S.Amdt. 2698

1. Adds SEC. ___. TRANSITION REQUIREMENTS wherever appropriate

   Adds a section

   Inserted: SEC. ___. TRANSITION REQUIREMENTS.

   Inserted: (a) Requirement.--

   Inserted: (1) In general.--Section 1860D-4(b) of the Social Security Act (42 U.S.C. 1395w-104(b)) is amended by adding at the end the following new paragraph:

   Inserted: "(4) Formulary transition.--The sponsor of a prescription drug plan is required to provide at least a 30-day supply of any drug that a new enrollee in the plan was taking prior to enrolling in such plan. For individuals residing in a long-term care setting, the sponsor of a prescription drug plan is required to provide at least a 90-day supply of any drug such individual was taking prior to enrolling in such plan. A formulary transition supply provided under this section shall be made by the sponsor of a prescription drug plan without imposing any prior authorization requirements or other access restrictions for individuals stabilized on a course of treatment and at the dosage previously prescribed by a physician or recommended by a physician going forward.

   Inserted: "(5) Customer service.--The sponsor of a prescription drug plan is required to provide--

   Inserted: "(A) accessible and trained customer service representatives available for full business hours from coast to coast to provide knowledgeable assistance to individuals seeking help with Medicare Part D including, but not limited to, beneficiaries, caseworkers, SHIP counselors, pharmacists, doctors, and caregivers;

   Inserted: "(B) at least one dedicated phone line for pharmacists with sufficient staff to reduce wait times for pharmacists seeking Medicare Part D assistance to no more than 20 minutes; and

   Inserted: "(C) sufficient staff to reduce wait times for all Medicare Part D-related calls to plan phone lines to no more than 20 minutes.".

   Inserted: (2) Application.--The requirements under paragraphs (4) and (5) of section 1860D-4(b) of the Social Security Act (42 U.S.C. 1395w-104(b)), as added by subsection (a), shall apply to the plan serving as the national point of sale contractor under part D of title XVIII of such Act.

   Inserted: (b) Effective Date and Enforcement.--

   Inserted: (1) Effective date.--The amendment made by subsection (a) shall take effect on the date of enactment of this Act.

   Inserted: (2) Enforcement.--The Secretary may impose a civil monetary penalty in an amount not to exceed $15,000 for conduct that a sponsor of a prescription drug plan or an organization offering an MA-PD plan knows or should know is a violation of the provisions of paragraph (4) or (5) of section 1860D-4(b) of the Social Security Act (42 U.S.C. 1395w-104(b)), as added by subsection (a). The provisions of section 1128A of the Social Security Act (42 U.S.C. a-7a), other than subsections (a) and (b) and the second sentence of subsection (f), shall apply to a civil monetary penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under subsection (a) of such section 1128A(a).

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   Inserted: SEC. ___. FEDERAL FALLBACK FOR FULL-BENEFIT DUAL ELIGIBLE INDIVIDUALS FOR 2006.

   Inserted: (a) In General.--

   Inserted: (1) In general.--If a full-benefit dual eligible individual (as defined in section 1935(c)(6) of the Social Security Act (42 U.S.C. 1396u-5(c)(6))), or an individual who is presumed to be such an individual pursuant to subsection (b), presents a prescription for a covered part D drug (as defined in section 1860D-2(e) of such Act (42 U.S.C. 1395w-102(e))) at a pharmacy in 2006 and the pharmacy is unable to locate or verify the individual's enrollment through a reasonable effort, including the use of the pharmacy billing system or by calling an official Medicare hotline, or to bill for the prescription through the plan serving as the national point of sale contractor, the pharmacy may provide a 30-day supply of the drug to the individual.

   Inserted: (2) Refill.--The pharmacy may provide an additional 30-day supply of a drug if the pharmacy continues to be unable to locate the individual's enrollment through such reasonable efforts or to bill for the prescription through the plan serving as the national point of sale contractor when a prescription is presented on or after the date that a prescription refill is appropriate, but in no case after December 31, 2006.

   Inserted: (3) Cost-sharing.--The cost-sharing for a prescription filled pursuant to this subsection shall be cost-sharing provided for under section 1860D-14(a) of the Social Security Act (42 U.S.C. 1395w-114(a)).

   Inserted: (b) Presumptive Eligibility.--An individual shall be presumed to be a full-benefit dual eligible individual (as so defined) if the individual presents at the pharmacy with--

   Inserted: (1) a government issued picture identification card;

   Inserted: (2) reliable evidence of Medicaid enrollment, such as a Medicaid card, recent history of Medicaid billing in the pharmacy patient profile, or a copy of a current Medicaid award letter; and

   Inserted: (3) reliable evidence of Medicare enrollment, such as a Medicare identification card, a Medicare enrollment approval letter, a Medicare Summary Notice, or confirmation from an official Medicare hotline.

   Inserted: (c) Payments to Pharmacists.--

   Inserted: (1) In general.--The Secretary of Health and Human Services shall reimburse pharmacists, to the extent that such pharmacists are not otherwise reimbursed by States or plans, for the costs incurred in complying with the requirements under subsection (a), including acquisition costs, dispensing costs, and other overhead costs. Such payments shall be made in a timely manner from the Medicare Prescription Drug Account under section 1860D-16 of the Social Security Act (42 U.S.C. 1395w-116) and shall be deemed to be payments from such Account under subsection (b) of such section.

   Inserted: (2) Retroactive application to beginning of 2006.--The costs incurred by a pharmacy which may be reimbursed under paragraph (1) shall include costs incurred during the period beginning on January 1, 2006, and before the date of enactment of this Act.

   Inserted: (d) Recovery of Costs From Plans by Secretary Not Pharmacies.--The Secretary of Health and Human Services shall establish a process for recovering the costs described in subsection (c)(1) from prescription drug plans (as defined in section 1860D-1(a)(3)(C) of the Social Security Act (42 U.S.C. 1394w-101(a)(3)(C))) and MA-PD plans (as defined in section 1860D-41(a)(14) of such Act (42 U.S.C. 1395w-151(a)(14))) if the Secretary determines that such plans should have incurred such costs. Amounts recovered pursuant to the preceding sentence shall be deposited in the Medicare Prescription Drug Account described in subsection (c)(1).

   Inserted: SEC. ___. ENSURING THAT FULL-BENEFIT DUAL ELIGIBLE INDIVIDUALS ARE NOT OVERCHARGED.

   Inserted: (a) In General.--Section 1860D-14 of the Social Security Act (42 U.S.C. 1395w-114) is amended--

   Inserted: (1) by redesignating subsection (d) as subsection (e); and

   Inserted: (2) by inserting after subsection (c) the following new subsection:

   Inserted: "(d) Ensuring Full-Benefit Dual Eligible Individuals Are Not Overcharged.--

   Inserted: "(1) In general.--The Secretary shall, as soon a possible after the date of enactment of this subsection, establish processes for the following:

   Inserted: "(A) Tracking inappropriate payments.--The Secretary shall track full-benefit dual eligible individuals enrolled in a prescription drug plan or an MA-PD plan to determine whether such individuals were inappropriately subject under the plan to a deductible or cost-sharing that is greater than is required under section 1860D-14.

   Inserted: "(B) Reduction in payments to plans and refunds to individuals.--If the Secretary determines under subparagraph (A) that an individual was overcharged, the Secretary shall--

   Inserted: "(i) reduce payments to the sponsor of the prescription drug plan under section 1860D-15 or to the organization offering the MA-PD plan under section 1853 that inappropriately charged the individual by an amount equal to the inappropriate charges; and

   Inserted: "(ii) refund such amount to the individual within 60 days of the determination that the individual was inappropriately charged.

   Inserted: If the Secretary does not provide for the refund under clause (i) within the 60 days provided for under such clause, interest at the rate established under section 6621(a)(1) of the Internal Revenue Code of 1986 shall be payable from the end of such 60-day period until the date of the refund.

   Inserted: "(2) Requirement.--The processes established under paragraph (1) shall provide for the ability of an individual to notify the Secretary if the individual believes that they were inappropriately subject under the plan to a deductible or cost-sharing that is greater than is required under section 1860D-14.".

   Inserted: (b) Report to Congress.--Not later than January 1, 2007, the Secretary of Health and Human Services shall submit a report to Congress on the implementation of the processes established under subsection (d) of section 1860D-14 of the Social Security Act (42 U.S.C. 1395w-114), as added by subsection (a).

   Inserted: SEC. ___. REIMBURSEMENT OF STATES FOR 2006 TRANSITION COSTS.

   Inserted: (a) Reimbursement.--

   Inserted: (1) In general.--Notwithstanding section 1935(d) of the Social Security Act (42 U.S.C. 1396u-5(d) or any other provision of law, the Secretary of Health and Human Services shall reimburse States for 100 percent of the costs incurred by the State during 2006 for covered part D drugs (as defined in section 1860D-2(e) of such Act (42 U.S.C. 1395w-102(e))) for part D eligible individuals (as defined in section 1860D-1(a)(3)(A) of the Social Security Act (42 U.S.C. 1394w-101(a)(3)(A))) which the State reasonably expected would have been covered under such part but were not because the individual was unable to access on a timely basis prescription drug benefits to which they were entitled under such part. Such payments shall be made from the Medicare Prescription Drug Account under section 1860D-16 of the Social Security Act (42 U.S.C. 1395w-116) and shall be deemed to be payments from such Account under subsection (b) of such section.

   Inserted: (2) Retroactive application to beginning of 2006.--The costs incurred by a State which may be reimbursed under paragraph (1) shall include costs incurred during the period beginning on January 1, 2006, and before the date of enactment of this Act.

   Inserted: (b) Recovery of Costs From Plans by Secretary Not States.--The Secretary of Health and Human Services shall establish a process for recovering the costs described in subsection (a)(1) from prescription drug plans (as defined in section 1860D-1(a)(3)(C) of the Social Security Act (42 U.S.C. 1394w-101(a)(3)(C))) and MA-PD plans (as defined in section 1860D-41(a)(14) of such Act (42 U.S.C. 1395w-151(a)(14))) if the Secretary determines that such plans should have incurred such costs. Amounts recovered pursuant to the preceding sentence shall be deposited in the Medicare Prescription Drug Account described in subsection (a)(1).

   Inserted: (c) State.--For purposes of this section, the term "State" includes the District of Columbia.

   Inserted: SEC. ___. FACILITATION OF IDENTIFICATION AND ENROLLMENT THROUGH PHARMACIES OF FULL-BENEFIT DUAL ELIGIBLE INDIVIDUALS IN THE MEDICARE PART D DRUG PROGRAM.

   Inserted: (a) In General.--The Secretary of Health and Human Services shall provide for outreach and education to every pharmacy that has participated in the Medicaid program under title XIV of the Social Security Act, particularly independent pharmacies, on the following:

   Inserted: (1) The needs of full-benefit dual eligible individuals and the challenges of meeting those needs.

   Inserted: (2) The processes for the transition from Medicaid prescription drug coverage to coverage under such part D for such individuals.

   Inserted: (3) The processes established by the Secretary to facilitate, at point of sale, identification of drug plan assignment of such population or enrollment of previously unidentified or new full-benefit dual eligible individuals into Medicare part D prescription drug coverage, including how pharmacies can use such processes to help ensure that such population makes a successful transition to Medicare part D without a lapse in prescription drug coverage.

   Inserted: (b) Holding Pharmacies Harmless for Certain Costs.--

   Inserted: (1) In general.--The Secretary of Health and Human Services shall provide for such payments to pharmacies as may be necessary to reimburse pharmacies fully for--

   Inserted: (A) transaction fees associated with the point-of-sale facilitated identification and enrollment processes referred to in subsection (a)(3); and

   Inserted: (B) costs associated with technology or software upgrades necessary to make any identification and enrollment inquiries as part of the processes under subsection (a)(3).

   Inserted: (2) Time.--Payments under paragraph (1) shall be made with respect to fees and costs incurred during the period beginning on December 1, 2005, and ending on June 1, 2006.

   Inserted: (3) Payments from account.--Payments under paragraph (1) shall be made from the Medicare Prescription Drug Account under section 1860D-16 of the Social Security Act (42 U.S.C. 1395w-116) and shall be deemed to be payments from such Account under subsection (b) of such section.

   Inserted: SEC. ___. STATE COVERAGE OF NON-FORMULARY PRESCRIPTION DRUGS FOR FULL-BENEFIT DUAL ELIGIBLE INDIVIDUALS DURING 2006.

   Inserted: (a) State Coverage of Non-Formulary Prescription Drugs for Full-Benefit Dual Eligible Individuals During 2006.--For prescriptions filled during 2006, notwithstanding section 1935(d) of the Social Security Act (42 U.S.C. 1396v(d)), a State (as defined for purposes of title XIX of such Act) may provide (and receive Federal financial participation for) medical assistance under such title with respect to prescription drugs provided to a full-benefit dual eligible individual (as defined in section 1935(c)(6) of such Act (42 U.S.C. 1396v(c)(6)) that are not on the formulary of the prescription drug plan under part D or the MA-PD plan under part C of title XVIII of such Act in which such individual is enrolled.

   Inserted: (b) Application.--

   Inserted: (1) Medicare as primary payer.--Nothing in subsection (a) shall be construed as changing or affecting the primary payer status of a prescription drug plan under part D or an MA-PD plan under part C of title XVIII of the Social Security Act with respect to prescription drugs furnished to any full-benefit dual eligible individual (as defined in section 1935(c)(6) of such Act (42 U.S.C. 1396v(c)(6)) during 2006.

   Inserted: (2) Third party liability.--Nothing in subsection (a) shall be construed as limiting the authority or responsibility of a State under section 1902(a)(25) of the Social Security Act (42 U.S.C. 1396a(a)(25)) to seek reimbursement from a prescription drug plan, an MA-PD plan, or any other third party, of the costs incurred by the State in providing prescription drug coverage during 2006.

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As printed