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106TH CONGRESS

2D SESSION H. R. 5614

To amend part C of title XVIII of the Social Security Act to improve

the Medicare+Choice Program.

IN THE HOUSE OF REPRESENTATIVES

NOVEMBER 1, 2000

Mr. ACKERMAN introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on Commerce, for a period to be subsequently 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 part C of title XVIII of the Social Security Act

to improve the Medicare+Choice Program.

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 ‘‘Seniors’ Health Care

5 Restoration Act of 2000’’.

6 SEC. 2. INCREASED PAYMENT FOR AREAS WITH TWO OR

7 FEWER MEDICARE+CHOICE CONTRACTS.

8 Section 1853 of the Social Security Act (42 U.S.C.

9 1395w–23) is amended—
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1 (1) in subsection (a)(1)(A), by striking ‘‘and

2 (i)’’ and inserting ‘‘(i), and (j)’’; and

3 (2) by adding at the end the following new sub4 section:

5 ‘‘(j) INCREASED PAYMENT FOR AREAS WITH 2 OR

6 FEWER MEDICARE+CHOICE CONTRACTS.—For months

7 during 2002 and 2003, in the case of a Medicare+Choice

8 payment area in which there is no more than two contracts

9 entered into under this part as of July 1 before the begin10 ning of the year involved, the amount of the monthly pay11 ment otherwise made under this section (taking into ac12 count, if applicable, subsection (i)) shall be increased by

1 13 ⁄2 percentage point of the total monthly payment other14 wise computed for such payment area.’’.

15 SEC. 3. INCREASE IN MINIMUM PERCENTAGE UPDATE.

16 Section 1853(c)(1)(C)(ii) of the Social Security Act

17 (42 U.S.C. 1395w–23(c)(1)(C)(ii)) is amended by insert18 ing ‘‘(or 104 percent in the case of 2001, 2002, and

19 2003)’’ after ‘‘102 percent’’.

20 SEC. 4. TRANSITION TO REVISED MEDICARE+CHOICE PAY21 MENT RATES.

22 (a) ANNOUNCEMENT OF REVISED

23 MEDICARE+CHOICE PAYMENT RATES.—Within 2 weeks

24 after the date of the enactment of this Act, the Secretary

25 of Health and Human Services shall determine, and shall
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1 announce (in a manner intended to provide notice to inter2 ested parties) Medicare+Choice capitation rates under

3 section 1853 of the Social Security Act (42 U.S.C.

4 1395w–23) for 2001, revised in accordance with the provi5 sions of this Act.

6 (b) REENTRY INTO PROGRAM PERMITTED FOR

7 MEDICARE+CHOICE PROGRAMS IN 2000.—A

8 Medicare+Choice organization that provided notice to the

9 Secretary of Health and Human Services as of July 3,

10 2000, that it was terminating its contract under part C

11 of title XVIII of the Social Security Act or was reducing

12 the service area of a Medicare+Choice plan offered under

13 such part shall be permitted to continue participation

14 under such part, or to maintain the service area of such

15 plan, for 2001 if it provides the Secretary with the infor16 mation described in section 1854(a)(1) of the Social Secu17 rity Act (42 U.S.C. 1395w–24(a)(1)) within 4 weeks after

18 the date of the enactment of this Act.

19 (c) REVISED SUBMISSION OF PROPOSED PREMIUMS

20 AND RELATED INFORMATION.—If—

21 (1) a Medicare+Choice organization provided

22 notice to the Secretary of Health and Human Serv23 ices as of July 3, 2000, that it was renewing its con24 tract under part C of title XVIII of the Social Secu-
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1 rity Act for all or part of the service area or areas

2 served under its current contract, and

3 (2) any part of the service area or areas ad4 dressed in such notice includes a county for which

5 the Medicare+Choice capitation rate under section

6 1853(c) of such Act (42 U.S.C. 1395w–23(c)) for

7 2001, as determined under subsection (a), is higher

8 than the rate previously determined for such year,

9 such organization shall revise its submission of the infor10 mation described in section 1854(a)(1) of the Social Secu11 rity Act (42 U.S.C. 1395w–24(a)(1)), and shall submit

12 such revised information to the Secretary, within 4 weeks

13 after the date of the enactment of this Act.

14 SEC. 5. PROVISION OF EMERGENCY OUTPATIENT PRE15 SCRIPTION DRUG COVERAGE FOR MEDICARE

16 BENEFICIARIES LOSING DRUG COVERAGE

17 UNDER MEDICARE+CHOICE PLANS.

18 (a) TEMPORARY COVERAGE OF OUTPATIENT PRE19 SCRIPTION DRUGS FOR MEDICARE BENEFICIARIES LOS20 ING PRESCRIPTION DRUG COVERAGE UNDER

21 MEDICARE+CHOICE PLANS.—

22 (1) IN GENERAL.—The Secretary of Health and

23 Human Services shall provide for coverage of out24 patient prescription drugs to eligible medicare bene25 ficiaries under this section. The Secretary shall pro-
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1 vide for such coverage by entering into agreements

2 with eligible organizations to furnish such coverage.

3 (2) TERM OF EMERGENCY COVERAGE.—The

4 Secretary shall provide coverage of outpatient pre5 scription drugs to an eligible medicare beneficiary

6 under this section for the 24-month period beginning

7 on the date the eligible medicare beneficiary loses

8 coverage of outpatient prescription drugs under the

9 Medicare+Choice plan in which the beneficiary is

10 enrolled.

11 (3) COST-SHARING.—With respect to coverage

12 of outpatient prescription drugs furnished under this

13 section, benefits under this section shall not begin

14 until the eligible medicare beneficiary has met a $50

15 deductible.

16 (4) PAYMENT.—The Secretary shall provide for

17 payment for such coverage under this section from

18 the Emergency Reserve Outpatient Prescription

19 Drug Account established under subsection (b).

20 (b) ACCOUNT FOR EMERGENCY OUTPATIENT PRE21 SCRIPTION DRUG BENEFIT IN SMI TRUST FUND.—

22 (1) ESTABLISHMENT.—There is hereby estab23 lished in the Federal Supplementary Medical Insur24 ance Trust Fund under section 1841 of the Social

25 Security Act (42 U.S.C. 1395t) an expenditure ac-
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1 count to be known as the ‘‘Emergency Reserve Out2 patient Prescription Drug Account’’.

3 (2) CREDITING OF FUNDS.—The Managing

4 Trustee shall credit to the Emergency Reserve Out5 patient Prescription Drug Account such amounts as

6 may be deposited in the Federal Supplementary

7 Medical Insurance Trust Fund as follows:

8 (A) Amounts appropriated to the account.

9 (B) Amounts equal to the annual out10 standing balance of the Health Care Fraud and

11 Abuse Control Account under section 1817(k)

12 of the Social Security Act (42 U.S.C. 1395i(k))

13 at the end of each fiscal year that the Secretary

14 determines may be made available to the Emer15 gency Reserve Outpatient Prescription Drug

16 Account.

17 (3) USE OF FUNDS.—Funds credited to the

18 Outpatient Prescription Drug Account may only be

19 used to pay for outpatient prescription drugs (and

20 associated administrative costs) furnished under this

21 section.

22 (4) CONFORMING AMENDMENT.—Section

23 1817(k)(3)(C) of such Act (42 U.S.C.

24 1395i(k)(3)(C)) is amended—
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1 (A) by striking ‘‘and’’ at the end of clause

2 (iv);

3 (B) by striking the period at the end of

4 clause (v) and inserting ‘‘; and’’; and

5 (C) by adding at the end the following new

6 clause:

7 ‘‘(vi) providing temporary emergency

8 coverage of outpatient prescription drugs

9 for eligible beneficiaries under section 5 of

10 the Seniors’ Health Care Restoration Act

11 of 2000.’’.

12 (c) DEFINITIONS.—In this section:

13 (1) ELIGIBLE MEDICARE BENEFICIARY.—The

14 term ‘‘eligible medicare beneficiary’’ means an

15 individual—

16 (A) who is enrolled in a Medicare+Choice

17 plan under part C of title XVIII of the Social

18 Security Act; and

19 (B)(i) whose enrollment in such plan is

20 terminated or may not be renewed or whose

21 service area has been reduced for the next con22 tract year because the plan has been terminated

23 or will not be offered in such contract year; or

24 (ii) whose coverage of outpatient prescrip25 tion drugs under such plan has been termi-
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1 nated, significantly reduced, or no longer pro2 vides for the coverage of a particular outpatient

3 prescription drug required.

4 (2) COVERED OUTPATIENT DRUG.—

5 (A) IN GENERAL.—Except as provided in

6 subparagraph (B), the term ‘‘covered outpatient

7 drug’’ means any of the following products:

8 (i) A drug which may be dispensed

9 only upon prescription, and—

10 (I) which is approved for safety

11 and effectiveness as a prescription

12 drug under section 505 of the Federal

13 Food, Drug, and Cosmetic Act;

14 (II)(aa) which was commercially

15 used or sold in the United States be16 fore the date of enactment of the

17 Drug Amendments of 1962 or which

18 is identical, similar, or related (within

19 the meaning of section 310.6(b)(1) of

20 title 21 of the Code of Federal Regu21 lations) to such a drug, and (bb)

22 which has not been the subject of a

23 final determination by the Secretary

24 that it is a ‘‘new drug’’ (within the

25 meaning of section 201(p) of the Fed-
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1 eral Food, Drug, and Cosmetic Act)

2 or an action brought by the Secretary

3 under section 301, 302(a), or 304(a)

4 of such Act to enforce section 502(f)

5 or 505(a) of such Act; or

6 (III)(aa) which is described in

7 section 107(c)(3) of the Drug Amend8 ments of 1962 and for which the Sec9 retary has determined there is a com10 pelling justification for its medical

11 need, or is identical, similar, or re12 lated (within the meaning of section

13 310.6(b)(1) of title 21 of the Code of

14 Federal Regulations) to such a drug,

15 and (bb) for which the Secretary has

16 not issued a notice of an opportunity

17 for a hearing under section 505(e) of

18 the Federal Food, Drug, and Cos19 metic Act on a proposed order of the

20 Secretary to withdraw approval of an

21 application for such drug under such

22 section because the Secretary has de23 termined that the drug is less than ef24 fective for all conditions of use pre-
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1 scribed, recommended, or suggested in

2 its labeling.

3 (ii) A biological product which—

4 (I) may only be dispensed upon

5 prescription;

6 (II) is licensed under section 351

7 of the Public Health Service Act; and

8 (III) is produced at an establish9 ment licensed under such section to

10 produce such product.

11 (iii) Insulin approved under appro12 priate Federal law.

13 (iv) A prescribed drug or biological

14 product that would meet the requirements

15 of clause (i) or (ii) but that is available

16 over-the-counter in addition to being avail17 able upon prescription.

18 (B) EXCLUSION.—The term ‘‘covered out19 patient drug’’ does not include any product—

20 (i) except as provided in subparagraph

21 (A)(iv), which may be distributed to indi22 viduals without a prescription;

23 (ii) when furnished as part of, or as

24 incident to, a diagnostic service or any

25 other item or service for which payment
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1 may be made under title XVIII of the So2 cial Security Act; or

3 (iii) that is a therapeutically equiva4 lent replacement for a product described in

5 clause (i) or (ii), as determined by the Sec6 retary.

7 (3) ELIGIBLE ORGANIZATION.—The term ‘‘eligi8 ble organization’’ means any organization that the

9 Secretary determines to be appropriate, including—

10 (A) pharmaceutical benefit management

11 companies;

12 (B) wholesale and retail pharmacist deliv13 ery systems;

14 (C) insurers;

15 (D) other organizations; or

16 (E) any combination of the entities de17 scribed in subparagraphs (A) through (D).

18 (4) SECRETARY.—The term ‘‘Secretary’’ means

19 the Secretary of Health and Human Services.

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