[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5307 Introduced in House (IH)]
109th CONGRESS
2d Session
H. R. 5307
To amend title XVIII of the Social Security Act to require the sponsor
of a prescription drug plan or an organization offering an MA-PD plan
to promptly pay claims submitted under part D, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
May 4, 2006
Mr. Pallone introduced the following bill; which was referred to the
Committee on Ways and Means, and in addition to the Committee on Energy
and Commerce, for a period to be subsequently determined by the
Speaker, in each case for consideration of such provisions as fall
within the jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to require the sponsor
of a prescription drug plan or an organization offering an MA-PD plan
to promptly pay claims submitted under part D, and for other purposes.
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 ``Pharmacists Medicare Relief 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 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 equal to the weighted average of
interest on 3-month marketable Treasury securities
determined for such period, increased by 0.1 percentage
point 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, as
appropriate, 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) Private right of action.--
``(i) In general.--Nothing in this
paragraph shall be construed to prohibit or
limit a claim or action not covered by the
subject matter of this section that any
individual or organization has against a
provider or a PDP sponsor.
``(ii) Anti-retaliation.--Consistent with
applicable Federal or State law, a PDP sponsor
shall not retaliate against an individual or
provider for exercising a right of action under
this subparagraph.''.
(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 of the
enactment of this Act.
SEC. 3. RESTRICTION ON CO-BRANDING.
(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 or an MA-PD plan offered by a Medicare Advantage
organization and any marketing materials distributed with respect to
such a plan shall not display the name or brand of any pharmacy.''.
(b) Penalty.--Section 1128B of the Social Security Act (42 U.S.C.
1320a-7b) is amended by adding at the end the following new subsection:
``(g) Whoever knowingly and willfully engages in co-branding
prohibited under section 1860D-4(l) with respect to a prescription drug
plan offered by a PDP sponsor under part D of title XVIII or a Medicare
Advantage plan offered by a Medicare Advantage organization under part
C of such title, shall be guilty of a felony and upon conviction
thereof shall be fined not more than $25,000 or imprisoned for not more
than five years, or both.''.
(c) Effective Date.--The amendments made by this section shall
apply to cards and marketing materials distributed on or after the date
that is 90 days after the date of the enactment of this Act.
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