117th CONGRESS 1st Session |
To amend title XVIII of the Social Security Act to ensure equal access of Medicare beneficiaries to community pharmacies in underserved areas as network pharmacies under Medicare prescription drug coverage, and for other purposes.
April 15, 2021
Mr. Welch (for himself, Mr. Griffith, Mr. Vicente Gonzalez of Texas, Mr. Crawford, Mr. Carter of Georgia, Mrs. Axne, Mr. Allen, Mr. Ruppersberger, and Mr. Westerman) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, 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
To amend title XVIII of the Social Security Act to ensure equal access of Medicare beneficiaries to community pharmacies in underserved areas as network pharmacies under Medicare prescription drug coverage, and for other purposes.
Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,
This Act may be cited as the “Ensuring Seniors Access to Local Pharmacies Act of 2021”.
SEC. 2. Allowing any State licensed pharmacy serving an underserved area to become a network pharmacy under Medicare prescription drug coverage.
(a) In general.—Section 1860D–4(b)(1)(B) of the Social Security Act (42 U.S.C. 1395w–104(b)(1)(B)) is amended—
(1) by striking “Discounts allowed for network pharmacies.—For” and inserting the following: “Discounts allowed for network pharmacies.—
“(i) IN GENERAL.—For”; and
(2) by adding at the end the following new clause:
“(ii) INCLUSION OF PHARMACIES LOCATED IN UNDERSERVED AREAS IN NETWORKS.—For plan years beginning on or after January 1, 2022, in the case of a prescription drug plan that has, in its network of pharmacies, one or more pharmacies located in a health professional shortage area (as defined in section 332(a)(1)(A) of the Public Health Service Act), in a medically underserved area (according to a designation under section 330(b)(3)(A) of the Public Health Service Act), among a medically underserved population (as defined in such section 330(b)(3)(A) of such Act), or in a rural area (as defined by the Federal Office of Rural Health Policy), and that provides a reduction in coinsurance or copayments described in clause (i) for covered part D drugs dispensed through such pharmacies, such plan shall extend to any pharmacy located in such area or among such population the option to be an in-network pharmacy with respect to such plan under terms and conditions (including the reductions described in clause (i)) comparable to those the plan has agreed upon with other in-network pharmacies located in such area or among such population.”.
SEC. 3. Reasonable reimbursement requirements.
Section 1860D–2(d)(1)(B) of the Social Security Act (42 U.S.C. 1395w–102(d)(1)(B)) is amended—
(1) by striking “Prices.—For purposes” and inserting “Prices.—
(2) by adding at the end the following new clauses:
“(ii) REASONABLE REIMBURSEMENT.—For plan years beginning on or after January 1, 2022, a PDP sponsor and a Medicare Advantage organization shall ensure that—
“(I) each prescription drug plan or MA–PD plan offered by the sponsor or organization does not reimburse a pharmacy or pharmacist an amount less than the amount that the pharmacy benefits manager reimburses a pharmacy benefits manager affiliate (as defined in clause (iv)); and
“(II) in no case may the negotiated price for a covered part D drug furnished by a pharmacy under a prescription drug plan or MA–PD plan offered by the sponsor or organization, be less than such pharmacy’s cost of purchasing and dispensing such drug and providing such other services associated with furnishing such drug as may be specified by the Secretary.
“(iii) CLAIM REIMBURSEMENT DISCLOSURE REQUIREMENTS.—With respect to payment made by a PDP sponsor or a Medicare Advantage organization to a pharmacy for a covered part D drug furnished by such pharmacy during a plan year beginning on or after January 1, 2022, such sponsor or organization shall promptly furnish all pricing components including the Network Reimbursement ID used to price the claim, any fees, pharmacy price concessions, discounts, subsidies, rebates, incentives, or any other forms of direct or indirect remuneration that affect payment and pricing of the claim as part of the claim adjudication response at the point-of sale. All pricing components described in the preceding sentence shall each be identified in a predetermined line item in the remittance advice that is standard across the industry. The PDP sponsor or Medicare Advantage organization shall include suitable claim-level detail on the electronic remittance advice that accompanies each payment. This claim-level detail shall include, in an industry standardized format, all fields needed to properly identify the claim, including the Claim Authorization Number, date of service, date of payment remittance, ingredient cost reimbursed, dispensing fee reimbursed, payment amounts including the Network ID used to price the claim, the specific dollar amounts and the appropriate qualifier codes for each payment adjustment including fees, pharmacy price concessions, or incentives.
“(iv) PHARMACY BENEFITS MANAGER AFFILIATE DEFINED.—For purposes of clause (ii), the term ‘pharmacy benefits manager affiliate’ means a pharmacy or pharmacist that directly or indirectly, through one or more intermediaries, owns or controls, is owned or controlled by, or is under common ownership or corporate control with a pharmacy benefits manager, PDP sponsor or a Medicare Advantage organization.”.