Patient Shared Savings Act

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. 1. Short title This Act may be cited as the Patient Shared Savings Act 2. Allowing prescription drug plans and MA–PD plans to share with enrollees a portion of savings from switching to lower cost therapeutic alternative medications (a) In general Section 1860D–4 of the Social Security Act ( 42 U.S.C. 1395w–104 (1) by redesignating subsection (m) (relating to program integrity transparency measures), as added by section 6063(c) of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act ( Public Law 115–271 (2) by adding at the end the following new subsection: (o) Sharing with enrollees a portion of savings from switching to a lower cost therapeutic alternative medication (1) In general For plan years beginning on or after January 1, 2021, a PDP sponsor of a prescription drug plan may have a program under which the PDP sponsor shares with an enrollee in the plan a portion of savings to the PDP sponsor as a result of the enrollee switching from a covered part D drug the enrollee is taking on an ongoing basis to a lower cost therapeutic alternative covered part D drug. (2) Requirements If a PDP sponsor implements a program described in paragraph (1), the following requirements shall apply with respect to the program: (A) Requirements with respect to enrollees The enrollee— (i) must have been taking the covered part D drug on an ongoing basis for at least 2 months as confirmed by claims analysis by the PDP sponsor prior to switching to the lower cost therapeutic alternative covered part D drug; and (ii) must have agreed to make such switch after consulting with their physician. (B) Requirements with respect to PDP sponsors The PDP sponsor must— (i) make available a shared savings report with therapeutic alternatives to eligible enrollees through Evidence of Benefits or other information sent to enrollees, or provide contracted providers with access to tools that include therapeutic alternatives and shared savings at the point of care; (ii) ensure that the total amount of savings shared with an enrollee with respect to the switch to a particular lower cost therapeutic alternative covered part D drug does not exceed an amount equal to 10 percent of the annualized net savings to the PDP sponsor as a result of the enrollee making such switch; (iii) only share such savings after the PDP sponsor confirms, based on claims analysis, that— (I) the enrollee has switched to the lower cost therapeutic alternative covered part D drug; and (II) the switch does not result in an increased cost to the program under this part; (iv) provide a tangible reward or incentive for the amount of such shared savings, which— (I) shall directly benefit the enrollee; (II) such sponsor may not— (aa) use to reduce plan premiums for the enrollee; or (bb) direct an enrollee to use to pay such premiums; and (III) may be in the form of a monetary rebate, gift card, discount coupon, or other item consistent with the President’s Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors, issued on October 3, 2019; and (v) provide an annual report to the Secretary, with respect to the preceding plan year, on the number of enrollees who receive shared savings under this subsection as a result of switching to a lower cost therapeutic alternative covered part D drug, the total amount of such savings shared with the enrollee and in what form, and the total savings to the PDP sponsor as a result of enrollees making such switch. (3) Authority to provide with respect to certain sub-populations or geographic areas A PDP sponsor may provide shared savings pursuant to this subsection for only a certain sub-population of enrollees or a geographically limited population of enrollees if the Secretary determines, based on a showing by the PDP sponsor, that the PDP sponsor is not discriminating based on the health status of enrollees. . (b) Exclusion from anti-Kickback prohibition Section 1128B(b)(3) of the Social Security Act (42 U.S.C. 1320a–7b(b)(3)) is amended— (1) in subparagraph (J)— (A) by moving such subparagraph 2 ems to the left; and (B) by striking and (2) in subparagraph (K)— (A) by moving such subparagraph 2 ems to the left; and (B) by striking the period at the end and inserting ; and (3) by adding at the end the following new subparagraph: (L) any shared savings provided under section 1860D–4(o). .

Summary: Patient Shared Savings Act This bill allows a prescription drug plan (PDP) sponsor under the Medicare prescription drug benefit to share realized savings from an enrollee's switch to a lower-cost therapeutic alternative with the enrollee, in accordance with specified requirements. Among other requirements, the enrollee must have been taking the original prescription drug for at least two months and must have consulted with a physician before making the switch. PDP sponsors must share the savings in a tangible form that directly benefits the enrollee (e.g., a monetary rebate).