Patient Shared Savings Act

II 116TH CONGRESS 1ST SESSION S. 3000 To amend title XVIII of the Social Security Act to allow PDP sponsors of prescription drug plans and Medicare Advantage organizations offering MA–PD plans to share with enrollees a portion of savings from switching to lower cost therapeutic alternative medications. IN THE SENATE OF THE UNITED STATES DECEMBER 9, 2019 Mr. CASSIDY (for himself and Ms. HASSAN) introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To amend title XVIII of the Social Security Act to allow PDP sponsors of prescription drug plans and Medicare Advantage organizations offering MA–PD plans to share with enrollees a portion of savings from switching to lower cost therapeutic alternative medications. 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 ‘‘Patient Shared Sav- 4 ings Act’’. 5 VerDate Sep 11 2014 04:18 Dec 12, 2019 Jkt 099200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\S3000.IS S3000 kjohnson on DSK79L0C42 with BILLS 2 •S 3000 IS SEC. 2. ALLOWING PRESCRIPTION DRUG PLANS AND MA– 1 PD PLANS TO SHARE WITH ENROLLEES A 2 PORTION OF SAVINGS FROM SWITCHING TO 3 LOWER COST THERAPEUTIC ALTERNATIVE 4 MEDICATIONS. 5 (a) IN GENERAL.—Section 1860D–4 of the Social 6 Security Act (42 U.S.C. 1395w–104) is amended— 7 (1) by redesignating subsection (m) (relating to 8 program integrity transparency measures), as added 9 by section 6063(c) of the Substance Use-Disorder 10 Prevention that Promotes Opioid Recovery and 11 Treatment for Patients and Communities Act (Pub- 12 lic Law 115–271), as subsection (n); and 13 (2) by adding at the end the following new sub- 14 section: 15 ‘‘(o) SHARING WITH ENROLLEES A PORTION OF 16 SAVINGS FROM SWITCHING TO A LOWER COST THERA- 17 PEUTIC ALTERNATIVE MEDICATION.— 18 ‘‘(1) IN GENERAL.—For plan years beginning 19 on or after January 1, 2021, a PDP sponsor of a 20 prescription drug plan may have a program under 21 which the PDP sponsor shares with an enrollee in 22 the plan a portion of savings to the PDP sponsor as 23 a result of the enrollee switching from a covered 24 part D drug the enrollee is taking on an ongoing 25 VerDate Sep 11 2014 04:18 Dec 12, 2019 Jkt 099200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S3000.IS S3000 kjohnson on DSK79L0C42 with BILLS 3 •S 3000 IS basis to a lower cost therapeutic alternative covered 1 part D drug. 2 ‘‘(2) REQUIREMENTS.—If a PDP sponsor im- 3 plements a program described in paragraph (1), the 4 following requirements shall apply with respect to 5 the program: 6 ‘‘(A) REQUIREMENTS WITH RESPECT TO 7 ENROLLEES.—The enrollee— 8 ‘‘(i) must have been taking the cov- 9 ered part D drug on an ongoing basis for 10 at least 2 months as confirmed by claims 11 analysis by the PDP sponsor prior to 12 switching to the lower cost therapeutic al- 13 ternative covered part D drug; and 14 ‘‘(ii) must have agreed to make such 15 switch after consulting with their physi- 16 cian. 17 ‘‘(B) REQUIREMENTS WITH RESPECT TO 18 PDP SPONSORS.—The PDP sponsor must— 19 ‘‘(i) make available a shared savings 20 report with therapeutic alternatives to eli- 21 gible enrollees through Evidence of Bene- 22 fits or other information sent to enrollees, 23 or provide contracted providers with access 24 to tools that include therapeutic alter- 25 VerDate Sep 11 2014 04:18 Dec 12, 2019 Jkt 099200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S3000.IS S3000 kjohnson on DSK79L0C42 with BILLS 4 •S 3000 IS natives and shared savings at the point of 1 care; 2 ‘‘(ii) ensure that the total amount of 3 savings shared with an enrollee with re- 4 spect to the switch to a particular lower 5 cost therapeutic alternative covered part D 6 drug does not exceed an amount equal to 7 10 percent of the annualized net savings to 8 the PDP sponsor as a result of the enrollee 9 making such switch; 10 ‘‘(iii) only share such savings after the 11 PDP sponsor confirms, based on claims 12 analysis, that— 13 ‘‘(I) the enrollee has switched to 14 the lower cost therapeutic alternative 15 covered part D drug; and 16 ‘‘(II) the switch does not result 17 in an increased cost to the program 18 under this part; 19 ‘‘(iv) provide a tangible reward or in- 20 centive for the amount of such shared sav- 21 ings, which— 22 ‘‘(I) shall directly benefit the en- 23 rollee; 24 ‘‘(II) such sponsor may not— 25 VerDate Sep 11 2014 04:18 Dec 12, 2019 Jkt 099200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S3000.IS S3000 kjohnson on DSK79L0C42 with BILLS 5 •S 3000 IS ‘‘(aa) use to reduce plan 1 premiums for the enrollee; or 2 ‘‘(bb) direct an enrollee to 3 use to pay such premiums; and 4 ‘‘(III) may be in the form of a 5 monetary rebate, gift card, discount 6 coupon, or other item consistent with 7 the President’s Executive Order on 8 Protecting and Improving Medicare 9 for Our Nation’s Seniors, issued on 10 October 3, 2019; and 11 ‘‘(v) provide an annual report to the 12 Secretary, with respect to the preceding 13 plan year, on the number of enrollees who 14 receive shared savings under this sub- 15 section as a result of switching to a lower 16 cost therapeutic alternative covered part D 17 drug, the total amount of such savings 18 shared with the enrollee and in what form, 19 and the total savings to the PDP sponsor 20 as a result of enrollees making such 21 switch. 22 ‘‘(3) AUTHORITY TO PROVIDE WITH RESPECT 23 TO CERTAIN SUB-POPULATIONS OR GEOGRAPHIC 24 AREAS.—A PDP sponsor may provide shared sav- 25 VerDate Sep 11 2014 04:18 Dec 12, 2019 Jkt 099200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S3000.IS S3000 kjohnson on DSK79L0C42 with BILLS 6 •S 3000 IS ings pursuant to this subsection for only a certain 1 sub-population of enrollees or a geographically lim- 2 ited population of enrollees if the Secretary deter- 3 mines, based on a showing by the PDP sponsor, that 4 the PDP sponsor is not discriminating based on the 5 health status of enrollees.’’. 6 (b) EXCLUSION FROM ANTI-KICKBACK PROHIBI- 7 TION.—Section 1128B(b)(3) of the Social Security Act 8 (42 U.S.C. 1320a–7b(b)(3)) is amended— 9 (1) in subparagraph (J)— 10 (A) by moving such subparagraph 2 ems to 11 the left; and 12 (B) by striking ‘‘and’’ at the end; 13 (2) in subparagraph (K)— 14 (A) by moving such subparagraph 2 ems to 15 the left; and 16 (B) by striking the period at the end and 17 inserting ‘‘; and’’; and 18 (3) by adding at the end the following new sub- 19 paragraph: 20 ‘‘(L) any shared savings provided under section 21 1860D–4(o).’’. 22 Æ VerDate Sep 11 2014 04:18 Dec 12, 2019 Jkt 099200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6301 E:\BILLS\S3000.IS S3000 kjohnson on DSK79L0C42 with BILLS