Text: H.R.1474 — 110th Congress (2007-2008)All Bill Information (Except Text)

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Introduced in House (03/12/2007)


110th CONGRESS
1st Session
H. R. 1474

To amend title XVIII of the Social Security Act to require the sponsor of a prescription drug plan or an organization offering an MA–PD plan to promptly pay claims submitted under part D and to prohibit the inclusion of certain identifying information of pharmacies on explanatory prescription drug information and cards distributed by prescription drug plan sponsors.


IN THE HOUSE OF REPRESENTATIVES
March 12, 2007

Mr. Berry (for himself, Ms. Herseth, Mr. Jones of North Carolina, Mr. Wicker, Mr. Allen, Mr. Aderholt, Mr. Ross, Mr. Graves, Mrs. Emerson, Mr. Courtney, and Mr. Moran of Kansas) 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 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 require the sponsor of a prescription drug plan or an organization offering an MA–PD plan to promptly pay claims submitted under part D and to prohibit the inclusion of certain identifying information of pharmacies on explanatory prescription drug information and cards distributed by prescription drug plan sponsors.

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 “Fair and Speedy Treatment (FAST) of Medicare Prescription Drug Claims Act of 2007”.

SEC. 2. Prompt payment by Medicare prescription drug plans and MA–PD plans under part D.

(a) Application to prescription drug plans.—Section 1860D–12(b) of the Social Security Act (42 U.S.C. 1395w–112 (b)) is amended by adding at the end the following new paragraph:

“(4) PROMPT PAYMENT OF CLEAN CLAIMS.—

“(A) PROMPT PAYMENT.—Each contract entered into with a PDP sponsor under this subsection with respect to a prescription drug plan offered by such sponsor shall provide that payment shall be issued, mailed, or otherwise transmitted with respect to all clean claims submitted under this part within the applicable number of calendar days after the date on which the claim is received.

“(B) DEFINITIONS.—In this paragraph:

“(I) CLEAN CLAIM.—The term ‘clean claim’ means a claim, with respect to a covered part D drug, that has no apparent defect or impropriety (including any lack of any required substantiating documentation) or particular circumstance requiring special treatment that prevents timely payment from being made on the claim under this part.

“(ii) APPLICABLE NUMBER OF CALENDAR DAYS.—The term ‘applicable number of calendar days’ means—

“(I) with respect to claims submitted electronically, 14 calendar days; and

“(II) with respect to claims submitted otherwise, 30 calendar days.

“(c) INTEREST PAYMENT.—If payment is not issued, mailed, or otherwise transmitted within the applicable number of calendar days (as defined in subparagraph (B)) after a clean claim is received, interest shall be paid at a rate used for purposes of section 3902(a) of title 31, United States Code (relating to interest penalties for failure to make prompt payments), for the period beginning on the day after the required payment date and ending on the date on which payment is made.

“(D) PROCEDURES INVOLVING CLAIMS.—

“(I) CLAIMS DEEMED TO BE CLEAN CLAIMS.—

“(I) IN GENERAL.—A claim for a covered part D drug shall be deemed to be a clean claim for purposes of this paragraph if the PDP sponsor involved does not provide a notification of deficiency to the claimant by the 10th day that begins after the date on which the claim is submitted.

“(II) NOTIFICATION OF DEFICIENCY.—For purposes of subclause (II), the term ‘notification of deficiency’ means a notification that specifies all defects or improprieties in the claim involved and that lists all additional information or documents necessary for the proper processing and payment of the claim.

“(ii) PAYMENT OF CLEAN PORTIONS OF CLAIMS.—A PDP sponsor shall, as appropriate, pay any portion of a claim for a covered part D drug that would be a clean claim but for a defect or impropriety in a separate portion of the claim in accordance with subparagraph (A).

“(iii) OBLIGATION TO PAY.—A claim for a covered part D drug submitted to a PDP sponsor that is not paid or contested by the provider within the applicable number of calendar days (as defined in subparagraph (B)) shall be deemed to be a clean claim and shall be paid by the PDP sponsor in accordance with subparagraph (A).

“(iv) DATE OF PAYMENT OF CLAIM.—Payment of a clean claim under subparagraph (A) is considered to have been made on the date on which full payment is received by the provider.

“(E) ELECTRONIC TRANSFER OF FUNDS.—A PDP sponsor shall pay all clean claims submitted electronically by an electronic funds transfer mechanism.”.

(b) Application to MA–PD plans.—Section 1857(f) of such Act (42 U.S.C. 1395w–27) is amended by adding at the end the following new paragraph:

“(3) INCORPORATION OF CERTAIN PRESCRIPTION DRUG PLAN CONTRACT REQUIREMENTS.—The provisions of section 1860D–12(b)(4) shall apply to contracts with a Medicare Advantage organization in the same manner as they apply to contracts with a PDP sponsor offering a prescription drug plan under part D.”.

(c) Effective date.—The amendments made by this section shall apply to contracts entered into or renewed on or after the date of the enactment of this Act.

SEC. 3. Restriction on co-branding.

(a) Application to prescription drug information disseminated.—Subsection (a) of section 1860D–4 of the Social Security Act (42 U.S.C. 1395w–104) is amended by adding at the end the following new paragraph:

“(5) RESTRICTION ON DISPLAYING PHARMACY BRAND OR TRADEMARK INFORMATION.—

“(A) IN GENERAL.—It is unlawful for a PDP sponsor of a prescription drug plan to display on any explanatory information described in subparagraph (B), with respect to benefits provided under this part, the brand or trademark of any pharmacy.

“(B) EXPLANATORY INFORMATION DESCRIBED.—For purposes of subparagraph (A), explanatory information is each of the following:

“(i) Information on evidence of coverage under this part.

“(ii) Information that summarizes benefits provided under this part.

“(iii) Enrollment and disenrollment forms.

“(iv) Enrollment and disenrollment letters.

“(v) Pharmacy directories.

“(vi) Formulary information.

“(vii) Grievance letters provided pursuant to subsection (f), coverage determination letters provided pursuant to subsection (g), and appeals letters provided pursuant to subsection (h).

“(viii) Exceptions process letters.

“(ix) Information contained in sales descriptions or sales presentations.”.

(b) Application to enrollee cards.—Subsection (b)(2)(A) of such section is amended by adding at the end the following new sentence: “It is unlawful for a PDP sponsor of a prescription drug plan to display on such a card the name, brand, or trademark of any pharmacy.”

(c) Effective date.—

(1) EXPLANATORY INFORMATION.—With respect to explanatory information dispensed on or after the date of the enactment of this Act, the amendment made by subsection (a) shall apply to such information on and after the date that is 90 days after such date of enactment.

(2) ENROLLEE CARDS.—With respect to cards dispensed before, on, or after the date of the enactment of this Act, the amendment made by subsection (b) shall apply to such cards on and after the date that is 90 days after such date of enactment. Any card dispensed before such date that is 90 days after the date of enactment that violates the second sentence of section 1860D–4(b)(2)(A) of the Social Security Act, as added by subsection (b), shall be reissued by such 90-day date.