PACE Part D Choice Act of 2023

II 118TH CONGRESS 1ST SESSION S. 1703 To amend title XVIII of the Social Security Act to ensure Medicare-only PACE program enrollees have a choice of prescription drug plans under Medicare part D. IN THE SENATE OF THE UNITED STATES MAY 18, 2023 Mr. CARPER (for himself and Mr. CASSIDY) 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 ensure Medicare-only PACE program enrollees have a choice of prescription drug plans under Medicare part D. 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 ‘‘PACE Part D Choice 4 Act of 2023’’. 5 VerDate Sep 11 2014 03:56 Jun 09, 2023 Jkt 039200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\S1703.IS S1703 kjohnson on DSK79L0C42PROD with BILLS 2 •S 1703 IS SEC. 2. ENSURING MEDICARE-ONLY PACE PROGRAM EN- 1 ROLLEES HAVE A CHOICE OF PRESCRIPTION 2 DRUG PLANS UNDER MEDICARE PART D. 3 Section 1860D–21(f) of the Social Security Act (42 4 U.S.C. 1395w–131(f)) is amended— 5 (1) in paragraph (1), by striking ‘‘and (3)’’ and 6 inserting ‘‘(3), and (4)’’; and 7 (2) by adding at the end the following new 8 paragraph: 9 ‘‘(4) ENSURING CHOICE OF PRESCRIPTION 10 DRUG PLANS.— 11 ‘‘(A) IN GENERAL.—For plan years begin- 12 ning on or after January 1, 2025, subject to 13 the succeeding provisions of this paragraph, an 14 applicable PACE program enrollee may elect to 15 enroll in a qualified standalone prescription 16 drug plan, in accordance with rules established 17 by the Secretary pursuant to this paragraph, 18 while enrolled under a PACE program. 19 ‘‘(B) DEFINITION OF APPLICABLE PACE 20 PROGRAM ENROLLEE; QUALIFIED STANDALONE 21 PRESCRIPTION DRUG PLAN.—In this paragraph: 22 ‘‘(i) APPLICABLE PACE PROGRAM EN- 23 ROLLEE.—The term ‘applicable PACE pro- 24 gram enrollee’ means a part D eligible in- 25 dividual who— 26 VerDate Sep 11 2014 03:56 Jun 09, 2023 Jkt 039200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S1703.IS S1703 kjohnson on DSK79L0C42PROD with BILLS 3 •S 1703 IS ‘‘(I) is not entitled to medical as- 1 sistance under title XIX; and 2 ‘‘(II) is enrolled under a PACE 3 program offered by a PACE provider. 4 ‘‘(ii) QUALIFIED STANDALONE PRE- 5 SCRIPTION DRUG PLAN.—The term ‘quali- 6 fied standalone prescription drug plan’ 7 means, with respect to an applicable PACE 8 program enrollee, a prescription drug 9 plan— 10 ‘‘(I) that is not an MA–PD plan; 11 ‘‘(II) that is not operated by the 12 PACE program under which the indi- 13 vidual is enrolled; and 14 ‘‘(III) for which the Secretary de- 15 termines, with respect to the applica- 16 ble PACE program enrollees enrolled 17 in a PACE program offered by such 18 PACE provider, that— 19 ‘‘(aa) the estimated bene- 20 ficiary out-of-pocket costs (as de- 21 fined in clause (iii)) for the plan 22 year for qualified prescription 23 drug coverage under the plan is 24 equal to or less than the esti- 25 VerDate Sep 11 2014 03:56 Jun 09, 2023 Jkt 039200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S1703.IS S1703 kjohnson on DSK79L0C42PROD with BILLS 4 •S 1703 IS mated out-of-pocket costs for 1 such coverage under the prescrip- 2 tion drug plan offered by the 3 PACE program in which the ap- 4 plicable PACE program enrollee 5 is enrolled; and 6 ‘‘(bb) the estimated total 7 amount of Federal subsidies for 8 the plan year for qualified pre- 9 scription drug coverage under the 10 plan (which may be estimated 11 using data from the previous 12 plan year) is equal to or less than 13 the estimated subsidy amount for 14 such coverage under the prescrip- 15 tion drug plan offered by the 16 PACE program in which the ap- 17 plicable PACE program enrollee 18 is enrolled. 19 ‘‘(iii) OUT-OF-POCKET COSTS DE- 20 FINED.—In this paragraph, the term ‘out- 21 of-pocket costs’ includes premiums imposed 22 under a prescription drug plan and, in the 23 case of coverage under a qualified stand- 24 alone prescription drug plan, deductibles, 25 VerDate Sep 11 2014 03:56 Jun 09, 2023 Jkt 039200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S1703.IS S1703 kjohnson on DSK79L0C42PROD with BILLS 5 •S 1703 IS copayments, coinsurance, and other cost- 1 sharing. 2 ‘‘(C) OUT-OF-POCKET COSTS.—In the case 3 where an applicable PACE program enrollee 4 elects to enroll in a qualified standalone pre- 5 scription drug plan pursuant to this paragraph, 6 the individual shall be responsible for any out- 7 of-pocket costs imposed under the plan (includ- 8 ing costs for nonformulary drugs) after the ap- 9 plication of any subsidies under section 1860D– 10 14 for an applicable PACE program enrollee 11 who is a subsidy eligible individual (as defined 12 in section 1860D–14(a)(3)). 13 ‘‘(D) REQUIREMENTS FOR PACE PRO- 14 GRAMS.— 15 ‘‘(i) EDUCATING AND HELPING EN- 16 ROLL BENEFICIARIES INTO A PART D PLAN 17 OPTION.—A PACE program shall be re- 18 quired to provide— 19 ‘‘(I) information to all applicable 20 PACE program enrollees who are en- 21 rolled under the PACE program re- 22 garding the option to enroll in a quali- 23 fied standalone prescription drug plan 24 under this paragraph; and 25 VerDate Sep 11 2014 03:56 Jun 09, 2023 Jkt 039200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S1703.IS S1703 kjohnson on DSK79L0C42PROD with BILLS 6 •S 1703 IS ‘‘(II) upon request of an applica- 1 ble PACE program enrollee, coun- 2 seling and coordination to assist appli- 3 cable PACE program enrollees in 4 making decisions regarding the selec- 5 tion of qualified standalone prescrip- 6 tion drug plans available to them. 7 ‘‘(ii) MONITORING DRUG UTILIZATION, 8 ADHERENCE, AND SPEND.—A PACE pro- 9 gram shall be required to monitor drug 10 utilization, medication adherence, and drug 11 spending (through claims data shared pur- 12 suant to subparagraph (F) and otherwise) 13 throughout the year with respect to any 14 applicable PACE program enrollee who 15 elects to enroll in a qualified standalone 16 prescription drug plan under this para- 17 graph in order to coordinate with the PDP 18 sponsor of such plan regarding the drug 19 benefits offered by the plan, including 20 upon request of an applicable PACE pro- 21 gram enrollee the filing of any grievances 22 or appeals with the plan on behalf of the 23 applicable PACE program enrollee. 24 VerDate Sep 11 2014 03:56 Jun 09, 2023 Jkt 039200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S1703.IS S1703 kjohnson on DSK79L0C42PROD with BILLS 7 •S 1703 IS ‘‘(E) DISENROLLMENT.—An applicable 1 PACE program enrollee may disenroll from the 2 qualified standalone prescription drug plan 3 elected by such applicable PACE program en- 4 rollee under subparagraph (A) if the enrollee 5 changes medication during the plan year or can 6 demonstrate an unexpected increase in out-of- 7 pocket costs post enrollment. 8 ‘‘(F) CLAIMS SHARING.—In the case where 9 an applicable PACE program enrollee enrolls in 10 a qualified standalone prescription drug plan, 11 the PACE program in which the individual is 12 enrolled and the PDP sponsor of the qualified 13 standalone prescription drug plan shall share 14 claims data with each other with respect to the 15 applicable PACE program enrollee as needed to 16 support care management for the applicable 17 PACE program enrollee (including for purposes 18 of monitoring and coordination required under 19 subparagraph (D)(ii)) and for purposes of com- 20 prehensive risk adjustment under section 21 1894(d). Such data shall be shared without the 22 need for any formal or informal request of the 23 PACE program in which the individual is en- 24 rolled or the PDP sponsor of the qualified 25 VerDate Sep 11 2014 03:56 Jun 09, 2023 Jkt 039200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S1703.IS S1703 kjohnson on DSK79L0C42PROD with BILLS 8 •S 1703 IS standalone prescription drug plan in which the 1 applicable PACE program enrollee is enrolled. 2 ‘‘(G) RULE OF CONSTRUCTION.—The au- 3 thority established under this paragraph for an 4 applicable PACE program enrollee to elect to 5 enroll in a qualified standalone prescription 6 drug plan shall not be construed as permitting 7 an applicable PACE program enrollee to enroll 8 in a prescription drug plan that is not a quali- 9 fied standalone prescription drug plan. 10 ‘‘(H) RELATION TO PACE STATUTES.— 11 ‘‘(i) IN GENERAL.—The authority pro- 12 vided under this paragraph for an applica- 13 ble PACE program enrollee to elect to en- 14 roll in a qualified standalone prescription 15 drug plan shall apply notwithstanding sub- 16 section (a)(1)(B)(i) of section 1894 and 17 such other provisions of sections 1894 and 18 1934 as the Secretary determines may con- 19 flict with the authority provided for under 20 this paragraph, including subsections 21 (a)(2)(B), (b)(1)(A)(i), (b)(1)(C), 22 (f)(2)(B)(ii), and (f)(2)(B)(v) of such sec- 23 tions. 24 VerDate Sep 11 2014 03:56 Jun 09, 2023 Jkt 039200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S1703.IS S1703 kjohnson on DSK79L0C42PROD with BILLS 9 •S 1703 IS ‘‘(ii) CLARIFICATION ON PAYMENT 1 FOR PART D DRUG COVERAGE.—Insofar as 2 an applicable PACE program enrollee is 3 enrolled in a qualified standalone prescrip- 4 tion drug plan under this paragraph, the 5 PACE program shall not be entitled to 6 payment under section 1894(d) for the 7 provision of qualified prescription drug 8 coverage under such standalone prescrip- 9 tion drug plan with respect to such appli- 10 cable PACE program enrollee.’’. 11 Æ VerDate Sep 11 2014 03:56 Jun 09, 2023 Jkt 039200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6301 E:\BILLS\S1703.IS S1703 kjohnson on DSK79L0C42PROD with BILLS