Access to Prescription Digital Therapeutics Act of 2023

To amend titles XVIII and XIX of the Social Security Act to provide for coverage of prescription digital therapeutics under such titles, and for other purposes. 1. Short title This Act may be cited as the Access to Prescription Digital Therapeutics Act of 2023 2. Coverage and payment of prescription digital therapeutics under the Medicare program (a) Prescription digital therapeutic defined Section 1861 of the Social Security Act ( 42 U.S.C. 1395x (nnn) Prescription digital therapeutic The term prescription digital therapeutic (1) is cleared or approved under section 510(k), 513(f)(2), or 515 of the Federal Food, Drug, and Cosmetic Act; (2) has a cleared or approved indication for the prevention, management, or treatment of a medical disease, condition, or disorder; (3) primarily uses software to achieve its intended result; and (4) is a device that is exempt from section 502(f)(1) of the Federal Food, Drug, and Cosmetic Act under section 801.109 of title 21 of the Code of Federal Regulations (or any successor regulation). . (b) Coverage as medical and other health service Section 1861(s)(2) of the Social Security Act ( 42 U.S.C. 1395x(s)(2) (1) in subparagraph (II), by striking and (2) in subparagraph (JJ), by adding and (3) by adding at the end the following new subparagraph: (KK) prescription digital therapeutics furnished on or after January 1, 2024; . (c) Requirements for prescription digital therapeutics under Medicare Part B of the Social Security Act ( 42 U.S.C. 1395j et seq. 1834B. Requirements for prescription digital therapeutics (a) Payment (1) In general Not later than 1 year after the date of enactment of this section, the Secretary shall establish a payment methodology for manufacturers of prescription digital therapeutics, which may consist of a one-time payment or periodic payments, as determined appropriate by the Secretary. (2) Considerations for payment methodology For purposes of establishing the payment methodology under paragraph (1), the Secretary shall consider— (A) the actual list charge of such prescription digital therapeutic; (B) the weighted median (calculated by arraying the distribution of all payment rates reported for the most recent period for which such rates were reported under subsection (c)(1) for each prescription digital therapeutic weighted by volume for each payor and each manufacturer) for such prescription digital therapeutic; (C) in the case of a prescription digital therapeutic that requires ongoing use, the amount for such ongoing use; and (D) other factors as determined by the Secretary. (b) Coding (1) In general Not later than 2 years after the date of enactment of this section, the Secretary shall establish product-specific HCPCS codes for prescription digital therapeutic covered under this title. (2) Temporary code The Secretary shall adopt temporary product-specific HCPCS codes for purposes of providing payment under this title until a permanent product-specific HCPCS code has been established under paragraph (1). (c) Manufacturer reporting (1) In general Beginning on January 1, 2024, each manufacturer of a prescription digital therapeutic covered under this title shall submit to the Secretary, at such time and in such manner as specified by the Secretary, and annually thereafter, a report describing— (A) the payment rate that was paid by each private payor for each prescription digital therapeutic during the period specified by the Secretary; (B) the volume of such prescription digital therapeutic distributed to each such payor for such period; and (C) the number of individual users of such prescription digital therapeutic for such period. (2) Treatment of discounts The payment rate reported by a manufacturer in accordance with paragraph (1)(A) shall reflect all discounts, rebates, coupons, and other price concessions, including those described in section 1847A(c)(3). (3) Civil monetary penalty (A) In general If the Secretary determines that a manufacturer has failed to report, or made a misrepresentation or omission in reporting, information under this subsection with respect to a prescription digital therapeutic, the Secretary may apply a civil money penalty in an amount of up to $10,000 per day for each failure to report or each such misrepresentation or omission. (B) Application The provisions of section 1128A (other than subsections (a) and (b)) shall apply to a civil money penalty under this paragraph in the same manner as they apply to a civil money penalty or proceeding under section 1128A(a). (4) Confidentiality Information reported under this subsection shall be treated in the same manner in which information disclosed by a manufacturer or a wholesaler of a covered outpatient drug is treated under section 1927(b)(3)(D). (d) Definitions For purposes of this section: (1) Actual list charge The term actual list charge (2) HCPCS The term HCPCS (3) Manufacturer The term manufacturer (4) Prescription digital therapeutic The term prescription digital therapeutic (5) Private payor The term private payor . 3. Coverage of prescription digital therapeutics under the Medicaid program (a) In general Section 1905(a) of the Social Security Act ( 42 U.S.C. 1396d(a) (1) in paragraph (30), by striking ; and (2) by redesignating paragraph (31) as paragraph (32); and (3) by inserting the following paragraph after paragraph (30): (31) prescription digital therapeutics (as defined in section 1861(nnn)); and . (b) Conforming amendments Effective the day after the amendments made by sections 5121 and 5122 of division FF of the Consolidated Appropriations Act, 2023 ( Public Law 117–328 (1) subsections (a)(84)(A) and (nn)(3) of section 1902 of the Social Security Act ( 42 U.S.C. 1396a paragraph (31) the last numbered paragraph (2) the fifth sentence of section 1905(a) of such Act ( 42 U.S.C. 1396d(a) paragraph (30) the last numbered paragraph

Summary: Access to Prescription Digital Therapeutics Act of 2023 This bill provides for Medicare and Medicaid coverage of prescription digital therapeutics (i.e., software applications that are used to prevent, manage, or treat medical conditions). The Centers for Medicare & Medicaid Services must establish a Medicare payment methodology for payments to manufacturers that takes into account certain factors (e.g., ongoing use); manufacturers must report specified information about private payors, subject to civil penalties.