[Congressional Record Volume 163, Number 127 (Thursday, July 27, 2017)]
[Senate]
[Pages S4514-S4519]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
SA 501. Mr. CARDIN submitted an amendment intended to be proposed by
him to the bill H.R. 1628, to provide for reconciliation pursuant to
title II of the concurrent resolution on the budget for fiscal year
2017; which was ordered to lie on the table; as follows:
At the appropriate place, insert the following:
DIVISION __
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This division may be cited as the
``Keeping Health Insurance Affordable Act of 2017''.
(b) Table of Contents.--The table of contents for this
division is as follows:
Sec. 1. Short title; table of contents.
TITLE I--MARKETPLACE STABILITY AND SECURITY
Sec. 101. Individual Market Reinsurance Fund.
Sec. 102. Public health insurance option.
TITLE II--HEALTH CARE FINANCIAL ASSISTANCE
Sec. 201. Increase in eligibility for premium assistance tax credits.
Sec. 202. Enhancements for reduced cost sharing.
TITLE III--DRUG PRICING
Sec. 301. Requiring drug manufacturers to provide drug rebates for
drugs dispensed to low-income individuals.
Sec. 302. Negotiation of prices for medicare prescription drugs.
Sec. 303. Guaranteed prescription drug benefits.
Sec. 304. Full reimbursement for qualified retiree prescription drug
plans.
TITLE IV--MEDICAID COLLABORATIVE CARE MODELS
Sec. 401. Enhanced FMAP for medical assistance provided through a
collaborative care model.
TITLE I--MARKETPLACE STABILITY AND SECURITY
SEC. 101. INDIVIDUAL MARKET REINSURANCE FUND.
(a) Establishment of Fund.--
(1) In general.--There is established the ``Individual
Market Reinsurance Fund'' to be administered by the Secretary
to provide funding for an individual market stabilization
reinsurance program in each State that complies with the
requirements of this section.
(2) Funding.--There is appropriated to the Fund, out of any
moneys in the Treasury not otherwise appropriated, such sums
as are necessary to carry out this section (other than
subsection (c)) for each calendar year beginning with 2018.
Amounts appropriated to the Fund shall remain available
without fiscal or calendar year limitation to carry out this
section.
(b) Individual Market Reinsurance Program.--
(1) Use of funds.--The Secretary shall use amounts in the
Fund to establish a reinsurance program under which the
Secretary shall make reinsurance payments to health insurance
issuers with respect to high-cost individuals enrolled in
qualified health plans offered by such issuers that are not
grandfathered health plans or transitional health plans for
any plan year beginning with the 2018 plan year. This
subsection constitutes budget authority in advance of
appropriations Acts and represents the obligation of the
Secretary to provide payments from the Fund in accordance
with this subsection.
(2) Amount of payment.--The payment made to a health
insurance issuer under subsection (a) with respect to each
high-cost individual enrolled in a qualified health plan
issued by the issuer that is not a grandfathered health plan
or a transitional health plan shall equal 80 percent of the
lesser of--
(A) the amount (if any) by which the individual's claims
incurred during the plan year exceeds--
(i) in the case of the 2018, 2019, or 2020 plan year,
$50,000; and
(ii) in the case of any other plan year, $100,000; or
(B) for plan years described in--
(i) subparagraph (A)(i), $450,000; and
(ii) subparagraph (A)(ii), $400,000.
(3) Indexing.--In the case of plan years beginning after
2018, the dollar amounts that appear in subparagraphs (A) and
(B) of paragraph (2) shall each be increased by an amount
equal to--
(A) such amount; multiplied by
(B) the premium adjustment percentage specified under
section 1302(c)(4) of the Affordable Care Act, but determined
by substituting ``2018'' for ``2013''.
(4) Payment methods.--
(A) In general.--Payments under this subsection shall be
based on such a method as the Secretary determines. The
Secretary may establish a payment method by which interim
payments of amounts under this subsection are made during a
plan year based on the Secretary's best estimate of amounts
that will be payable after obtaining all of the information.
(B) Requirement for provision of information.--
(i) Requirement.--Payments under this subsection to a
health insurance issuer are conditioned upon the furnishing
to the Secretary, in a form and manner specified by the
Secretary, of such information as may be required to carry
out this subsection.
(ii) Restriction on use of information.--Information
disclosed or obtained pursuant to clause (i) is subject to
the HIPAA privacy and security law, as defined in section
3009(a) of the Public Health Service Act (42 U.S.C. 300jj-
19(a)).
(5) Secretary flexibility for budget neutral revisions to
reinsurance payment specifications.--If the Secretary
determines appropriate, the Secretary may substitute higher
dollar amounts for the dollar amounts specified under
subparagraphs (A) and (B) of paragraph (2) (and adjusted
under paragraph (3), if applicable) if the Secretary
certifies that such substitutions, considered together,
neither increase nor decease the total projected payments
under this subsection.
(c) Outreach and Enrollment.--
(1) In general.--During the period that begins on January
1, 2018, and ends on December 31, 2020, the Secretary shall
award grants to eligible entities for the following purposes:
(A) Outreach and enrollment.--To carry out outreach, public
education activities, and enrollment activities to raise
awareness of the availability of, and encourage enrollment
in, qualified health plans.
(B) Assisting individuals transition to qualified health
plans.--To provide assistance to individuals who are enrolled
in health insurance coverage that is not a qualified health
plan enroll in a qualified health plan.
(C) Assisting enrollment in public health programs.--To
facilitate the enrollment of eligible individuals in the
Medicare program or in a State Medicaid program, as
appropriate.
(D) Raising awareness of premium assistance and cost-
sharing reductions.--To distribute fair and impartial
information concerning enrollment in qualified health plans
and the availability of premium assistance tax credits under
section 36B of the Internal Revenue Code of 1986 and cost-
sharing reductions under section 1402 of the Patient
Protection and Affordable Care Act, and to assist eligible
individuals in applying for such tax credits and cost-sharing
reductions.
(2) Eligible entities defined.--
(A) In general.--In this subsection, the term ``eligible
entity'' means--
(i) a State; or
(ii) a nonprofit community-based organization.
(B) Enrollment agents.--Such term includes a licensed
independent insurance agent or broker that has an arrangement
with a State or nonprofit community-based organization to
enroll eligible individuals in qualified health plans.
(C) Exclusions.--Such term does not include an entity
that--
(i) is a health insurance issuer; or
(ii) receives any consideration, either directly or
indirectly, from any health insurance issuer in connection
with the enrollment of any qualified individuals or employees
of a qualified employer in a qualified health plan.
(3) Priority.--In awarding grants under this subsection,
the Secretary shall give priority to awarding grants to
States or eligible entities in States that have geographic
rating areas at risk of having no qualified health plans in
the individual market.
(4) Funding.--Out of any moneys in the Treasury not
otherwise appropriated, $500,000,000 is appropriated to the
Secretary for each of calendar years 2018 through 2020, to
carry out this subsection.
(d) Reports to Congress.--
(1) Annual report.--The Secretary shall submit a report to
Congress, not later than January 21, 2019, and each year
thereafter, that contains the following information for the
most recently ended year:
(A) The number and types of plans in each State's
individual market, specifying the number that are qualified
health plans, grandfathered health plans, or health insurance
coverage that is not a qualified health plan.
(B) The impact of the reinsurance payments provided under
this section on the availability of coverage, cost of
coverage, and coverage options in each State.
(C) The amount of premiums paid by individuals in each
State by age, family size, geographic area in the State's
individual market, and category of health plan (as described
in subparagraph (A)).
(D) The process used to award funds for outreach and
enrollment activities awarded to eligible entities under
subsection (c), the
[[Page S4515]]
amount of such funds awarded, and the activities carried out
with such funds.
(E) Such other information as the Secretary deems relevant.
(2) Evaluation report.--Not later than January 31, 2022,
the Secretary shall submit to Congress a report that--
(A) analyzes the impact of the funds provided under this
section on premiums and enrollment in the individual market
in all States; and
(B) contains a State-by-State comparison of the design of
the programs carried out by States with funds provided under
this section.
(e) Definitions.--In this section:
(1) Secretary.--The term ``Secretary'' means the Secretary
of the Department of Health and Human Services.
(2) Fund.--The term ``Fund'' means the Individual Market
Reinsurance Fund established under subsection (a).
(3) Grandfathered health plan.--The term ``grandfathered
health plan'' has the meaning given that term in section
1251(e) of the Patient Protection and Affordable Care Act.
(4) High-cost individual.--The term ``high-cost
individual'' means an individual enrolled in a qualified
health plan (other than a grandfathered health plan or a
transitional health plan) who incurs claims in excess of
$50,000 during a plan year.
(5) State.--The term ``State'' means each of the 50 States
and the District of Columbia.
(6) Transitional health plan.--The term ``transitional
health plan'' means a plan continued under the letter issued
by the Centers for Medicare & Medicaid Services on November
14, 2013, to the State Insurance Commissioners outlining a
transitional policy for coverage in the individual and small
group markets to which section 1251 of the Patient Protection
and Affordable Care Act does not apply, and under the
extension of the transitional policy for such coverage set
forth in the Insurance Standards Bulletin Series guidance
issued by the Centers for Medicare & Medicaid Services on
March 5, 2014, February 29, 2016, and February 13, 2017.
SEC. 102. PUBLIC HEALTH INSURANCE OPTION.
(a) In General.--Part 3 of subtitle D of title I of the
Patient Protection and Affordable Care Act (Public Law 111-
148) is amended by adding at the end the following new
section:
``SEC. 1325. PUBLIC HEALTH INSURANCE OPTION.
``(a) Establishment and Administration of a Public Health
Insurance Option.--
``(1) Establishment.--For years beginning with 2018, the
Secretary of Health and Human Services (in this subtitle
referred to as the `Secretary') shall provide for the
offering through Exchanges established under this title of a
health benefits plan (in this Act referred to as the `public
health insurance option') that ensures choice, competition,
and stability of affordable, high-quality coverage throughout
the United States in accordance with this section. In
designing the option, the Secretary's primary responsibility
is to create a low-cost plan without compromising quality or
access to care.
``(2) Offering through exchanges.--
``(A) Exclusive to exchanges.--The public health insurance
option shall only be made available through Exchanges
established under this title.
``(B) Ensuring a level playing field.--Consistent with this
section, the public health insurance option shall comply with
requirements that are applicable under this title to health
benefits plans offered through such Exchanges, including
requirements related to benefits, benefit levels, provider
networks, notices, consumer protections, and cost sharing.
``(C) Provision of benefit levels.--The public health
insurance option--
``(i) shall offer bronze, silver, and gold plans; and
``(ii) may offer platinum plans.
``(3) Administrative contracting.--The Secretary may enter
into contracts for the purpose of performing administrative
functions (including functions described in subsection (a)(4)
of section 1874A of the Social Security Act) with respect to
the public health insurance option in the same manner as the
Secretary may enter into contracts under subsection (a)(1) of
such section. The Secretary has the same authority with
respect to the public health insurance option as the
Secretary has under subsections (a)(1) and (b) of section
1874A of the Social Security Act with respect to title XVIII
of such Act. Contracts under this subsection shall not
involve the transfer of insurance risk to such entity.
``(4) Ombudsman.--The Secretary shall establish an office
of the ombudsman for the public health insurance option which
shall have duties with respect to the public health insurance
option similar to the duties of the Medicare Beneficiary
Ombudsman under section 1808(c)(2) of the Social Security
Act. In addition, such office shall work with States to
ensure that information and notice is provided that the
public health insurance option is one of the health plans
available through an Exchange.
``(5) Data collection.--The Secretary shall collect such
data as may be required to establish premiums and payment
rates for the public health insurance option and for other
purposes under this section, including to improve quality and
to reduce racial, ethnic, and other disparities in health and
health care.
``(6) Access to federal courts.--The provisions of Medicare
(and related provisions of title II of the Social Security
Act) relating to access of Medicare beneficiaries to Federal
courts for the enforcement of rights under Medicare,
including with respect to amounts in controversy, shall apply
to the public health insurance option and individuals
enrolled under such option under this title in the same
manner as such provisions apply to Medicare and Medicare
beneficiaries.
``(b) Premiums and Financing.--
``(1) Establishment of premiums.--
``(A) In general.--The Secretary shall establish
geographically adjusted premium rates for the public health
insurance option--
``(i) in a manner that complies with the premium rules
under paragraph (3); and
``(ii) at a level sufficient to fully finance the costs
of--
``(I) health benefits provided by the public health
insurance option; and
``(II) administrative costs related to operating the public
health insurance option.
``(B) Contingency margin.--In establishing premium rates
under subparagraph (A), the Secretary shall include an
appropriate amount for a contingency margin.
``(2) Account.--
``(A) Establishment.--There is established in the Treasury
of the United States an account for the receipts and
disbursements attributable to the operation of the public
health insurance option, including the start-up funding under
subparagraph (B). Section 1854(g) of the Social Security Act
shall apply to receipts described in the previous sentence in
the same manner as such section applies to payments or
premiums described in such section.
``(B) Start-up funding.--
``(i) In general.--In order to provide for the
establishment of the public health insurance option there is
hereby appropriated to the Secretary, out of any funds in the
Treasury not otherwise appropriated, $2,000,000,000. In order
to provide for initial claims reserves before the collection
of premiums, there is hereby appropriated to the Secretary,
out of any funds in the Treasury not otherwise appropriated,
such sums as necessary to cover 90 days worth of claims
reserves based on projected enrollment.
``(ii) Amortization of start-up funding.--The Secretary
shall provide for the repayment of the startup funding
provided under clause (i) to the Treasury in an amortized
manner over the 10-year period beginning with 2018.
``(iii) Limitation on funding.--Nothing in this subsection
shall be construed as authorizing any additional
appropriations to the account, other than such amounts as are
otherwise provided with respect to other health benefits
plans participating under the Exchange involved.
``(3) Insurance rating rules.--The premium rate charged for
the public health insurance option may not vary except as
provided under section 2701 of the Public Health Service Act.
``(c) Payment Rates for Items and Services.--
``(1) Rates established by secretary.--
``(A) In general.--The Secretary shall establish payment
rates for the public health insurance option for services and
health care providers consistent with this subsection and may
change such payment rates in accordance with subsection (d).
``(B) Initial payment rules.--
``(i) In general.--During 2018, 2019, and 2020, the
Secretary shall set the payment rates under this subsection
for services and providers described in subparagraph (A)
equal to the payment rates for equivalent services and
providers under parts A and B of Medicare, subject to clause
(ii), paragraph (4), and subsection (d).
``(ii) Exceptions.--The Secretary may determine the extent
to which Medicare adjustments applicable to base payment
rates under parts A and B of Medicare for graduate medical
education and disproportionate share hospitals shall apply
under this section.
``(C) For new services.--The Secretary shall modify payment
rates described in subparagraph (B) in order to accommodate
payments for services, such as well-child visits, that are
not otherwise covered under Medicare.
``(D) Prescription drugs.--Payment rates under this
subsection for prescription drugs that are not paid for under
part A or part B of Medicare shall be at rates negotiated by
the Secretary.
``(2) Subsequent periods; provider network.--
``(A) Subsequent periods.--Beginning with 2021 and for
subsequent years, the Secretary shall continue to use an
administrative process to set such rates in order to promote
payment accuracy, to ensure adequate beneficiary access to
providers, and to promote affordability and the efficient
delivery of medical care consistent with subsection (a)(1).
Such rates shall not be set at levels expected to increase
average medical costs per enrollee covered under the public
health insurance option beyond what would be expected if the
process under paragraph (1)(B) were continued, as certified
by the Office of the Actuary of the Centers for Medicare &
Medicaid Services.
``(B) Establishment of a provider network.--Health care
providers participating under Medicare are participating
providers in the public health insurance option unless they
opt out in a process established by the Secretary.
[[Page S4516]]
``(3) Administrative process for setting rates.--Chapter 5
of title 5, United States Code shall apply to the process for
the initial establishment of payment rates under this
subsection but not to the specific methodology for
establishing such rates or the calculation of such rates.
``(4) Construction.--Nothing in this section shall be
construed as limiting the Secretary's authority to correct
for payments that are excessive or deficient, taking into
account the provisions of subsection (a)(1) and any
appropriate adjustments based on the demographic
characteristics of enrollees covered under the public health
insurance option, but in no case shall the correction of
payments under this paragraph result in a level of
expenditures per enrollee that exceeds the level of
expenditures that would have occurred under paragraph (1)(B),
as certified by the Office of the Actuary of the Centers for
Medicare & Medicaid Services.
``(5) Construction.--Nothing in this section shall be
construed as affecting the authority of the Secretary to
establish payment rates, including payments to provide for
the more efficient delivery of services, such as the
initiatives provided for under subsection (d).
``(6) Limitations on review.--There shall be no
administrative or judicial review of a payment rate or
methodology established under this subsection or under
subsection (d).
``(d) Modernized Payment Initiatives and Delivery System
Reform.--
``(1) In general.--For plan years beginning with 2018, the
Secretary may utilize innovative payment mechanisms and
policies to determine payments for items and services under
the public health insurance option. The payment mechanisms
and policies under this subsection may include patient-
centered medical home and other care management payments,
accountable care organizations, value-based purchasing,
bundling of services, differential payment rates, performance
or utilization based payments, partial capitation, and direct
contracting with providers. Payment rates under such payment
mechanisms and policies shall not be set at levels expected
to increase average medical costs per enrollee covered under
the public health insurance option beyond what would be
expected if the process under subsection (c)(1)(B) were
continued, as certified by the Office of the Actuary of the
Centers for Medicare & Medicaid Services.
``(2) Requirements for innovative payments.--The Secretary
shall design and implement the payment mechanisms and
policies under this subsection in a manner that--
``(A) seeks to--
``(i) improve health outcomes;
``(ii) reduce health disparities (including racial, ethnic,
and other disparities);
``(iii) provide efficient and affordable care;
``(iv) address geographic variation in the provision of
health services; or
``(v) prevent or manage chronic illness; and
``(B) promotes care that is integrated, patient-centered,
high-quality, and efficient.
``(3) Encouraging the use of high value services.--To the
extent allowed by the benefit standards applied to all health
benefits plans participating under the Exchange involved, the
public health insurance option may modify cost sharing and
payment rates to encourage the use of services that promote
health and value.
``(4) Non-uniformity permitted.--Nothing in this subtitle
shall prevent the Secretary from varying payments based on
different payment structure models (such as accountable care
organizations and medical homes) under the public health
insurance option for different geographic areas.
``(e) Provider Participation.--
``(1) In general.--The Secretary shall establish conditions
of participation for health care providers under the public
health insurance option.
``(2) Licensure or certification.--The Secretary shall not
allow a health care provider to participate in the public
health insurance option unless such provider is appropriately
licensed or certified under State law.
``(3) Payment terms for providers.--
``(A) Physicians.--The Secretary shall provide for the
annual participation of physicians under the public health
insurance option, for which payment may be made for services
furnished during the year, in one of 2 classes:
``(i) Preferred physicians.--Those physicians who agree to
accept the payment rate established under this section
(without regard to cost-sharing) as the payment in full.
``(ii) Participating, non-preferred physicians.--Those
physicians who agree not to impose charges (in relation to
the payment rate described in subsection (c) for such
physicians) that exceed the ratio permitted under section
1848(g)(2)(C) of the Social Security Act.
``(B) Other providers.--The Secretary shall provide for the
participation (on an annual or other basis specified by the
Secretary) of health care providers (other than physicians)
under the public health insurance option under which payment
shall only be available if the provider agrees to accept the
payment rate established under subsection (c) (without regard
to cost-sharing) as the payment in full.
``(4) Exclusion of certain providers.--The Secretary shall
exclude from participation under the public health insurance
option a health care provider that is excluded from
participation in a Federal health care program (as defined in
section 1128B(f) of the Social Security Act).
``(f) Application of Fraud and Abuse Provisions.--
Provisions of law (other than criminal law provisions)
identified by the Secretary by regulation, in consultation
with the Inspector General of the Department of Health and
Human Services, that impose sanctions with respect to waste,
fraud, and abuse under Medicare, such as the False Claims Act
(31 U.S.C. 3729 et seq.), shall also apply to the public
health insurance option.
``(g) Medicare Defined.--For purposes of this section, the
term `Medicare' means the health insurance programs under
title XVIII of the Social Security Act.''.
(b) Conforming Amendments.--
(1) Treatment as qualified health plan.--Section 1301(a)(2)
of the Patient Protection and Affordable Care Act is
amended--
(A) in the heading, by inserting ``, the public health
insurance option,'' before ``and''; and
(B) by inserting ``the public health insurance option under
section 1325,'' before ``and a multi-State plan''.
(2) Level playing field.--Section 1324(a) of such Act is
amended by inserting ``the public health insurance option
under section 1325,'' before ``or a multi-State qualified
health plan''.
TITLE II--HEALTH CARE FINANCIAL ASSISTANCE
SEC. 201. INCREASE IN ELIGIBILITY FOR PREMIUM ASSISTANCE TAX
CREDITS.
(a) In General.--Subparagraph (A) of section 36B(c)(1) of
the Internal Revenue Code of 1986 is amended by striking
``400 percent'' and inserting ``600 percent''.
(b) Conforming Amendment.--The table contained in clause
(i) of section 36B(b)(3)(A)(i) of the Internal Revenue Code
of 1986 is amended by striking ``400%'' and inserting
``600%''.
(c) Reconciliation of Credit and Advance Credit.--Clause
(i) of section 36B(f)(2)(B) of the Internal Revenue Code of
1986 is amended--
(1) by striking ``In the case of'' and all that follows
through ``the amount of'' and inserting ``The amount of'',
and
(2) by striking ``but less than 400%'' in the table.
(d) Effective Date.--The amendments made by this section
shall apply to taxable years beginning after December 31,
2017.
SEC. 202. ENHANCEMENTS FOR REDUCED COST SHARING.
(a) Modification of Amount.--
(1) In general.--Section 1402(c)(2) of the Patient
Protection and Affordable Care Act is amended to read as
follows:
``(2) Additional reduction.--The Secretary shall establish
procedures under which the issuer of a qualified health plan
to which this section applies shall further reduce cost-
sharing under the plan in a manner sufficient to--
``(A) in the case of an eligible insured whose household
income is not less than 100 percent but not more than 200
percent of the poverty line for a family of the size
involved, increase the plan's share of the total allowed
costs of benefits provided under the plan to 95 percent of
such costs;
``(B) in the case of an eligible insured whose household
income is more than 200 percent but not more than 300 percent
of the poverty line for a family of the size involved,
increase the plan's share of the total allowed costs of
benefits provided under the plan to 90 percent of such costs;
and
``(C) in the case of an eligible insured whose household
income is more than 300 percent but not more than 400 percent
of the poverty line for a family of the size involved,
increase the plan's share of the total allowed costs of
benefits provided under the plan to 85 percent of such
costs.''.
(2) Conforming amendment.--Clause (i) of section
1402(c)(1)(B) of such Act is amended to read as follows:
``(i) In general.--The Secretary shall ensure the reduction
under this paragraph shall not result in an increase in the
plan's share of the total allowed costs of benefits provided
under the plan above--
``(I) 95 percent in the case of an eligible insured
described in paragraph (2)(A);
``(II) 90 percent in the case of an eligible insured
described in paragraph (2)(B); and
``(III) 85 percent in the case of an eligible insured
described in paragraph (2)(C).''.
(3) Effective date.--The amendments made by this subsection
shall apply to plan years beginning after December 31, 2017.
(b) Funding.--Section 1402 of the Patient Protection and
Affordable Care Act is amended by adding at the end the
following new subsection:
``(g) Funding.--Out of any funds in the Treasury not
otherwise appropriated, there are appropriated to the
Secretary such sums as may be necessary for payments under
this section.''.
TITLE III--DRUG PRICING
SEC. 301. REQUIRING DRUG MANUFACTURERS TO PROVIDE DRUG
REBATES FOR DRUGS DISPENSED TO LOW-INCOME
INDIVIDUALS.
(a) In General.--Section 1860D-2 of the Social Security Act
(42 U.S.C. 1395w-102) is amended--
(1) in subsection (e)(1), in the matter preceding
subparagraph (A), by inserting ``and subsection (f)'' after
``this subsection''; and
(2) by adding at the end the following new subsection:
``(f) Prescription Drug Rebate Agreement for Rebate
Eligible Individuals.--
[[Page S4517]]
``(1) Requirement.--
``(A) In general.--For plan years beginning on or after
January 1, 2019, in this part, the term `covered part D drug'
does not include any drug or biological product that is
manufactured by a manufacturer that has not entered into and
have in effect a rebate agreement described in paragraph (2).
``(B) 2018 plan year requirement.--Any drug or biological
product manufactured by a manufacturer that declines to enter
into a rebate agreement described in paragraph (2) for the
period beginning on January 1, 2018, and ending on December
31, 2018, shall not be included as a `covered part D drug'
for the subsequent plan year.
``(2) Rebate agreement.--A rebate agreement under this
subsection shall require the manufacturer to provide to the
Secretary a rebate for each rebate period (as defined in
paragraph (6)(B)) ending after December 31, 2017, in the
amount specified in paragraph (3) for any covered part D drug
of the manufacturer dispensed after December 31, 2017, to any
rebate eligible individual (as defined in paragraph (6)(A))
for which payment was made by a PDP sponsor or MA
organization under this part for such period, including
payments passed through the low-income and reinsurance
subsidies under sections 1860D-14 and 1860D-15(b),
respectively. Such rebate shall be paid by the manufacturer
to the Secretary not later than 30 days after the date of
receipt of the information described in section 1860D-
12(b)(7), including as such section is applied under section
1857(f)(3), or 30 days after the receipt of information under
subparagraph (D) of paragraph (3), as determined by the
Secretary. Insofar as not inconsistent with this subsection,
the Secretary shall establish terms and conditions of such
agreement relating to compliance, penalties, and program
evaluations, investigations, and audits that are similar to
the terms and conditions for rebate agreements under
paragraphs (3) and (4) of section 1927(b).
``(3) Rebate for rebate eligible medicare drug plan
enrollees.--
``(A) In general.--The amount of the rebate specified under
this paragraph for a manufacturer for a rebate period, with
respect to each dosage form and strength of any covered part
D drug provided by such manufacturer and dispensed to a
rebate eligible individual, shall be equal to the product
of--
``(i) the total number of units of such dosage form and
strength of the drug so provided and dispensed for which
payment was made by a PDP sponsor or an MA organization under
this part for the rebate period, including payments passed
through the low-income and reinsurance subsidies under
sections 1860D-14 and 1860D-15(b), respectively; and
``(ii) the amount (if any) by which--
``(I) the Medicaid rebate amount (as defined in
subparagraph (B)) for such form, strength, and period,
exceeds
``(II) the average Medicare drug program rebate eligible
rebate amount (as defined in subparagraph (C)) for such form,
strength, and period.
``(B) Medicaid rebate amount.--For purposes of this
paragraph, the term `Medicaid rebate amount' means, with
respect to each dosage form and strength of a covered part D
drug provided by the manufacturer for a rebate period--
``(i) in the case of a single source drug or an innovator
multiple source drug, the amount specified in paragraph
(1)(A)(ii)(II) or (2)(C) of section 1927(c) plus the amount,
if any, specified in subparagraph (A)(ii) of paragraph (2) of
such section, for such form, strength, and period; or
``(ii) in the case of any other covered outpatient drug,
the amount specified in paragraph (3)(A)(i) of such section
for such form, strength, and period.
``(C) Average medicare drug program rebate eligible rebate
amount.--For purposes of this subsection, the term `average
Medicare drug program rebate eligible rebate amount' means,
with respect to each dosage form and strength of a covered
part D drug provided by a manufacturer for a rebate period,
the sum, for all PDP sponsors under part D and MA
organizations administering an MA-PD plan under part C, of--
``(i) the product, for each such sponsor or organization,
of--
``(I) the sum of all rebates, discounts, or other price
concessions (not taking into account any rebate provided
under paragraph (2) or any discounts under the program under
section 1860D-14A) for such dosage form and strength of the
drug dispensed, calculated on a per-unit basis, but only to
the extent that any such rebate, discount, or other price
concession applies equally to drugs dispensed to rebate
eligible Medicare drug plan enrollees and drugs dispensed to
PDP and MA-PD enrollees who are not rebate eligible
individuals; and
``(II) the number of the units of such dosage and strength
of the drug dispensed during the rebate period to rebate
eligible individuals enrolled in the prescription drug plans
administered by the PDP sponsor or the MA-PD plans
administered by the MA organization; divided by
``(ii) the total number of units of such dosage and
strength of the drug dispensed during the rebate period to
rebate eligible individuals enrolled in all prescription drug
plans administered by PDP sponsors and all MA-PD plans
administered by MA organizations.
``(D) Use of estimates.--The Secretary may establish a
methodology for estimating the average Medicare drug program
rebate eligible rebate amounts for each rebate period based
on bid and utilization information under this part and may
use these estimates as the basis for determining the rebates
under this section. If the Secretary elects to estimate the
average Medicare drug program rebate eligible rebate amounts,
the Secretary shall establish a reconciliation process for
adjusting manufacturer rebate payments not later than 3
months after the date that manufacturers receive the
information collected under section 1860D-12(b)(7)(B).
``(4) Length of agreement.--The provisions of paragraph (4)
of section 1927(b) (other than clauses (iv) and (v) of
subparagraph (B)) shall apply to rebate agreements under this
subsection in the same manner as such paragraph applies to a
rebate agreement under such section.
``(5) Other terms and conditions.--The Secretary shall
establish other terms and conditions of the rebate agreement
under this subsection, including terms and conditions related
to compliance, that are consistent with this subsection.
``(6) Definitions.--In this subsection and section 1860D-
12(b)(7):
``(A) Rebate eligible individual.--The term `rebate
eligible individual' means--
``(i) a subsidy eligible individual (as defined in section
1860D-14(a)(3)(A));
``(ii) a Medicaid beneficiary treated as a subsidy eligible
individual under clause (v) of section 1860D-14(a)(3)(B); and
``(iii) any part D eligible individual not described in
clause (i) or (ii) who is determined for purposes of the
State plan under title XIX to be eligible for medical
assistance under clause (i), (iii), or (iv) of section
1902(a)(10)(E).
``(B) Rebate period.--The term `rebate period' has the
meaning given such term in section 1927(k)(8).''.
(b) Reporting Requirement for the Determination and Payment
of Rebates by Manufacturers Related to Rebate for Rebate
Eligible Medicare Drug Plan Enrollees.--
(1) Requirements for pdp sponsors.--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:
``(7) Reporting requirement for the determination and
payment of rebates by manufacturers related to rebate for
rebate eligible medicare drug plan enrollees.--
``(A) In general.--For purposes of the rebate under section
1860D-2(f) for contract years beginning on or after January
1, 2019, each contract entered into with a PDP sponsor under
this part with respect to a prescription drug plan shall
require that the sponsor comply with subparagraphs (B) and
(C).
``(B) Report form and contents.--Not later than a date
specified by the Secretary, a PDP sponsor of a prescription
drug plan under this part shall report to each manufacturer--
``(i) information (by National Drug Code number) on the
total number of units of each dosage, form, and strength of
each drug of such manufacturer dispensed to rebate eligible
Medicare drug plan enrollees under any prescription drug plan
operated by the PDP sponsor during the rebate period;
``(ii) information on the price discounts, price
concessions, and rebates for such drugs for such form,
strength, and period;
``(iii) information on the extent to which such price
discounts, price concessions, and rebates apply equally to
rebate eligible Medicare drug plan enrollees and PDP
enrollees who are not rebate eligible Medicare drug plan
enrollees; and
``(iv) any additional information that the Secretary
determines is necessary to enable the Secretary to calculate
the average Medicare drug program rebate eligible rebate
amount (as defined in paragraph (3)(C) of such section), and
to determine the amount of the rebate required under this
section, for such form, strength, and period.
Such report shall be in a form consistent with a standard
reporting format established by the Secretary.
``(C) Submission to secretary.--Each PDP sponsor shall
promptly transmit a copy of the information reported under
subparagraph (B) to the Secretary for the purpose of audit
oversight and evaluation.
``(D) Confidentiality of information.--The provisions of
subparagraph (D) of section 1927(b)(3), relating to
confidentiality of information, shall apply to information
reported by PDP sponsors under this paragraph in the same
manner that such provisions apply to information disclosed by
manufacturers or wholesalers under such section, except--
``(i) that any reference to `this section' in clause (i) of
such subparagraph shall be treated as being a reference to
this section;
``(ii) the reference to the Director of the Congressional
Budget Office in clause (iii) of such subparagraph shall be
treated as including a reference to the Medicare Payment
Advisory Commission; and
``(iii) clause (iv) of such subparagraph shall not apply.
``(E) Oversight.--Information reported under this paragraph
may be used by the Inspector General of the Department of
Health and Human Services for the statutorily authorized
purposes of audit, investigation, and evaluations.
``(F) Penalties for failure to provide timely information
and provision of false
[[Page S4518]]
information.--In the case of a PDP sponsor--
``(i) that fails to provide information required under
subparagraph (B) on a timely basis, the sponsor is subject to
a civil money penalty in the amount of $10,000 for each day
in which such information has not been provided; or
``(ii) that knowingly (as defined in section 1128A(i))
provides false information under such subparagraph, the
sponsor is subject to a civil money penalty in an amount not
to exceed $100,000 for each item of false information.
Such civil money penalties are in addition to other penalties
as may be prescribed by law. The provisions of section 1128A
(other than subsections (a) and (b)) shall apply to a civil
money penalty under this subparagraph in the same manner as
such provisions apply to a penalty or proceeding under
section 1128A(a).''.
(2) Application to ma organizations.--Section 1857(f)(3) of
the Social Security Act (42 U.S.C. 1395w-27(f)(3)) is amended
by adding at the end the following:
``(D) Reporting requirement related to rebate for rebate
eligible medicare drug plan enrollees.--Section 1860D-
12(b)(7).''.
(c) Deposit of Rebates Into Medicare Prescription Drug
Account.--Section 1860D-16(c) of the Social Security Act (42
U.S.C. 1395w-116(c)) is amended by adding at the end the
following new paragraph:
``(6) Rebate for rebate eligible medicare drug plan
enrollees.--Amounts paid under a rebate agreement under
section 1860D-2(f) shall be deposited into the Account.''.
(d) Exclusion From Determination of Best Price and Average
Manufacturer Price Under Medicaid.--
(1) Exclusion from best price determination.--Section
1927(c)(1)(C)(ii)(I) of the Social Security Act (42 U.S.C.
1396r-8(c)(1)(C)(ii)(I)) is amended by inserting ``and
amounts paid under a rebate agreement under section 1860D-
2(f)'' after ``this section''.
(2) Exclusion from average manufacturer price
determination.--Section 1927(k)(1)(B)(i) of the Social
Security Act (42 U.S.C. 1396r-8(k)(1)(B)(i)) is amended--
(A) in subclause (IV), by striking ``and'' after the
semicolon;
(B) in subclause (V), by striking the period at the end and
inserting ``; and''; and
(C) by adding at the end the following:
``(VI) amounts paid under a rebate agreement under section
1860D-2(f).''.
SEC. 302. NEGOTIATION OF PRICES FOR MEDICARE PRESCRIPTION
DRUGS.
Section 1860D-11 of the Social Security Act (42 U.S.C.
1395w-111) is amended by striking subsection (i) (relating to
noninterference) and inserting the following:
``(i) Negotiation; No National Formulary or Price
Structure.--
``(1) Negotiation of prices with manufacturers.--In order
to ensure that beneficiaries enrolled under prescription drug
plans and MA-PD plans pay the lowest possible price, the
Secretary shall have and exercise authority similar to that
of other Federal entities that purchase prescription drugs in
bulk to negotiate contracts with manufacturers of covered
part D drugs, consistent with the requirements and in
furtherance of the goals of providing quality care and
containing costs under this part.
``(2) No national formulary or price structure.--In order
to promote competition under this part and in carrying out
this part, the Secretary may not require a particular
formulary or institute a price structure for the
reimbursement of covered part D drugs.''.
SEC. 303. GUARANTEED PRESCRIPTION DRUG BENEFITS.
(a) In General.--Section 1860D-3 of the Social Security Act
(42 U.S.C. 1395w-103) is amended to read as follows:
``access to a choice of qualified prescription drug coverage
``Sec. 1860D-3. (a) Assuring Access to a Choice of
Coverage.--
``(1) Choice of at least three plans in each area.--
Beginning on January 1, 2019, the Secretary shall ensure that
each part D eligible individual has available, consistent
with paragraph (2), a choice of enrollment in--
``(A) a nationwide prescription drug plan offered by the
Secretary in accordance with subsection (b); and
``(B) at least 2 qualifying plans (as defined in paragraph
(3)) in the area in which the individual resides, at least
one of which is a prescription drug plan.
``(2) Requirement for different plan sponsors.--The
requirement in paragraph (1)(B) is not satisfied with respect
to an area if only one entity offers all the qualifying plans
in the area.
``(3) Qualifying plan defined.--For purposes of this
section, the term `qualifying plan' means--
``(A) a prescription drug plan;
``(B) an MA-PD plan described in section 1851(a)(2)(A)(i)
that provides--
``(i) basic prescription drug coverage; or
``(ii) qualified prescription drug coverage that provides
supplemental prescription drug coverage so long as there is
no MA monthly supplemental beneficiary premium applied under
the plan, due to the application of a credit against such
premium of a rebate under section 1854(b)(1)(C); or
``(C) a nationwide prescription drug plan offered by the
Secretary in accordance with subsection (b).
``(b) HHS as PDP Sponsor for a Nationwide Prescription Drug
Plan.--
``(1) In general.--The Secretary, acting through the
Administrator of the Centers for Medicare & Medicaid
Services, shall take such steps as may be necessary to
qualify and serve as a PDP sponsor and to offer a
prescription drug plan that offers basic prescription drug
coverage throughout the United States. Such a plan shall be
in addition to, and not in lieu of, other prescription drug
plans offered under this part.
``(2) Premium; solvency; authorities.--In carrying out
paragraph (1), the Secretary--
``(A) shall establish a premium in the amount of $37 for
months in 2019 and, for months in subsequent years, in the
amount specified in this paragraph for months in the previous
year increased by the annual percentage increase described in
section 1860D-2(b)(6) (relating to growth in medicare
prescription drug costs per beneficiary) for the year
involved;
``(B) is deemed to have met any applicable solvency and
capital adequacy standards; and
``(C) shall exercise such authorities (including the use of
regional or other pharmaceutical benefit managers) as the
Secretary determines necessary to offer the prescription drug
plan in the same or a comparable manner as is the case for
prescription drug plans offered by private PDP sponsors.
``(c) Flexibility in Risk Assumed.--In order to ensure
access pursuant to subsection (a) in an area the Secretary
may approve limited risk plans under section 1860D-11(f) for
the area.''.
(b) Conforming Amendment.--Section 1860D-11(g) of the
Social Security Act (42 U.S.C. 1395w-111(g)) is amended by
adding at the end the following new paragraph:
``(8) Application.--This subsection shall not apply on or
after January 1, 2019.''.
(c) Effective Date.--The amendments made by this section
shall apply to plan years beginning on or after January 1,
2019.
SEC. 304. FULL REIMBURSEMENT FOR QUALIFIED RETIREE
PRESCRIPTION DRUG PLANS.
(a) Elimination of True Out-of-Pocket Limitation.--Section
1860D-2(b)(4)(C)(iii) of the Social Security Act (42 U.S.C.
1395w-102(b)(4)(C)(iii) is amended--
(1) in subclause (III), by striking ``or'' at the end;
(2) in subclause (IV), by striking the period at the end
and inserting ``; or''; and
(3) by adding at the end the following new subclause:
``(V) under a qualified retiree prescription drug plan (as
defined in section 1860D-22(a)(2)).''.
(b) Equalization of Subsidies.--Notwithstanding any other
provision of law, the Secretary of Health and Human Services
shall provide for such increase in the special subsidy
payment amounts under section 1860D-22(a)(3) of the Social
Security Act (42 U.S.C. 1395w-132(a)(3)) as may be
appropriate to provide for payments in the aggregate
equivalent to the payments that would have been made under
section 1860D-15 of such Act (42 U.S.C. 1395w-115) if the
individuals were not enrolled in a qualified retiree
prescription drug plan. In making such computation, the
Secretary shall not take into account the application of the
amendments made by section 1202 of the Medicare Prescription
Drug, Improvement, and Modernization Act of 2003 (Public Law
108-173; 117 Stat. 2480).
(c) Effective Date.--This section, and the amendments made
by this section, shall take effect on January 1, 2019.
TITLE IV--MEDICAID COLLABORATIVE CARE MODELS
SEC. 401. ENHANCED FMAP FOR MEDICAL ASSISTANCE PROVIDED
THROUGH A COLLABORATIVE CARE MODEL.
Section 1905 of the Social Security Act (42 U.S.C. 1396d)
is amended--
(1) in the first sentence of subsection (b)--
(A) by striking ``, and (5)'' and inserting ``, (5)''; and
(B) by inserting ``, and (6) beginning January 1, 2018, the
Federal medical assistance percentage shall be 100 percent
with respect to medical assistance provided by a State for
items and services delivered through a collaborative care
model (as defined in subsection (ee)) or an evidence-based
model (which may be a collaborative care model) that
integrates behavioral health services into primary care
treatment'' before the period;
(2) by adding at the end the following new subsection:
``(ee) Collaborative Care Models.--
``(1) In general.--The term `collaborative care model'
means a model for providing health care to individuals which
adheres to the core services described in paragraph (2) and
under which each individual receiving care through the model
receives care from a collaborative team of providers
described in paragraph (3).
``(2) Core services.--The services described in this
paragraph are:
``(A) Comprehensive care management.
``(B) Care coordination and health promotion.
``(C) Comprehensive transitional care from inpatient
settings to other settings, including appropriate follow up.
``(D) Individual and family support, which shall include
authorized representatives.
``(E) Referral to community and social support services, as
appropriate.
``(F) The use of health information technology to link
services, as feasible and appropriate.
[[Page S4519]]
``(3) Collaborative health team.--A team described in this
paragraph includes the following providers:
``(A) A primary care provider such as a primary care
phsyician, an internist, a nurse practitioner, or a
physician's assistant.
``(B) Care management staff which shall include a member
who is a registered professional nurse, a clinical social
worker, or a psychologist, and who specializes in primary
care management and is trained to provide evidence based care
coordination, brief behavioral interventions, and to support
treatments (including medications) initiated by a primary
care physician.
``(C) A psychiatric consultant who shall advise the primary
care provider as necessary (either in person or remotely).''.
______