PACE Part D Choice Act of 2021
Bill: H.R.4941 | Sponsor: Rep. Blumenauer, Earl (D-OR)
Policy area: Health

Summary:
PACE Part D Choice Act of 2021
This bill allows Medicare-only beneficiaries who are enrolled in Programs of All-Inclusive Care for the Elderly (PACE) to choose prescription drug plans that are not operated by PACE. (PACE is a program under Medicare and Medicaid that provides in-home and community services for certain individuals as an alternative to nursing home care.)
Specifically, the bill allows PACE enrollees who are Medicare (but not Medicaid) beneficiaries to choose a prescription drug plan that is not a Medicare Advantage plan or operated by PACE and for which annual out-of-pocket costs and federal subsidies are equal to or less than that under the applicable PACE prescription drug plan. The bill also allows for disenrollment from a chosen plan upon a change in medication or demonstration of an unexpected increase in out-of-pocket costs.
PACE programs must conduct outreach, monitor data, and coordinate benefits with respect to such options.

To amend title XVIII of the Social Security Act to ensure Medicare-only 
 PACE program enrollees have a choice of prescription drug plans under 
                            Medicare part D.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``PACE Part D Choice Act of 2021''.

SEC. 2. ENSURING MEDICARE-ONLY PACE PROGRAM ENROLLEES HAVE A CHOICE OF 
              PRESCRIPTION DRUG PLANS UNDER MEDICARE PART D.

    Section 1860D-21(f) of the Social Security Act (42 U.S.C. 1395w-
131(f)) is amended--
            (1) in paragraph (1), by striking ``and (3)'' and inserting 
        ``(3), and (4)''; and
            (2) by adding at the end the following new paragraph:
            ``(4) Ensuring choice of prescription drug plans.--
                    ``(A) In general.--For plan years beginning on or 
                after January 1, 2023, subject to the succeeding 
                provisions of this paragraph, an applicable PACE 
                program enrollee may elect to enroll in a qualified 
                standalone prescription drug plan, in accordance with 
                rules established by the Secretary pursuant to this 
                paragraph, while enrolled under a PACE program.
                    ``(B) Definition of applicable pace program 
                enrollee; qualified standalone prescription drug 
                plan.--In this paragraph:
                            ``(i) Applicable pace program enrollee.--
                        The term `applicable PACE program enrollee' 
                        means a part D eligible individual who--
                                    ``(I) is not entitled to medical 
                                assistance under title XIX; and
                                    ``(II) is enrolled under a PACE 
                                program offered by a PACE provider.
                            ``(ii) Qualified standalone prescription 
                        drug plan.--The term `qualified standalone 
                        prescription drug plan' means, with respect to 
                        an applicable PACE program enrollee, a 
                        prescription drug plan--
                                    ``(I) that is not an MA-PD plan;
                                    ``(II) that is not operated by the 
                                PACE program under which the individual 
                                is enrolled; and
                                    ``(III) for which the Secretary 
                                determines, with respect to the 
                                applicable PACE program enrollees 
                                enrolled in a PACE program offered by 
                                such PACE provider, that--
                                            ``(aa) the estimated 
                                        beneficiary out-of-pocket costs 
                                        (as defined in clause (iii)) 
                                        for the plan year for qualified 
                                        prescription drug coverage 
                                        under the plan is equal to or 
                                        less than the estimated out-of-
                                        pocket costs for such coverage 
                                        under the prescription drug 
                                        plan offered by the PACE 
                                        program in which the applicable 
                                        PACE program enrollee is 
                                        enrolled; and
                                            ``(bb) the estimated total 
                                        amount of Federal subsidies for 
                                        the plan year for qualified 
                                        prescription drug coverage 
                                        under the plan (which may be 
                                        estimated using data from the 
                                        previous plan year) is equal to 
                                        or less than the estimated 
                                        subsidy amount for such 
                                        coverage under the prescription 
                                        drug plan offered by the PACE 
                                        program in which the applicable 
                                        PACE program enrollee is 
                                        enrolled.
                            ``(iii) Out-of-pocket costs defined.--In 
                        this paragraph, the term `out-of-pocket costs' 
                        includes premiums imposed under a prescription 
                        drug plan and, in the case of coverage under a 
                        qualified standalone prescription drug plan, 
                        deductibles, copayments, coinsurance, and other 
                        cost-sharing.
                    ``(C) Out-of-pocket costs.--In the case where an 
                applicable PACE program enrollee elects to enroll in a 
                qualified standalone prescription drug plan pursuant to 
                this paragraph, the individual shall be responsible for 
                any out-of-pocket costs imposed under the plan 
                (including costs for nonformulary drugs) after the 
                application of any subsidies under section 1860D-14 for 
                an applicable PACE program enrollee who is a subsidy 
                eligible individual (as defined in section 1860D-
                14(a)(3)).
                    ``(D) Requirements for pace programs.--
                            ``(i) Educating and helping enroll 
                        beneficiaries into a part d plan option.--A 
                        PACE program shall be required to provide--
                                    ``(I) information to all applicable 
                                PACE program enrollees who are enrolled 
                                under the PACE program regarding the 
                                option to enroll in a qualified 
                                standalone prescription drug plan under 
                                this paragraph; and
                                    ``(II) upon request of an 
                                applicable PACE program enrollee, 
                                counseling and coordination to assist 
                                applicable PACE program enrollees in 
                                making decisions regarding the 
                                selection of qualified standalone 
                                prescription drug plans available to 
                                them.
                            ``(ii) Monitoring drug utilization, 
                        adherence, and spend.--A PACE program shall be 
                        required to monitor drug utilization, 
                        medication adherence, and drug spending 
                        (through claims data shared pursuant to 
                        subparagraph (F) and otherwise) throughout the 
                        year with respect to any applicable PACE 
                        program enrollee who elects to enroll in a 
                        qualified standalone prescription drug plan 
                        under this paragraph in order to coordinate 
                        with the PDP sponsor of such plan regarding the 
                        drug benefits offered by the plan, including 
                        upon request of an applicable PACE program 
                        enrollee the filing of any grievances or 
                        appeals with the plan on behalf of the 
                        applicable PACE program enrollee.
                    ``(E) Disenrollment.--An applicable PACE program 
                enrollee may disenroll from the qualified standalone 
                prescription drug plan elected by such applicable PACE 
                program enrollee under subparagraph (A) if the enrollee 
                changes medication during the plan year or can 
                demonstrate an unexpected increase in out-of-pocket 
                costs post enrollment.
                    ``(F) Claims sharing.--In the case where an 
                applicable PACE program enrollee enrolls in a qualified 
                standalone prescription drug plan, the PACE program in 
                which the individual is enrolled and the PDP sponsor of 
                the qualified standalone prescription drug plan shall 
                share claims data with each other with respect to the 
                applicable PACE program enrollee as needed to support 
                care management for the applicable PACE program 
                enrollee (including for purposes of monitoring and 
                coordination required under subparagraph (D)(ii)) and 
                for purposes of comprehensive risk adjustment under 
                section 1894(d). Such data shall be shared without the 
                need for any formal or informal request of the PACE 
                program in which the individual is enrolled or the PDP 
                sponsor of the qualified standalone prescription drug 
                plan in which the applicable PACE program enrollee is 
                enrolled.
                    ``(G) Rule of construction.--The authority 
                established under this paragraph for an applicable PACE 
                program enrollee to elect to enroll in a qualified 
                standalone prescription drug plan shall not be 
                construed as permitting an applicable PACE program 
                enrollee to enroll in a prescription drug plan that is 
                not a qualified standalone prescription drug plan.
                    ``(H) Relation to pace statutes.--
                            ``(i) In general.--The authority provided 
                        under this paragraph for an applicable PACE 
                        program enrollee to elect to enroll in a 
                        qualified standalone prescription drug plan 
                        shall apply notwithstanding subsection 
                        (a)(1)(B)(1) of section 1894 and such other 
                        provisions of sections 1894 and 1934 as the 
                        Secretary determines may conflict with the 
                        authority provided for under this paragraph, 
                        including subsections (a)(2)(B), (b)(1)(A)(i), 
                        (b)(1)(C), (f)(2)(B)(ii), and (f)(2)(B)(v) of 
                        such sections.
                            ``(ii) Clarification on payment for part d 
                        drug coverage.--Insofar as an applicable PACE 
                        program enrollee is enrolled in a qualified 
                        standalone prescription drug plan under this 
                        paragraph, the PACE program shall not be 
                        entitled to payment under section 1894(d) for 
                        the provision of qualified prescription drug 
                        coverage under such standalone prescription 
                        drug plan with respect to such applicable PACE 
                        program enrollee.''.
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