I 

109TH CONGRESS 

2D SESSION H. R. 5182 

To amend title XVIII of the Social Security Act to require the sponsor 

of a prescription drug plan or an organization offering an MA–PD 

plan to promptly pay claims submitted under part D, and for other 

purposes. 

IN THE HOUSE OF REPRESENTATIVES 

APRIL 25, 2006 

Mr. JONES of North Carolina (for himself, Mr. BERRY, Mr. RANGEL, Mr. 

MORAN of Kansas, Mr. WEINER, Mr. MARSHALL, Mr. TAYLOR of Mississippi, Mr. JEFFERSON, Mr. ETHERIDGE, Mr. WICKER, Mr. ROSS, Mr. 

WEXLER, Mr. HOLDEN, Mr. DOYLE, Mr. MOORE of Kansas, Mr. BROWN

of Ohio, Mr. ABERCROMBIE, and Mr. ALLEN) 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 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 title XVIII of the Social Security Act to require 

the sponsor of a prescription drug plan or an organization offering an MA–PD plan to promptly pay claims 

submitted under part D, and for other purposes. 

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


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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Fair and Speedy 

3 Treatment (FAST) of Medicare Prescription Drug Claims 

4 Act of 2006’’. 

5 SEC. 2. PROMPT PAYMENT BY MEDICARE PRESCRIPTION 

6 DRUG PLANS AND MA–PD PLANS UNDER 

7 PART D. 

8 (a) APPLICATION TO PRESCRIPTION DRUG PLANS.— 

9 Section 1860D–12(b) of the Social Security Act (42 

10 U.S.C. 1395w–112 (b)) is amended by adding at the end 

11 the following new paragraph: 

12 ‘‘(4) PROMPT PAYMENT OF CLEAN CLAIMS.— 

13 ‘‘(A) PROMPT PAYMENT.—Each contract 

14 entered into with a PDP sponsor under this 

15 subsection with respect to a prescription drug 

16 plan offered by such sponsor shall provide that 

17 payment shall be issued, mailed, or otherwise 

18 transmitted with respect to all clean claims sub19 mitted under this part within the applicable 

20 number of calendar days after the date on 

21 which the claim is received. 

22 ‘‘(B) DEFINITIONS.—In this paragraph: 

23 ‘‘(i) CLEAN CLAIM.—The term ‘clean 

24 claim’ means a claim, with respect to a 

25 covered part D drug, that has no apparent 

26 defect or impropriety (including any lack 


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1 of any required substantiating documenta2 tion) or particular circumstance requiring 

3 special treatment that prevents timely pay4 ment from being made on the claim under 

5 this part. 

6 ‘‘(ii) APPLICABLE NUMBER OF CAL7 ENDAR DAYS.—The term ‘applicable num8 ber of calendar days’ means— 

9 ‘‘(I) with respect to claims sub10 mitted electronically, 14 calendar 

11 days; and 

12 ‘‘(II) with respect to claims sub13 mitted otherwise, 30 calendar days. 

14 ‘‘(C) INTEREST PAYMENT.—If payment is 

15 not issued, mailed, or otherwise transmitted 

16 within the applicable number of calendar days 

17 (as defined in subparagraph (B)) after a clean 

18 claim is received, interest shall be paid at a rate 

19 used for purposes of section 3902(a) of title 31, 

20 United States Code (relating to interest pen21 alties for failure to make prompt payments), for 

22 the period beginning on the day after the re23 quired payment date and ending on the date on 

24 which payment is made. 

25 ‘‘(D) PROCEDURES INVOLVING CLAIMS.— 


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1 ‘‘(i) CLAIMS DEEMED TO BE CLEAN

2 CLAIMS.— 

3 ‘‘(I) IN GENERAL.—A claim for a 

4 covered part D drug shall be deemed 

5 to be a clean claim for purposes of 

6 this paragraph if the PDP sponsor in7 volved does not provide a notification 

8 of deficiency to the claimant by the 

9 10th day that begins after the date on 

10 which the claim is submitted. 

11 ‘‘(II) NOTIFICATION OF DEFI12 CIENCY.—For purposes of subclause 

13 (II), the term ‘notification of defi14 ciency’ means a notification that 

15 specifies all defects or improprieties in 

16 the claim involved and that lists all 

17 additional information or documents 

18 necessary for the proper processing 

19 and payment of the claim. 

20 ‘‘(ii) PAYMENT OF CLEAN PORTIONS

21 OF CLAIMS.—A PDP sponsor shall, as ap22 propriate, pay any portion of a claim for a 

23 covered part D drug that would be a clean 

24 claim but for a defect or impropriety in a 


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1 separate portion of the claim in accordance 

2 with subparagraph (A). 

3 ‘‘(iii) OBLIGATION TO PAY.—A claim 

4 for a covered part D drug submitted to a 

5 PDP sponsor that is not paid or contested 

6 by the provider within the applicable num7 ber of calendar days (as defined in sub8 paragraph (B)) shall be deemed to be a 

9 clean claim and shall be paid by the PDP 

10 sponsor in accordance with subparagraph 

11 (A). 

12 ‘‘(iv) DATE OF PAYMENT OF CLAIM.— 

13 Payment of a clean claim under subpara14 graph (A) is considered to have been made 

15 on the date on which full payment is re16 ceived by the provider. 

17 ‘‘(E) ELECTRONIC TRANSFER OF

18 FUNDS.—A PDP sponsor shall pay all clean 

19 claims submitted electronically by an electronic 

20 funds transfer mechanism.’’. 

21 (b) APPLICATION TO MA–PD PLANS.—Section 

22 1857(f) of such Act (42 U.S.C. 1395w–27) is amended 

23 by adding at the end the following new paragraph: 

24 ‘‘(3) INCORPORATION OF CERTAIN PRESCRIP25 TION DRUG PLAN CONTRACT REQUIREMENTS.—The 


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1 provisions of section 1860D–12(b)(4) shall apply to 

2 contracts with a Medicare Advantage organization in 

3 the same manner as they apply to contracts with a 

4 PDP sponsor offering a prescription drug plan 

5 under part D.’’. 

6 (c) EFFECTIVE DATE.—The amendments made by 

7 this section shall apply to contracts entered into or re8 newed on or after the date of the enactment of this Act. 

9 SEC. 3. RESTRICTION ON CO-BRANDING. 

10 (a) IN GENERAL.—Section 1860D–4(b)(2)(A) of the 

11 Social Security Act (42 U.S.C. 1395w–104(b)(2)(A)) is 

12 amended by adding at the end the following new sen13 tences: ‘‘It is unlawful for a PDP sponsor of a prescription 

14 drug plan to display on such a card the name, brand, or 

15 trademark of any pharmacy.’’ 

16 (b) EFFECTIVE DATE.—With respect to cards dis17 pensed before, on, or after the date of the enactment of 

18 this Act, the amendment made by this section shall apply 

19 to such cards on and after the date that is 90 days after 

20 such date of enactment. Any card dispensed before such 

21 date that is 90 days after the date of enactment that vio22 lates the second sentence of section 1860D–4(b)(2)(A) of 

23 the Social Security Act, as added by subsection (a), shall 

24 be reissued by such 90-day date. 


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1 SEC. 4. MINIMUM DISPENSING FEES FOR GENERIC COV2 ERED PART D DRUGS. 

3 (a) IN GENERAL.—Section 1860D–4(b)(1) of the So4 cial Security Act (42 U.S.C. 1395w–104(b)(1)) is amend5 ed by adding at the end the following new subparagraph: 

6 ‘‘(F) MINIMUM DISPENSING FEES FOR GE7 NERIC COVERED PART D DRUGS.— 

8 ‘‘(i) IN GENERAL.—Each PDP spon9 sor under this subsection with respect to a 

10 prescription drug plan offered by such 

11 sponsor shall provide that the amount of a 

12 dispensing fee paid to a participating phar13 macy for a generic covered part D drug 

14 that is therapeutically equivalent and bio15 equivalent to a brand name drug that is a 

16 covered part D drug dispensed through the 

17 pharmacy, shall be an amount that is not 

18 less than the minimum generic drug dis19 pensing fee specified under clause (ii). 

20 ‘‘(ii) MINIMUM GENERIC DRUG DIS21 PENSING FEE SPECIFIED.—The minimum 

22 generic drug dispensing fee specified under 

23 this clause for generic covered part D 

24 drugs dispensed— 

25 ‘‘(I) in calendar year 2006, is 

26 $14; and 


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1 ‘‘(II) in subsequent calendar 

2 years, is the minimum generic drug 

3 dispensing fee under this clause for 

4 the previous year increased by the an5 nual percentage increase in the con6 sumer price index (all items; U.S. city 

7 average) as of July of such previous 

8 year. 

9 Any amount established under subclause 

10 (II), that is based on an increase of $1 or 

11 $3, that is not a multiple of 5 cents or 10 

12 cents, respectively, shall be rounded to the 

13 nearest multiple of 5 cents or 10 cents, re14 spectively.’’. 

15 (b) EFFECTIVE DATE.—The amendment made by 

16 subsection (a) shall apply to prescriptions filled on or after 

17 the date that is the first day of the first contract year 

18 after the date of the enactment of this Act. 

19 SEC. 5. PROVISION OF MEDICATION THERAPY MANAGE20 MENT SERVICES UNDER PART D. 

21 (a) PROVISION OF MEDICATION THERAPY MANAGE22 MENT SERVICES UNDER PART D.— 

23 (1) IN GENERAL.—Section 1860D–4(c)(2) of 

24 the Social Security Act (42 U.S.C.1395w–104(c)(2)) 

25 is amended— 


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1 (A) in subparagraph (A)— 

2 (i) in clause (i)— 

3 (I) by inserting ‘‘or other health 

4 care provider with advanced training 

5 in medication management’’ after 

6 ‘‘furnished by a pharmacist’’; and 

7 (II) by striking ‘‘targeted bene8 ficiaries described in clause (ii)’’ and 

9 inserting ‘‘targeted beneficiaries speci10 fied under clause (ii)’’ 

11 (ii) by striking clause (ii) and insert12 ing the following: 

13 ‘‘(ii) TARGETED BENEFICIARIES.— 

14 The Secretary shall specify the population 

15 of part D eligible individuals appropriate 

16 for services under a medication therapy 

17 management program based on the fol18 lowing characteristics: 

19 ‘‘(I) Having a disease state in 

20 which evidence-based medicine has 

21 demonstrated the benefit of medica22 tion therapy management intervention 

23 based on objective outcome measures. 

24 ‘‘(II) Taking multiple covered 

25 part D drugs or having a disease state 


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1 in which a complex combination medi2 cation regimen is utilized. 

3 ‘‘(III) Being identified as likely 

4 to incur annual costs for covered part 

5 D drugs that exceed a level specified 

6 by the Secretary or where acute or 

7 chronic decompensation of disease 

8 would likely increase expenditures 

9 under the Federal Hospital Insurance 

10 Trust Fund or the Federal Supple11 mentary Medical Insurance Trust 

12 Fund under sections 1817 and 1841, 

13 respectively, such as through the re14 quirement of emergency care or acute 

15 hospitalization.’’; 

16 (B) by striking subparagraph (B) and in17 serting the following: 

18 ‘‘(B) ELEMENTS.— 

19 ‘‘(i) MINIMUM DEFINED PACKAGE OF

20 SERVICES.—The Secretary shall specify a 

21 minimum defined package of medication 

22 therapy management services that shall be 

23 provided to each enrollee. Such package 

24 shall be based on the following consider25 ations: 


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1 ‘‘(I) Performing necessary assess2 ments of the health status of each en3 rollee. 

4 ‘‘(II) Providing medication ther5 apy review to identify, resolve, and 

6 prevent medication-related problems, 

7 including adverse events. 

8 ‘‘(III) Increasing enrollee under9 standing to promote the appropriate 

10 use of medications by enrollees and to 

11 reduce the risk of potential adverse 

12 events associated with medications, 

13 through beneficiary and family edu14 cation, counseling, and other appro15 priate means. 

16 ‘‘(IV) Increasing enrollee adher17 ence with prescription medication 

18 regimens through medication refill re19 minders, special packaging, and other 

20 compliance programs and other appro21 priate means. 

22 ‘‘(V) Promoting detection of ad23 verse drug events and patterns of 

24 overuse and underuse of prescription 

25 drugs. 


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1 ‘‘(VI) Developing a medication 

2 action plan which may alter the medi3 cation regimen, when permitted by the 

4 State licensing authority. This infor5 mation should be provided to, or ac6 cessible by, the primary health care 

7 provider of the enrollee. 

8 ‘‘(VII) Monitoring and evaluating 

9 the response to therapy and evalu10 ating the safety and effectiveness of 

11 the therapy, which may include lab12 oratory assessment. 

13 ‘‘(VIII) Providing disease-specific 

14 medication therapy management serv15 ices when appropriate. 

16 ‘‘(IX) Coordinating and inte17 grating medication therapy manage18 ment services within the broader scope 

19 of health care management services 

20 being provided to each enrollee. 

21 ‘‘(ii) DELIVERY OF SERVICES.— 

22 ‘‘(I) PERSONAL DELIVERY.—To 

23 the extent feasible, face-to-face inter24 action shall be the preferred method 


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1 of delivery of medication therapy man2 agement services. 

3 ‘‘(II) INDIVIDUALIZED.—Such 

4 services shall be patient-specific and 

5 individualized and shall be provided 

6 directly to the patient by a pharmacist 

7 or other health care provider with ad8 vanced training in medication man9 agement. 

10 ‘‘(III) DISTINCT FROM OTHER

11 ACTIVITIES.—Such services shall be 

12 distinct from any activities related to 

13 formulary development and use, gen14 eralized patient education and infor15 mation activities, and any population16 focused quality assurance measures 

17 for medication use. 

18 ‘‘(iii) OPPORTUNITY TO IDENTIFY PA19 TIENTS IN NEED OF MEDICATION THERAPY

20 MANAGEMENT SERVICES.—The program 

21 shall provide opportunities for health care 

22 providers to identify patients who should 

23 receive medication therapy management 

24 services.’’; 


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1 (C) by striking subparagraph (E) and in2 serting the following: 

3 ‘‘(E) PHARMACY FEES.— 

4 ‘‘(i) IN GENERAL.—The PDP sponsor 

5 of a prescription drug plan shall pay phar6 macists and others providing services 

7 under the medication therapy management 

8 program under this paragraph based on 

9 the time and intensity of services provided 

10 to enrollees. 

11 ‘‘(ii) SUBMISSION ALONG WITH PLAN

12 INFORMATION.—Each such sponsor shall 

13 disclose to the Secretary upon request the 

14 amount of any such payments and shall 

15 submit a description of how such payments 

16 are calculated along with the information 

17 submitted under section 1860D–11(b). 

18 Such description shall be submitted at the 

19 same time and in a similar manner to the 

20 manner in which the information described 

21 in paragraph (2) of such section is sub22 mitted.’’; and 

23 (D) by adding at the end the following new 

24 subparagraph: 


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1 ‘‘(F) PHARMACY ACCESS REQUIRE2 MENTS.—The PDP sponsor of a prescription 

3 drug plan shall secure the participation in its 

4 network of a sufficient number of retail phar5 macies to assure that enrollees have the option 

6 of obtaining services under the medication ther7 apy management program under this paragraph 

8 directly from community-based retail phar9 macies.’’. 

10 (2) EFFECTIVE DATE.—The amendments made 

11 by this subsection shall apply to medication therapy 

12 management services provided on or after January 

13 1, 2008. 

14 (b) MEDICATION THERAPY MANAGEMENT DEM15 ONSTRATION PROGRAM.—Section 1860D–4(c) of the So16 cial Security Act (42 U.S.C.1395w–104(c)) is amended by 

17 adding at the end the following new paragraph: 

18 ‘‘(3) COMMUNITY-BASED MEDICATION THERAPY

19 MANAGEMENT DEMONSTRATION PROGRAM.— 

20 ‘‘(A) ESTABLISHMENT.— 

21 ‘‘(i) IN GENERAL.—By not later than 

22 January 1, 2008, the Secretary shall es23 tablish a 2-year demonstration program, 

24 based on the recommendations of the Best 

25 Practices Commission established under 


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1 subparagraph (B), with both PDP spon2 sors of prescription drug plans and Medi3 care Advantage Organizations offering 

4 MA–PD plans, to examine the impact of 

5 medication therapy management furnished 

6 by a pharmacist in a community-based or 

7 ambulatory-based setting on quality of 

8 care, spending under this part, and patient 

9 health. 

10 ‘‘(ii) SITES.— 

11 ‘‘(I) IN GENERAL.—Subject to 

12 subclause (II), the Secretary shall 

13 designate not less than 10 PDP spon14 sors of prescription drug plans or 

15 Medicare Advantage organizations of16 fering MA–PD plans, none of which 

17 provide prescription drug coverage 

18 under such plans in the same PDP or 

19 MA region, respectively, to conduct 

20 the demonstration program under this 

21 paragraph. 

22 ‘‘(II) DESIGNATION CONSISTENT

23 WITH RECOMMENDATIONS OF BEST

24 PRACTICES COMMISSION.—The Sec25 retary shall ensure that the designaVerDate Aug 31 2005 00:36 May 02, 2006 Jkt 049200 PO 00000 Frm 00016 Fmt 6652 Sfmt 6201 E:\BILLS\H5182.IH H5182

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1 tion of sites under subclause (I) is 

2 consistent with the recommendations 

3 of the Best Practices Commission 

4 under subparagraph (B)(ii). 

5 ‘‘(B) BEST PRACTICES COMMISSION.— 

6 ‘‘(i) ESTABLISHMENT.—The Secretary 

7 shall establish a Best Practices Commis8 sion composed of representatives from 

9 pharmacy organizations, health care orga10 nizations, beneficiary advocates, chronic 

11 disease groups, and other stakeholders (as 

12 determined appropriate by the Secretary) 

13 for the purpose of developing a best prac14 tices model for medication therapy man15 agement. 

16 ‘‘(ii) RECOMMENDATIONS.—The Com17 mission shall submit to the Secretary rec18 ommendations on the following: 

19 ‘‘(I) The minimum number of en20 rollees that should be included in the 

21 demonstration program, and at each 

22 demonstration program site, to deter23 mine the impact of medication ther24 apy management furnished by a phar25 macist in a community-based setting 


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1 on quality of care, spending under 

2 this part, and patient health. 

3 ‘‘(II) The number of urban and 

4 rural sites that should be included in 

5 the demonstration program to ensure 

6 that prescription drug plans and MA– 

7 PD plans offered in urban and rural 

8 areas are adequately represented. 

9 ‘‘(III) A best practices model for 

10 medication therapy management to be 

11 implemented under the demonstration 

12 program under this paragraph. 

13 ‘‘(C) REPORTS.— 

14 ‘‘(i) INTERIM REPORT.—Not later 

15 than 1 year after the commencement of the 

16 demonstration program, the Secretary 

17 shall submit to Congress an interim report 

18 on such program. 

19 ‘‘(ii) FINAL REPORT.—Not later than 

20 6 months after the completion of the dem21 onstration program, the Secretary shall 

22 submit to Congress a final report on such 

23 program, together with recommendations 

24 for such legislation and administrative acVerDate Aug 31 2005 00:36 May 02, 2006 Jkt 049200 PO 00000 Frm 00018 Fmt 6652 Sfmt 6201 E:\BILLS\H5182.IH H5182

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1 tion as the Secretary determines appro2 priate. 

3 ‘‘(D) WAIVER AUTHORITY.—The Secretary 

4 may waive such requirements of titles XI and 

5 XVIII as may be necessary for the purpose of 

6 carrying out the demonstration program under 

7 this paragraph.’’. 

Æ 


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