Ensuring Seniors Access to Local Pharmacies Act of 2019

I 116TH CONGRESS 1ST SESSION H. R. 4946 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. IN THE HOUSE OF REPRESENTATIVES OCTOBER 31, 2019 Mr. WELCH (for himself, Mr. GRIFFITH, Mr. LOEBSACK, Mr. CARTER of Georgia, Mr. GONZALEZ of Texas, Mr. CRAWFORD, Mr. WESTERMAN, Mr. DAVID P. ROE of Tennessee, Mrs. RODGERS of Washington, Mrs. AXNE, Mr. ALLEN, and Mr. PETERSON) 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 subse- quently 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 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 Representa- 1 tives of the United States of America in Congress assembled, 2 VerDate Sep 11 2014 02:32 Nov 08, 2019 Jkt 099200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H4946.IH H4946 pamtmann on DSKBC07HB2PROD with BILLS 2 •HR 4946 IH SECTION 1. SHORT TITLE. 1 This Act may be cited as the ‘‘Ensuring Seniors Ac- 2 cess to Local Pharmacies Act of 2019’’. 3 SEC. 2. ALLOWING ANY STATE LICENSED PHARMACY SERV- 4 ING AN UNDERSERVED AREA TO BECOME A 5 NETWORK PHARMACY UNDER MEDICARE 6 PRESCRIPTION DRUG COVERAGE. 7 (a) IN GENERAL.—Section 1860D–4(b)(1)(B) of the 8 Social Security Act (42 U.S.C. 1395w–104(b)(1)(B)) is 9 amended— 10 (1) by striking ‘‘DISCOUNTS ALLOWED FOR 11 NETWORK PHARMACIES.—For’’ and inserting the 12 following: ‘‘DISCOUNTS ALLOWED FOR NETWORK 13 PHARMACIES.— 14 ‘‘(i) IN GENERAL.—For’’; and 15 (2) by adding at the end the following new 16 clause: 17 ‘‘(ii) INCLUSION OF PHARMACIES LO- 18 CATED IN UNDERSERVED AREAS IN NET- 19 WORKS.—For plan years beginning on or 20 after January 1, 2020, in the case of a 21 prescription drug plan that has, in its net- 22 work of pharmacies, one or more phar- 23 macies located in a health professional 24 shortage area (as defined in section 25 332(a)(1)(A) of the Public Health Service 26 VerDate Sep 11 2014 02:32 Nov 08, 2019 Jkt 099200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H4946.IH H4946 pamtmann on DSKBC07HB2PROD with BILLS 3 •HR 4946 IH Act), in a medically underserved area (ac- 1 cording to a designation under section 2 330(b)(3)(A) of the Public Health Service 3 Act), among a medically underserved popu- 4 lation (as defined in such section 5 330(b)(3)(A) of such Act), or in a rural 6 area (as defined by the Federal Office of 7 Rural Health Policy), and that provides a 8 reduction in coinsurance or copayments de- 9 scribed in clause (i) for covered part D 10 drugs dispensed through such pharmacies, 11 such plan shall extend to any pharmacy lo- 12 cated in such area or among such popu- 13 lation the option to be an in-network phar- 14 macy with respect to such plan under 15 terms and conditions (including the reduc- 16 tions described in clause (i)) comparable to 17 those the plan has agreed upon with other 18 in-network pharmacies located in such area 19 or among such population.’’. 20 SEC. 3. REASONABLE REIMBURSEMENT REQUIREMENTS. 21 Section 1860D–2(d)(1)(B) of the Social Security Act 22 (42 U.S.C. 1395w–102(d)(1)(B)) is amended— 23 (1) by striking ‘‘PRICES.—For purposes’’ and 24 inserting ‘‘PRICES.— 25 VerDate Sep 11 2014 02:32 Nov 08, 2019 Jkt 099200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H4946.IH H4946 pamtmann on DSKBC07HB2PROD with BILLS 4 •HR 4946 IH ‘‘(i) IN GENERAL.—For purposes’’; 1 and 2 (2) by adding at the end the following new 3 clauses: 4 ‘‘(ii) REASONABLE REIMBURSE- 5 MENT.—For plan years beginning on or 6 after January 1, 2020, a PDP sponsor and 7 a Medicare Advantage organization shall 8 ensure that— 9 ‘‘(I) each prescription drug plan 10 or MA–PD plan offered by the spon- 11 sor or organization does not reimburse 12 a pharmacy or pharmacist an amount 13 less than the amount that the phar- 14 macy benefits manager reimburses a 15 pharmacy benefits manager affiliate 16 (as defined in clause (iv)) providing 17 the same pharmacist services; and 18 ‘‘(II) in no case may the nego- 19 tiated price for a covered part D drug 20 furnished by a pharmacy under a pre- 21 scription drug plan or MA–PD plan 22 offered by the sponsor or organiza- 23 tion, be less than such pharmacy’s 24 cost of purchasing and dispensing 25 VerDate Sep 11 2014 02:32 Nov 08, 2019 Jkt 099200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H4946.IH H4946 pamtmann on DSKBC07HB2PROD with BILLS 5 •HR 4946 IH such drug and providing such other 1 services associated with furnishing 2 such drug as may be specified by the 3 Secretary. 4 ‘‘(iii) CLAIM REIMBURSEMENT DIS- 5 CLOSURE REQUIREMENTS.—With respect 6 to payment made by a PDP sponsor or a 7 Medicare Advantage organization to a 8 pharmacy for a covered part D drug fur- 9 nished by such pharmacy during a plan 10 year beginning on or after January 1, 11 2020, such sponsor or organization shall 12 promptly furnish all pricing components 13 including the Network Reimbursement ID 14 used to price the claim, any fees, pharmacy 15 price concessions, discounts, subsidies, re- 16 bates, incentives, or any other forms of di- 17 rect or indirect remuneration that affect 18 payment and pricing of the claim as part 19 of the claim adjudication response at the 20 point-of sale. All pricing components de- 21 scribed in the preceding sentence shall 22 each be identified in a predetermined line 23 item in the remittance advice that is stand- 24 ard across the industry. The PDP sponsor 25 VerDate Sep 11 2014 02:32 Nov 08, 2019 Jkt 099200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H4946.IH H4946 pamtmann on DSKBC07HB2PROD with BILLS 6 •HR 4946 IH or Medicare Advantage organization shall 1 include suitable claim-level detail on the 2 electronic remittance advice that accom- 3 panies each payment. This claim-level de- 4 tail shall include, in an industry standard- 5 ized format, all fields needed to properly 6 identify the claim, including the Claim Au- 7 thorization Number, date of service, date 8 of payment remittance, ingredient cost re- 9 imbursed, dispensing fee reimbursed, pay- 10 ment amounts including the Network ID 11 used to price the claim, the specific dollar 12 amounts and the appropriate qualifier 13 codes for each payment adjustment includ- 14 ing fees, pharmacy price concessions, or in- 15 centives. 16 ‘‘(iv) PHARMACY BENEFITS MANAGER 17 AFFILIATE DEFINED.—For purposes of 18 clause (ii), the term ‘pharmacy benefits 19 manager affiliate’ means a pharmacy or 20 pharmacist that directly or indirectly, 21 through one or more intermediaries, owns 22 or controls, is owned or controlled by, or is 23 VerDate Sep 11 2014 02:32 Nov 08, 2019 Jkt 099200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H4946.IH H4946 pamtmann on DSKBC07HB2PROD with BILLS 7 •HR 4946 IH under common ownership or control with a 1 pharmacy benefits manager.’’. 2 Æ VerDate Sep 11 2014 02:32 Nov 08, 2019 Jkt 099200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6301 E:\BILLS\H4946.IH H4946 pamtmann on DSKBC07HB2PROD with BILLS