I 
115TH CONGRESS 
1ST SESSION H. R. 1038 
To amend title XVIII of the Social Security Act to prohibit prescription 
drug plan sponsors and MA–PD organizations under the Medicare pro-
gram from retroactively reducing payment on clean claims submitted 
by pharmacies. 
IN THE HOUSE OF REPRESENTATIVES 
FEBRUARY 14, 2017 
Mr. GRIFFITH (for himself, Mr. WELCH, Mr. COLLINS of Georgia, Mr. JONES, 
Mrs. MCMORRIS RODGERS, Mr. BLUM, Mr. CRAWFORD, Mr. CARTER of 
Georgia, Mr. ROE of Tennessee, Mr. BABIN, Mr. SESSIONS, Mr. 
BARLETTA, Mr. MASSIE, Mr. HARPER, Mr. FERGUSON, Mr. GOODLATTE, 
Mr. DOGGETT, and Mrs. ROBY) 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 de-
termined 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 prohibit 
prescription drug plan sponsors and MA–PD organiza-
tions under the Medicare program from retroactively re-
ducing payment on clean claims submitted by phar-
macies. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
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SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Improving Trans-
parency and Accuracy in Medicare Part D Spending Act’’. 
SEC. 2. PROHIBITING MEDICARE PDP SPONSORS AND MA– 
PD ORGANIZATIONS FROM RETROACTIVELY 
REDUCING PAYMENT ON CLEAN CLAIMS SUB-
MITTED BY PHARMACIES. 
(a) IN GENERAL.—Section 1860D–12(b)(4)(A) of 
the Social Security Act (42 U.S.C. 1395w–112(b)(4)(A)) 
is amended by adding at the end the following new clause: 
‘‘(iv) PROHIBITING RETROACTIVE RE-
DUCTIONS
IN
PAYMENTS
ON
CLEAN 
CLAIMS.—Each contract entered into with 
a PDP sponsor under this part with re-
spect to a prescription drug plan offered 
by such sponsor shall provide that after 
the date of receipt of a clean claim sub-
mitted by a pharmacy, the PDP sponsor 
(or an agent of the PDP sponsor) may not 
retroactively reduce payment on such claim 
directly or indirectly through aggregated 
effective rate or otherwise except in the 
case such claim is found to not be a clean 
claim (such as in the case of a claim lack-
ing required substantiating documentation) 
during the course of a routine audit as 
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permitted pursuant to written agreement 
between the PDP sponsor (or such an 
agent) and such pharmacy. The previous 
sentence shall not prohibit any retroactive 
increase in payment to a pharmacy pursu-
ant to a written agreement between a PDP 
sponsor (or an agent of such sponsor) and 
such pharmacy.’’. 
(b) EFFECTIVE DATE.—The amendment made by 
subsection (a) shall apply with respect to contracts entered 
into on or after January 1, 2018. 
Æ 
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