations for such legislation and administrative 
     action as the Secretary determines appropriate.
       ``(D) Waiver authority.--The Secretary may waive such 
     requirements of titles XI and XVIII as may be necessary for 
     the purpose of carrying out the demonstration program under 
     this paragraph.''.
  Mr. ENZI. Mr. President, I rise to introduce the Pharmacist Access 
and Recognition in Medicare Act. I have enjoyed working closely with 
Chairman Cochran and Senator Talent on

[[Page S3222]]

this bill that will help protect the valuable role that pharmacists 
play in our communities.
  I have spent a lot of time over the past few months traveling around 
my home State of Wyoming talking to seniors about the new Medicare 
prescription drug benefit. This new voluntary benefit represents the 
most significant improvement to Medicare since its inception in 1965. 
Because of this new benefit, more seniors have prescription drug 
coverage and are able to purchase the medicines they need. Since the 
benefit took effect on January 1, 2006, 17,700 beneficiaries in Wyoming 
have signed up for prescription drug coverage and 27 million 
beneficiaries nationwide have drug coverage. I encourage all 
beneficiaries to enroll in a prescription drug plan before May 15, 
2006.
  I strongly support our community pharmacists. The changeover to 
Medicare Part D hasn't been easy and has produced several obstacles 
they have had to deal with as they have worked to serve Medicare 
beneficiaries. In traveling around my State over the past few months, I 
have talked to a few pharmacists who mentioned a few key problems they 
are facing with this new Medicare program that I believe we should 
address.
  The first is an issue of cash flow management. As the only accountant 
in the United States Senate, I understand this problem. Most 
pharmacists have to pay their wholesalers like clockwork two times a 
month, but they are not receiving their reimbursement from the 
prescription drug plans in a similar timely fashion. This bill changes 
that. The bill states that plans have to reimburse all ``clean claims'' 
every 14 days. The bill also facilitates a quicker reimbursement by 
specifying that claims submitted electronically shall be paid by 
electronic transfer of funds. This is a small change in the law that I 
believe will play a large role in helping ease the transition to the 
new program for our local and community pharmacists.
  The second issue I have heard about is called co-branding. Some of 
the prescription drug plans have partnered with some of the larger 
pharmacies and the plans are putting pharmacy logos on the benefit 
cards the beneficiaries use to get their prescriptions filled. Some 
people have told me that this is very confusing, because beneficiaries 
think that they must go to the pharmacy listed on the card. My bill 
says that co-branding is no longer allowed and all newly issued cards 
will not have pharmacy logos on them.
  The final thing this bill does is expand upon what was in the 
Medicare bill that passed in 2003 regarding medication therapy 
management programs. I am pleased to say that Wyoming is ahead of the 
curve in this area. A few years ago, the Wyoming Department of Health 
partnered with the University of Wyoming to provide a service called 
Wyoming PharmAssist, which directly connects patients with registered 
pharmacists to review their medications for possible drug interactions 
and duplications. I was pleased to learn that this service is more 
advanced than systems in other States, providing patients with ways to 
reduce their monthly medication costs while improving safety. The 
Wyoming PharmAssist program can save clients $152 per month and $1,844 
a year. Wyoming Pharm-Assist pays registered pharmacists for these 
unique services and is a model for the Nation. My bill tries to make 
the Federal program more like the very successful program in Wyoming.
  I commend all the pharmacists across the country who are working so 
hard to make this new Medicare program work. They are getting life 
saving drugs to seniors who may not have been able to afford them 
before. I am proud to say I voted for this program back in 2003 and I 
am pleased with all the progress we are making.
  I believe the Senate operates under what I call the 80/20 rule. 80 
percent of the things that get done around here are non-contentious 
issues with support from both parties. The other 20 percent are the 
contentious issues that we seem to spend all our time talking about. I 
think this bill falls into the 80 percent category. This is a small 
bill that will do a lot of good for our pharmacists. It has wide 
support and I look forward to working with Chairman Grassley to help 
move this bill through his Committee.
  I invite my colleagues to join me and Senators Cochran and Talent as 
sponsors of this bill to allow pharmacists to continue to provide the 
best quality care for seniors and the disabled who rely on them for 
their medications.
  I ask that the text of the bill following my statement be placed in 
the Record.
                                 ______