I
107TH CONGRESS
2D SESSION
H. R. 5539
To amend title XVIII of the Social Security Act to provide for coverage
of medication therapy management services, including disease specific
management services, for certain high-risk patients under the Medicare
Program.
IN THE HOUSE OF REPRESENTATIVES
OCTOBER 2, 2002
Mr. PICKERING introduced the following bill; which was referred to the Com-
mittee 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 provide
for coverage of medication therapy management services,
including disease specific management services, for cer-
tain high-risk patients under the Medicare Program.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; PURPOSE.
(a) SHORT TITLE.—This Act may be cited as the
‘‘Medicare Medication Therapy Management Services Cov-
erage Act of 2002’’.
(b) PURPOSE.—The purpose of this Act is to provide
coverage of medication therapy management services
under the medicare program for beneficiaries at risk for
potential medication problems, such as beneficiaries tak-
ing multiple medications and beneficiaries with complex
or chronic medical conditions.
SEC. 2. MEDICARE COVERAGE OF MEDICATION THERAPY
MANAGEMENT 
SERVICES 
FOR 
CERTAIN
HIGH-RISK PATIENTS.
(a) IN GENERAL.—Section 1861 of the Social Secu-
rity Act (42 U.S.C. 1395x) is amended—
(1) in subsection (s)(2)—
(A) by striking ‘‘and’’ at the end of sub-
paragraph (U);
(B) by adding ‘‘and’’ at the end of sub-
paragraph (V); and
(C) by adding at the end the following new
subparagraph:
‘‘(W) medication therapy management services
(as defined in subsection (ww)(1)(A)) for individuals
who are receiving medication for a condition and are
otherwise determined to be at high risk (as defined
by the Secretary), and including disease specific
management services for individuals who are receiv-
ing medication for the treatment of asthma or diabe-
tes, lipid reducing medication, anti-coagulation medi-
cation, or medication for such other chronic diseases
as the Secretary may specify;’’;
(2) by adding at the end the following new sub-
section:
‘‘Medication Therapy Management Services; Qualified
Pharmacist
‘‘(ww)(1)(A) The term ‘medication therapy manage-
ment services’ means—
‘‘(i) services or programs furnished by a quali-
fied pharmacist in an eligible State which are
designed—
‘‘(I) to assure that medications are used
appropriately by individuals;
‘‘(II) to enhance individuals’ understanding
of the appropriate use of medications;
‘‘(III) to increase individuals’ compliance
with prescription medication regimens;
‘‘(IV) to reduce the risk of potential ad-
verse events associated with medications; and
‘‘(V) to reduce the need for other costly
medical services through better management of
medication therapy; and
‘‘(ii) services provided by qualified pharmacists
in collaboration with physicians and other health
care professionals when necessary, involving case
management, disease management, patient training
and education, medication refill reminders, medica-
tion therapy problem resolution, laboratory testing
conducted to monitor medication therapy, other serv-
ices of qualified pharmacists that enhance the use of
prescription medications, and such other professional
services of qualified pharmacists, consistent with the
scope of the practice of pharmacy as defined by ap-
plicable State law or regulation.
‘‘(B) The term ‘disease specific management services’
means medication therapy management services provided
to individuals who are receiving medication for the treat-
ment of asthma or diabetes, lipid reducing medication,
anti-coagulation medication, or medication for such other
chronic diseases as the Secretary may specify, only pursu-
ant to a protocol with the individual’s treating physician
under which the qualified pharmacist may initiate or mod-
ify the medication therapy, and carry out such additional
medication therapy management services as is provided
under State law or regulation, as permitted under the pro-
tocol.
‘‘(C) Covered medication therapy management serv-
ices are covered under this title only if they are docu-
mented and shared with the appropriate physician and
other health care providers (as established under a report-
ing system developed by State Boards of Pharmacy).
‘‘(2) The term ‘qualified pharmacist’ means an indi-
vidual who—
‘‘(A) is a licensed pharmacist in good standing
with the State Board of Pharmacy;
‘‘(B) with respect only to the provision of dis-
ease specific management services, is currently cer-
tified by a nationally recognized licensed certification
or credentialing program to furnish medication man-
agement therapy services for the diseases referred to
in paragraph (1)(B); and
‘‘(C) has a separate, private consultation area
in which to provide covered.
‘‘(3) The term ‘eligible State’ means a State that
meets such criteria as the Secretary may establish for the
licensing or credentialing of qualified pharmacists for the
provision of medication therapy management services in
the State, and shall include a State that is eligible for pay-
ments under title XIX for the provision of such services
under the State plan.’’; and
(3) in subsection (aa)(6), by inserting ‘‘(or,
with respect to subsection (ww)(1)(B), a qualified
pharmacist)’’ after ‘‘nurse practitioner’’ and by in-
serting ‘‘(or pharmacist’s)’’ after ‘‘practitioner’s’’.
(b) PAYMENT.—
(1) IN GENERAL.—Section 1833(a)(1) of such
Act (42 U.S.C. 1395l(a)(1)) is amended—
(A) in subsection (a)(1)—
(i) by striking ‘‘and’’ before ‘‘(U)’’;
and
(ii) by inserting before the semicolon
at the end the following: ‘‘, and (V) with
respect to covered medication therapy
management services (as defined in section
1861(ww)(1)), the amounts paid shall be
80 percent of the lesser of the actual
charge or the amounts specified under the
fee schedule developed under subsection
(p)’’; and
(B) by inserting after subsection (o) the
following new subsection:
‘‘(p) With respect to medication therapy management
services (as defined in section 1861(ww)(1)), the Secretary
shall establish a fee schedule—
‘‘(1) under which payments are based on an en-
counter and increase in 15 minute increments; and
‘‘(2) in which, in order to be paid for a 15-
minute increment, the majority of the time be spent
by the qualified pharmacist in providing covered
services.’’.
(2) APPLICATION OF BALANCE BILLING LIMITA-
TIONS.—Section 1842(b)(18)(C) of such Act (42
U.S.C. 1395u(b)(18)(C)) is amended by adding at
the end the following new clause:
‘‘(vii) A qualified pharmacist (as defined in sec-
tion 1861(ww)(2)).’’.
(3) REPORT TO CONGRESS.—Not later than 3
years after the date of the enactment of this Act, the
Secretary of Health and Human Services shall sub-
mit to Congress a report on fee schedule developed
under section 1834(p) of the Social Security Act (as
added by paragraph (1)) for covered medication
therapy management services under part B of the
medicare program.
(c) PROGRAM OPERATION.—
(1) DEVELOPMENT
IN
CONSULTATION
WITH
PHARMACY
ORGANIZATIONS.—The 
Secretary 
of
Health and Human Services shall carry out the
amendments made by this section in cooperation
with organizations representing qualified phar-
macists, including—
(A) identifying medication therapy man-
agement services that will be covered; and
(B) establishing payment mechanisms for
such services.
(2) ONGOING
EVALUATION.—The Secretary
shall provide for an ongoing evaluation and docu-
mentation of the provision of medication therapy
management services under such amendment in im-
proving quality of care and reducing health care
costs.
(d) EFFECTIVE DATE.—The amendments made by
this section shall apply to services furnished on or after
January 1, 2004.
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