To provide for necessary beneficiary protections in order to ensure access to coverage under the Medicare part D prescription drug program.

SA 2730. Mr. NELSON of Florida (for himself, Mr. Bingaman, Mrs.
Clinton, Mr. Lieberman, Mr. Schumer, and Mr. Salazar) proposed an
amendment to amendment SA 2707 proposed by Mr. Frist (for Mr. Grassley
(for himself and Mr. Baucus)) to the bill H.R. 4297, to provide for
reconciliation pursuant to section 201(b) of the concurrent resolution
on the budget for fiscal year 2006; as follows:

At the appropriate place, insert the following:

SEC. ___. TRANSITION REQUIREMENTS.

(a) Requirement.--
(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:
``(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.
``(5) Customer service.--The sponsor of a prescription drug
plan is required to provide--
``(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;
``(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
``(C) sufficient staff to reduce wait times for all
Medicare Part D-related calls to plan phone lines to no more
than 20 minutes.''.
(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.
(b) Effective Date and Enforcement.--
(1) Effective date.--The amendment made by subsection (a)
shall take effect on the date of enactment of this Act.
(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).

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

(a) In General.--
(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.
(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.
(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)).
(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--
(1) a government issued picture identification card;
(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
(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.
(c) Payments to Pharmacists.--
(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.
(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.
(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).

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

(a) In General.--Section 1860D-14 of the Social Security
Act (42 U.S.C. 1395w-114) is amended--
(1) by redesignating subsection (d) as subsection (e); and
(2) by inserting after subsection (c) the following new
subsection:
``(d) Ensuring Full-Benefit Dual Eligible Individuals Are
Not Overcharged.--

[[Page S678]]

``(1) In general.--The Secretary shall, as soon a possible
after the date of enactment of this subsection, establish
processes for the following:
``(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.
``(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--
``(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
``(ii) refund such amount to the individual within 60 days
of the determination that the individual was inappropriately
charged.
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.
``(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.''.
(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).

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

(a) Reimbursement.--
(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.
(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.
(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).
(c) State.--For purposes of this section, the term
``State'' includes the District of Columbia.

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

(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:
(1) The needs of full-benefit dual eligible individuals and
the challenges of meeting those needs.
(2) The processes for the transition from Medicaid
prescription drug coverage to coverage under such part D for
such individuals.
(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.
(b) Holding Pharmacies Harmless for Certain Costs.--
(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--
(A) transaction fees associated with the point-of-sale
facilitated identification and enrollment processes referred
to in subsection (a)(3); and
(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).
(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.
(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.

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

(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.
(b) Application.--
(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.
(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.

SEC. __. PROTECTION FOR MEDICARE BENEFICIARIES WHO ENROLL IN
THE PRESCRIPTION DRUG BENEFIT DURING 2006.

(a) Extended Period of Open Enrollment During All of 2006
Without Late Enrollment Penalty.--Section 1851(e)(3)(B) of
the Social Security Act (42 U.S.C. 1395w-21(e)(3)(B)) is
amended--
(1) in clause (iii), by striking ``May 15, 2006'' and
inserting ``December 31, 2006''; and
(2) by adding at the end the following new sentence:
``An individual making an election during the period
beginning on November 15, 2006, and ending on December 15,
2006, shall specify whether the election is to be effective
with respect to 2006 or with respect to 2007 (or both).''.
(b) One-Time Change of Plan Enrollment for Medicare
Prescription Drug Benefit During All of 2006.--
(1) In general.--Section 1851(e) of the Social Security Act
(42 U.S.C. 1395w-21(e)) is amended--
(A) in paragraph (2)(B)--
(i) in the heading, by striking ``for first 6 months'';
(ii) in clause (i), by striking ``the first 6 months of
2006,'' and all that follows through ``is a Medicare+Choice
eligible individual,'' and inserting ``2006,''; and
(iii) in clause (ii), by inserting ``(other than during
2006)'' after ``paragraph (3)''; and
(B) in paragraph (4), by striking ``2006'' and inserting
``2007'' each place it appears.
(2) Conforming amendment.--Section 1860D-1(b)(1)(B)(iii) of
the Social Security Act (42 U.S.C. 1395w-101(b)(1)(B)(iii))
is amended by striking ``subparagraphs (B) and (C) of
paragraph (2)'' and inserting ``paragraph (2)(C)''.
(c) Effective Date.--The amendments made by this section
shall take effect as if included in the enactment of the
Medicare Prescription Drug, Improvement, and Modernization
Act of 2003 (Public Law 108-173).
______