II 

117TH CONGRESS 

2D SESSION S. 5106 

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 

NOVEMBER 16, 2022 

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. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘PACE Part D Choice 

5 Act of 2022’’. 


kjohnson on DSK79L0C42PROD with BILLS
2 

•S 5106 IS

1 SEC. 2. ENSURING MEDICARE-ONLY PACE PROGRAM EN2 ROLLEES HAVE A CHOICE OF PRESCRIPTION 

3 DRUG PLANS UNDER MEDICARE PART D. 

4 Section 1860D–21(f) of the Social Security Act (42 

5 U.S.C. 1395w–131(f)) is amended— 

6 (1) in paragraph (1), by striking ‘‘and (3)’’ and 

7 inserting ‘‘(3), and (4)’’; and 

8 (2) by adding at the end the following new 

9 paragraph: 

10 ‘‘(4) ENSURING CHOICE OF PRESCRIPTION

11 DRUG PLANS.— 

12 ‘‘(A) IN GENERAL.—For plan years begin13 ning on or after January 1, 2023, subject to 

14 the succeeding provisions of this paragraph, an 

15 applicable PACE program enrollee may elect to 

16 enroll in a qualified standalone prescription 

17 drug plan, in accordance with rules established 

18 by the Secretary pursuant to this paragraph, 

19 while enrolled under a PACE program. 

20 ‘‘(B) DEFINITION OF APPLICABLE PACE

21 PROGRAM ENROLLEE; QUALIFIED STANDALONE

22 PRESCRIPTION DRUG PLAN.—In this paragraph: 

23 ‘‘(i) APPLICABLE PACE PROGRAM EN24 ROLLEE.—The term ‘applicable PACE pro25 gram enrollee’ means a part D eligible in26 dividual who— 


kjohnson on DSK79L0C42PROD with BILLS
3 

•S 5106 IS

1 ‘‘(I) is not entitled to medical as2 sistance under title XIX; and 

3 ‘‘(II) is enrolled under a PACE 

4 program offered by a PACE provider. 

5 ‘‘(ii) QUALIFIED STANDALONE PRE6 SCRIPTION DRUG PLAN.—The term ‘quali7 fied standalone prescription drug plan’ 

8 means, with respect to an applicable PACE 

9 program enrollee, a prescription drug 

10 plan— 

11 ‘‘(I) that is not an MA–PD plan; 

12 ‘‘(II) that is not operated by the 

13 PACE program under which the indi14 vidual is enrolled; and 

15 ‘‘(III) for which the Secretary de16 termines, with respect to the applica17 ble PACE program enrollees enrolled 

18 in a PACE program offered by such 

19 PACE provider, that— 

20 ‘‘(aa) the estimated bene21 ficiary out-of-pocket costs (as de22 fined in clause (iii)) for the plan 

23 year for qualified prescription 

24 drug coverage under the plan is 

25 equal to or less than the estiVerDate Sep 11 2014 02:08 Nov 18, 2022 Jkt 039200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S5106.IS S5106

kjohnson on DSK79L0C42PROD with BILLS
4 

•S 5106 IS

1 mated out-of-pocket costs for 

2 such coverage under the prescrip3 tion drug plan offered by the 

4 PACE program in which the ap5 plicable PACE program enrollee 

6 is enrolled; and 

7 ‘‘(bb) the estimated total 

8 amount of Federal subsidies for 

9 the plan year for qualified pre10 scription drug coverage under the 

11 plan (which may be estimated 

12 using data from the previous 

13 plan year) is equal to or less than 

14 the estimated subsidy amount for 

15 such coverage under the prescrip16 tion drug plan offered by the 

17 PACE program in which the ap18 plicable PACE program enrollee 

19 is enrolled. 

20 ‘‘(iii) OUT-OF-POCKET COSTS DE21 FINED.—In this paragraph, the term ‘out22 of-pocket costs’ includes premiums imposed 

23 under a prescription drug plan and, in the 

24 case of coverage under a qualified stand25 alone prescription drug plan, deductibles, 


kjohnson on DSK79L0C42PROD with BILLS
5 

•S 5106 IS

1 copayments, coinsurance, and other cost2 sharing. 

3 ‘‘(C) OUT-OF-POCKET COSTS.—In the case 

4 where an applicable PACE program enrollee 

5 elects to enroll in a qualified standalone pre6 scription drug plan pursuant to this paragraph, 

7 the individual shall be responsible for any out8 of-pocket costs imposed under the plan (includ9 ing costs for nonformulary drugs) after the ap10 plication of any subsidies under section 1860D– 

11 14 for an applicable PACE program enrollee 

12 who is a subsidy eligible individual (as defined 

13 in section 1860D–14(a)(3)). 

14 ‘‘(D) REQUIREMENTS FOR PACE PRO15 GRAMS.— 

16 ‘‘(i) EDUCATING AND HELPING EN17 ROLL BENEFICIARIES INTO A PART D PLAN

18 OPTION.—A PACE program shall be re19 quired to provide— 

20 ‘‘(I) information to all applicable 

21 PACE program enrollees who are en22 rolled under the PACE program re23 garding the option to enroll in a quali24 fied standalone prescription drug plan 

25 under this paragraph; and 


kjohnson on DSK79L0C42PROD with BILLS
6 

•S 5106 IS

1 ‘‘(II) upon request of an applica2 ble PACE program enrollee, coun3 seling and coordination to assist appli4 cable PACE program enrollees in 

5 making decisions regarding the selec6 tion of qualified standalone prescrip7 tion drug plans available to them. 

8 ‘‘(ii) MONITORING DRUG UTILIZATION, 

9 ADHERENCE, AND SPEND.—A PACE pro10 gram shall be required to monitor drug 

11 utilization, medication adherence, and drug 

12 spending (through claims data shared pur13 suant to subparagraph (F) and otherwise) 

14 throughout the year with respect to any 

15 applicable PACE program enrollee who 

16 elects to enroll in a qualified standalone 

17 prescription drug plan under this para18 graph in order to coordinate with the PDP 

19 sponsor of such plan regarding the drug 

20 benefits offered by the plan, including 

21 upon request of an applicable PACE pro22 gram enrollee the filing of any grievances 

23 or appeals with the plan on behalf of the 

24 applicable PACE program enrollee. 


kjohnson on DSK79L0C42PROD with BILLS
7 

•S 5106 IS

1 ‘‘(E) DISENROLLMENT.—An applicable 

2 PACE program enrollee may disenroll from the 

3 qualified standalone prescription drug plan 

4 elected by such applicable PACE program en5 rollee under subparagraph (A) if the enrollee 

6 changes medication during the plan year or can 

7 demonstrate an unexpected increase in out-of8 pocket costs post enrollment. 

9 ‘‘(F) CLAIMS SHARING.—In the case where 

10 an applicable PACE program enrollee enrolls in 

11 a qualified standalone prescription drug plan, 

12 the PACE program in which the individual is 

13 enrolled and the PDP sponsor of the qualified 

14 standalone prescription drug plan shall share 

15 claims data with each other with respect to the 

16 applicable PACE program enrollee as needed to 

17 support care management for the applicable 

18 PACE program enrollee (including for purposes 

19 of monitoring and coordination required under 

20 subparagraph (D)(ii)) and for purposes of com21 prehensive risk adjustment under section 

22 1894(d). Such data shall be shared without the 

23 need for any formal or informal request of the 

24 PACE program in which the individual is en25 rolled or the PDP sponsor of the qualified 


kjohnson on DSK79L0C42PROD with BILLS
8 

•S 5106 IS

1 standalone prescription drug plan in which the 

2 applicable PACE program enrollee is enrolled. 

3 ‘‘(G) RULE OF CONSTRUCTION.—The au4 thority established under this paragraph for an 

5 applicable PACE program enrollee to elect to 

6 enroll in a qualified standalone prescription 

7 drug plan shall not be construed as permitting 

8 an applicable PACE program enrollee to enroll 

9 in a prescription drug plan that is not a quali10 fied standalone prescription drug plan. 

11 ‘‘(H) RELATION TO PACE STATUTES.— 

12 ‘‘(i) IN GENERAL.—The authority pro13 vided under this paragraph for an applica14 ble PACE program enrollee to elect to en15 roll in a qualified standalone prescription 

16 drug plan shall apply notwithstanding sub17 section (a)(1)(B)(1) of section 1894 and 

18 such other provisions of sections 1894 and 

19 1934 as the Secretary determines may con20 flict with the authority provided for under 

21 this paragraph, including subsections 

22 (a)(2)(B), (b)(1)(A)(i), (b)(1)(C), 

23 (f)(2)(B)(ii), and (f)(2)(B)(v) of such sec24 tions. 


kjohnson on DSK79L0C42PROD with BILLS
9 

•S 5106 IS

1 ‘‘(ii) CLARIFICATION ON PAYMENT

2 FOR PART D DRUG COVERAGE.—Insofar as 

3 an applicable PACE program enrollee is 

4 enrolled in a qualified standalone prescrip5 tion drug plan under this paragraph, the 

6 PACE program shall not be entitled to 

7 payment under section 1894(d) for the 

8 provision of qualified prescription drug 

9 coverage under such standalone prescrip10 tion drug plan with respect to such appli11 cable PACE program enrollee.’’. 

Æ 


kjohnson on DSK79L0C42PROD with BILLS