I 116TH CONGRESS 1ST SESSION H. R. 789 To amend title XVIII of the Social Security Act to prohibit prescription drug plan sponsors and MA–PD organizations under the Medicare pro- gram from retroactively reducing payment on clean claims submitted by pharmacies. IN THE HOUSE OF REPRESENTATIVES JANUARY 24, 2019 Mr. WELCH (for himself, Mr. CARTER of Georgia, Mr. COLLINS of Georgia, and Mrs. RODGERS of Washington) 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 provi- sions as fall within the jurisdiction of the committee concerned A BILL To amend title XVIII of the Social Security Act to prohibit prescription drug plan sponsors and MA–PD organiza- tions under the Medicare program from retroactively re- ducing payment on clean claims submitted by phar- macies. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE. 3 This Act may be cited as the ‘‘Improving Trans- 4 parency and Accuracy in Medicare Part D Spending Act’’. 5 VerDate Sep 11 2014 04:06 Feb 02, 2019 Jkt 089200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H789.IH H789 kjohnson on DSK79L0C42 with BILLS 2 •HR 789 IH SEC. 2. PROHIBITING MEDICARE PDP SPONSORS AND MA– 1 PD ORGANIZATIONS FROM RETROACTIVELY 2 REDUCING PAYMENT ON CLEAN CLAIMS SUB- 3 MITTED BY PHARMACIES. 4 (a) IN GENERAL.—Section 1860D–12(b)(4)(A) of 5 the Social Security Act (42 U.S.C. 1395w–112(b)(4)(A)) 6 is amended by adding at the end the following new clause: 7 ‘‘(iv) PROHIBITING RETROACTIVE RE- 8 DUCTIONS IN PAYMENTS ON CLEAN 9 CLAIMS.—Each contract entered into with 10 a PDP sponsor under this part with re- 11 spect to a prescription drug plan offered 12 by such sponsor shall provide that after 13 the date of receipt of a clean claim sub- 14 mitted by a pharmacy, the PDP sponsor 15 (or an agent of the PDP sponsor) may not 16 retroactively reduce payment on such claim 17 directly or indirectly through aggregated 18 effective rate or otherwise except in the 19 case such claim is found to not be a clean 20 claim (such as in the case of a claim lack- 21 ing required substantiating documentation) 22 during the course of a routine audit as 23 permitted pursuant to written agreement 24 between the PDP sponsor (or such an 25 agent) and such pharmacy. The previous 26 VerDate Sep 11 2014 04:06 Feb 02, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H789.IH H789 kjohnson on DSK79L0C42 with BILLS 3 •HR 789 IH sentence shall not prohibit any retroactive 1 increase in payment to a pharmacy pursu- 2 ant to a written agreement between a PDP 3 sponsor (or an agent of such sponsor) and 4 such pharmacy.’’. 5 (b) EFFECTIVE DATE.—The amendment made by 6 subsection (a) shall apply with respect to contracts entered 7 into on or after January 1, 2020. 8 Æ VerDate Sep 11 2014 04:06 Feb 02, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6301 E:\BILLS\H789.IH H789 kjohnson on DSK79L0C42 with BILLS