Provides for changes under Medicaid with respect to the enrollment process, including providing for automatic reenrollment without need to reapply.
[Congressional Bills 108th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1568 Introduced in House (IH)]
108th CONGRESS
1st Session
H. R. 1568
To amend part B of title XVIII of the Social Security Act to provide
for a prescription drug benefit with a high deductible at no additional
premium and access to discount prices on drugs and to provide for the
operation of such benefit without a deductible for certain low-income
Medicare beneficiaries.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
April 2, 2003
Mr. Dooley of California (for himself, Mrs. Tauscher, Mr. Kind, Mr.
Davis of Florida, Mr. Smith of Washington, Mr. Stenholm, Mr. Emanuel,
Mr. Cooper, Mr. Hill, Mr. Ford, Mr. Peterson of Minnesota, Mr. Cardoza,
Mr. Case, Mr. Cramer, Mr. Moore, Ms. Harman, Mr. Miller of North
Carolina, Mr. Davis of Alabama, Mrs. McCarthy of New York, Mr. Israel,
Mr. Wu, Mr. Marshall, Mr. Lucas of Kentucky, Mr. Matheson, and Mr.
Larsen of Washington) 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 part B of title XVIII of the Social Security Act to provide
for a prescription drug benefit with a high deductible at no additional
premium and access to discount prices on drugs and to provide for the
operation of such benefit without a deductible for certain low-income
Medicare beneficiaries.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Medicare Rx Now
Act of 2003''.
(b) Amendments to Social Security Act.--Except as otherwise
specifically provided, whenever in this Act an amendment is expressed
in terms of an amendment to or repeal of a section or other provision,
the reference shall be considered to be made to that section or other
provision of the Social Security Act.
(c) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
Sec. 2. Purpose.
TITLE I--PART B DRUG BENEFIT WITH HIGH DEDUCTIBLE AND NO PREMIUM
Sec. 101. Inclusion of high-deductible outpatient prescription drug
benefit under part B.
Sec. 102. Provision of benefits through medicare approved prescription
drug plans.
TITLE II--BENEFITS FOR LOW-INCOME BENEFICIARIES
Sec. 201. Benefits for low-income beneficiaries.
Sec. 202. Improving enrollment process under medicaid.
SEC. 2. PURPOSE.
The purpose of this Act is to provide for outpatient prescription
drug benefits to medicare beneficiaries in the following manner:
(1) Medicare beneficiaries enrolled under medicare part B
qualify for outpatient prescription drug benefits after an
annual deductible (initially set at $4,000) has been met. This
benefit is available without any additional premium.
(2) There are fixed dollar copayments for this coverage,
with the average of such copayments equal to 20 percent of the
benefits and the amount of the copayments varying depending
upon whether the drugs are generic, preferred brand-name, or
non-preferred brand-name drugs.
(3) The benefits are provided through medicare-approved
prescription drug plans. These plans may be current plans, such
as Medicare+Choice plans, employer-based retiree coverage,
medigap plans, State assistance programs, medicaid, drug
discount card plans, and other qualified plans (as determined
by the Secretary). All of these plans must offer, in addition
to the high-deductible coverage, discounts for prescription
drugs both while the annual deductible is being satisfied and
after it is satisfied.
(4) To assure access to medicare-approved prescription drug
plans for all medicare beneficiaries, the Secretary will
solicit bids for prescription drug discount plans that will be
available in all geographic regions to all medicare
beneficiaries.
(5) All pharmacies that comply with electronic claims
processing standards may provide drugs under the program.
(6) The Act also provides for the availability of
additional benefits in the form of a waiver of the annual
deductible, thereby providing immediate entitlement to
prescription drug benefits, for medicare beneficiaries who have
incomes under 200 percent of the poverty line and who are not
eligible for medicaid prescription drug benefits.
TITLE I--PART B DRUG BENEFIT WITH HIGH DEDUCTIBLE AND NO PREMIUM
SEC. 101. INCLUSION OF HIGH-DEDUCTIBLE OUTPATIENT PRESCRIPTION DRUG
BENEFIT UNDER PART B.
(a) Coverage.--Section 1832(a) (42 U.S.C. 1395k(a)) is amended--
(1) by striking ``and'' at the end of paragraph (1);
(2) by striking the period at the end of paragraph (2) and
inserting ``; and''; and
(3) by adding at the end the following new paragraph:
``(3) entitlement to have payment made on his behalf
(subject to the provisions of this part) for high-deductible
outpatient prescription drug coverage under section 1845.''.
(b) Description of High-Deductible Prescription Drug Benefit.--
Title XVIII is amended by inserting after section 1844 the following
new section:
``outpatient prescription drug coverage
``Sec. 1845. (a) High-Deductible Outpatient Prescription Drug
Coverage Defined.--
``(1) In general.--For purposes of this part, the term
`high-deductible outpatient prescription drug coverage' means
payment of--
``(A) expenses for covered outpatient prescription
drugs incurred in a year after the individual has
incurred expenses for such drugs in the year of an
amount equal to the annual deductible specified in
paragraph (2); reduced by
``(B) cost-sharing described in paragraph (3).
``(2) Annual deductible.--
``(A) In general.--The annual deductible under this
paragraph--
``(i) for 2005 is equal to $4,000; and
``(ii) for a subsequent year is equal to
the amount specified in subparagraph (B) for
that year, except that, if the amount specified
in such subparagraph is not a multiple of $10,
it shall be rounded to the nearest multiple of
$10.
``(B) Inflationary adjustment.--The amount
specified in this subparagraph--
``(i) for 2005, is $4,000; or
``(ii) the amount specified in this
subparagraph for a subsequent year is the
amount specified in this subparagraph for the
previous year increased by the annual
percentage increase in average per capita
aggregate expenditures for covered outpatient
prescription drugs in the United States for
medicare beneficiaries, as determined by the
Secretary for the 12-month period ending in
July of the previous year.
``(3) Cost-sharing.--
``(A) Three-tiered copayment structure.--Subject to
the succeeding provisions of this paragraph, in the
case of a covered outpatient drug that is dispensed in
a year to an eligible individual, the individual shall
be responsible for a copayment for the drug in an
amount equal to the following (or, if less, the price
for the drug negotiated pursuant to subsection (c)(5)):
``(i) Generic drugs.--In the case of a
generic covered outpatient drug, the base
copayment amount specified in accordance with
subparagraph (B) for each prescription (as
defined by the Secretary) of such drug.
``(ii) Preferred brand name drugs.--In the
case of a preferred brand name covered
outpatient drug, 4 times the copayment amount
applied under clause (i) for each prescription
(as so defined) of such drug.
``(iii) Nonpreferred brand name drug.--In
the case of a nonpreferred brand name covered
outpatient drug, 150 percent of the copayment
amount applied under clause (ii) for each
prescription (as so defined) of such drug.
``(B) Establishment of base copayment amount
consistent with 80:20 benefit ratio.--For each year
beginning with 2005 the Secretary shall establish a
base copayment amount in a manner consistent with the
principle (subject to reasonable rounding rules) that
the ratio of the aggregate amount of benefits provided
under this section to the aggregate copayments under
this paragraph for each year should be approximately
equal to 80 to 20.
``(C) Discounts allowed for network pharmacies.--A
medicare-approved prescription drug plan may reduce
copayments for its designees below the level otherwise
provided under this paragraph, but in no case shall
such a reduction result in an increase in payments made
by the Secretary under this section to a plan.
``(D) Treatment of medically necessary nonpreferred
drugs.--A nonpreferred brand name drug shall be treated
as a preferred brand name drug under this paragraph if
such nonpreferred drug is determined (pursuant to
procedures established under subsection (c)(6)) to be
medically necessary.
``(E) Requirement for designation of preferred
brand name drugs.--Within each category of therapeutic-
equivalent covered outpatient prescription drugs (as
defined by the Secretary), each medicare-approved prescription drug
plan shall provide for the designation of at least one preferred brand
name covered outpatient drug.
``(4) Payment of benefits beyond deductible.--
``(A) In general.--There shall be paid from the
Federal Supplementary Medical Insurance Trust Fund, in
the case of each individual who is covered under the
insurance program established by this part and incurs
expenses for covered outpatient prescription drugs with
respect to which benefits are payable under this
section, amounts equal to the amounts provided under
paragraph (1).
``(B) Counting of incurred expenses.--Expenses with
respect to covered outpatient prescription drugs under
this section shall--
``(i) be treated as incurred regardless of
whether they are reimbursed by a third-party
payor;
``(ii) not be treated as incurred unless
the expenses were incurred during a period in
which the individual was covered under this
part; and
``(iii) not be treated as incurred unless
information concerning the transaction giving
rise to such expenses has been electronically
transmitted by the pharmacy or other entity
dispensing the covered outpatient prescription
drugs to the medicare-approved prescription
drug plan consistent with electronic claims
standards established under subsection
(c)(3).''.
SEC. 102. PROVISION OF BENEFITS THROUGH MEDICARE APPROVED PRESCRIPTION
DRUG PLANS.
(a) In General.--Section 1845 of the Social Security Act, as
inserted by section 101(a), is further amended by adding at the end the
following:
``(b) Provision of Benefits Through a Medicare Approved
Prescription Drug Plan.--
``(1) In general.--In the case of an individual entitled to
benefits for high-deductible outpatient prescription drug
coverage under this section, the individual shall obtain such
benefits through a medicare-approved prescription drug plan
that is designated under this subsection.
``(2) Designation process.--The Secretary shall provide for
a process for designation of medicare-approved prescription
drug plans consistent with the following:
``(A) Frequency of designations.--The Secretary
shall permit individuals, on an annual basis and at
such other times during a year as the Secretary may
specify, to change the plan designated.
``(B) Dissemination of information.--The Secretary
shall provide for the dissemination of information on
designation of plans under this subsection. Such
dissemination may be coordinated with the dissemination
of information on Medicare+Choice plan selection under
part C.
``(C) Default assignment.--In the case of an
individual who is enrolled under this part who has not
otherwise designated a medicare-approved prescription
drug plan, the Secretary shall assign the individual to
an appropriate prescription drug discount card plan
serving the area in which the individual resides.
``(D) Deemed designation.--The Secretary may deem
an individual who is enrolled in a medicare-approved
prescription drug plan described in subparagraph (A)
through (E) of subsection (c)(2) as having designated
such plan, but shall permit the individual to designate
a prescription drug discount card plan instead. The
Secretary shall establish rules in cases where an
individual is enrolled in more than one such plan.
``(3) Designee defined.--In this section, the term
`designee' means such an individual who makes such a
designation and, with respect to a plan, an individual who has
designated that plan under this subsection.
``(c) Medicare-Approved Prescription Drug Plans.--
``(1) In general.--For purposes of this part, the term
`medicare-approved prescription drug plan' means a health plan
or program described in paragraph (2) that--
``(A) provides at least high-deductible outpatient
prescription drug coverage to designees of that plan or
program;
``(B) meets the applicable requirements of
paragraph (3) and succeeding paragraphs of this
subsection with respect to such designees;
``(C) has entered into an agreement with the
Secretary to provide and exchange electronically such
information as the Secretary may require for the
administration of the program of benefits under this
section; and
``(D) meets such additional requirements as the
Secretary may specify, including requiring the
provision of appropriate periodic audits.
``(2) Types of plans and programs that may qualify.--The
types of plans and programs that may qualify as a medicare-
approved prescription drug plan are the following:
``(A) A Medicare+Choice plan.
``(B) A group health plan, including a retirement
health benefits plan, that provides prescription drug
coverage.
``(C) A State plan under title XIX.
``(D) A health benefits plan under the Federal
employees' health benefits program under chapter 89 of
title 5, United States Code.
``(E) A medicare supplemental policy.
``(F) State pharmaceutical assistance program.
``(G) A prescription drug discount card plan
(described in subsection (d)).
``(H) Any other prescription drug plan that is
determined to meet such requirements as the Secretary
establishes.
``(3) Administration through card-based electronic
mechanism.--
``(A) Use of medicare prescription drug card.--
Claims for benefits under this section under a
medicare-approved prescription drug plan may only be
made electronically through the use of an electronic
prescription card system (in this paragraph referred to
as the `system').
``(B) Standards for electronic prescription card
system.--The Secretary shall establish standards for
the system, including the following:
``(i) Cards.--Standards for claims cards to
be used by designees under the system.
``(ii) Coordination of electronic
information.--Standards for the real-time
transmittal among pharmacies, medicare-approved
prescription drug plans, and the Secretary
(including an appropriate data clearinghouse
operated by or under contract with the
Secretary) of information on expenses incurred
for covered outpatient prescription drugs by
designees.
``(iii) Confidentiality.--Standards that
assure the confidentiality of individually
identifiable information of designees and that
are consistent with the regulations promulgated
under section 264(c) of the Health Insurance
Portability and Accountability Act of 1996.
``(4) Acceptance of claims through all qualifying
pharmacies.--A medicare-approved prescription drug plan shall
provide for acceptance and process of claims for designees from
any pharmacy that meets standards the Secretary has established
under paragraph (3) to carry out real-time transmittal of
claims to such plans and that provides for disclosure, in the
case of dispensing of a brand name drug to a designee, of
information on the availability of generic equivalents at
reduced cost to the designee.
``(5) Requirement to negotiate discounts and generic
equivalents.--A medicare-approved prescription drug plan shall
provide designees of the plan with the following:
``(A) Negotiated prices.--Access to negotiated
prices (including applicable discounts) used for
payment for covered outpatient drugs, regardless of the
fact that no benefits or only partial benefits may be
payable with respect to such drugs because of the
application of the deductible under subsection (a)(2)
or copayment under subsection (a)(3).
``(B) Generic equivalents.--Information on the
availability of generic equivalents at reduced cost to
such designees.
``(6) Treatment of nonpreferred brand name drugs.--
``(A) Procedures regarding the determination of
drugs that are medically necessary.--
``(i) In general.--A medicare-approved
prescription drug plan shall have in place
procedures on a case-by-case basis to treat a
nonpreferred brand name drug as a preferred
brand name drug for purposes of subsection (a)
if the nonpreferred brand name drug is
determined--
``(I) to be not as effective for
the designee in preventing or slowing
the deterioration of, or improving or
maintaining, the health of the individual; or
``(II) to have a significant
adverse effect on the individual.
``(ii) Requirement.--The procedures under
clause (i) shall require that determinations
under such clause are based on professional
medical judgment, the medical condition of the
enrollee, and other medical evidence.
``(B) Procedures regarding appeal rights with
respect to denials of care.--Such a plan shall have in
place procedures to ensure a timely internal review
(and timely independent external review) for resolution
of denials of coverage in accordance with the medical
exigencies of the case in accordance with requirements
established by the Secretary that are comparable to
such requirements for Medicare+Choice organizations
under part C and to ensure notice to designees
regarding such procedures. A designee shall have the
further right to an appeal of such a denial of coverage
in the same manner as is provided under section
1852(g)(5) in the case of a failure to receive health
services under a Medicare+Choice plan.
``(7) Prompt payment of pharmacies for covered benefits.--
Medicare-approved prescription drug plans shall provide for
payment to qualifying pharmacies of benefits under subsection
(a)(4) promptly in accordance with rules no less generous than
the rules applicable under section 1842(c)(2)(B).
``(8) Education.--Medicare-approved prescription drug plans
shall apply methods to identify and educate providers,
pharmacists, and designees regarding--
``(A) instances or patterns concerning the
unnecessary or inappropriate prescribing or dispensing
of covered outpatient prescription drugs;
``(B) instances or patterns of substandard care;
``(C) potential adverse reactions to covered
outpatient prescription drugs;
``(D) inappropriate use of antibiotics;
``(E) appropriate use of generic products; and
``(F) the importance of using covered outpatient
prescription drugs in accordance with the instruction
of prescribing providers.
``(9) Not at financial risk.--The entity offering a
medicare-approved prescription drug plan shall not be at
financial risk for the provision of high-deductible
prescription drug coverage under the plan to designees, but
there shall be performance incentives (based on risk corridors
negotiated between the entity and the Secretary and subject to
audit) in relation to the administration of the contract and
the entity's ability to reduce costs through appropriate
incentive mechanisms.
``(10) Provision of data.--The entity offering such a plan
shall provide the Secretary with such information as is
required to make payments to the entity under this section.
``(d) Prescription Drug Discount Card Plans.--
``(1) Solicitation of bids.--The Secretary shall solicit
bids from entities to offer prescription drug discount card
plans to individuals enrolled under this part either nationwide
or in large geographic areas. The Secretary shall award bids in
a manner so that such plans are offered in all areas of the
United States. The Secretary may not award a contract based on
such a bid to an entity with respect to a plan unless the
entity and plan meet the applicable requirements to be a
medicare-approved prescription drug plan under this section.
``(2) Limitation on benefits.--The entity offering a
prescription drug discount card plan shall not offer (or charge
for) benefits to designees of the plan in addition to high-
deductible prescription drug coverage, access to negotiated
prices, and other benefits required under this section and, in
the case of subsidy eligible individuals, benefits under
subsection (h).
``(e) Payment of Plans.--
``(1) In general.--The Secretary shall provide, in the
contract entered into between the Secretary and entities that
offer medicare-approved prescription drug plans, for payment to
the plans for high-deductible prescription drug coverage
offered through the plan, including expanded coverage for low-
income individuals under subsection (g) and taking into account
performance incentives described in paragraph (2). In addition,
in the case of prescription drug discount card plans, the
Secretary shall provide for payment of administrative costs in
carrying out the contract (taking into account the performance
incentives described in paragraph (2)), based on rates
negotiated between the Secretary and the entity in the
solicitation process under subsection (d).
``(2) Incentives for cost and utilization management and
quality improvement.--The Secretary shall include in the
contract such financial or other performance incentives for
cost and utilization management and quality improvement as the
Secretary may deem appropriate.
``(f) Covered Outpatient Prescription Drugs Defined.--
``(1) In general.--Except as provided in this subsection,
for purposes of this section, the term `covered outpatient
prescription drug' means--
``(A) a drug that may be dispensed only upon a
prescription and that is described in subparagraph
(A)(i) or (A)(ii) of section 1927(k)(2); or
``(B) a biological product described in clauses (i)
through (iii) of subparagraph (B) of such section or
insulin described in subparagraph (C) of such section,
and such term includes a vaccine licensed under section 351 of
the Public Health Service Act and any use of a covered
outpatient drug for a medically accepted indication (as defined
in section 1927(k)(6)).
``(2) Exclusions.--
``(A) In general.--Such term does not include drugs
or classes of drugs, or their medical uses, which may
be excluded from coverage or otherwise restricted under
section 1927(d)(2), other than subparagraph (E) thereof
(relating to smoking cessation agents), or under
section 1927(d)(3), as the Secretary may specify and
does not include such other medicines, classes, and
uses as the Secretary may specify consistent with the
goals of providing quality care and containing costs
under this section.
``(B) Avoidance of duplicate coverage.--A drug
prescribed for an individual that would otherwise be a
covered outpatient prescription drug under this section
shall not be so considered if payment for such drug is
available under part A or under this part (other than
under this section).''.
(b) No Effect on Part B Premium.--
(1) In general.--Section 1839(a) (42 U.S.C. 1395r(a)) is
amended by adding at the end the following new paragraph:
``(5) Notwithstanding the previous provisions of this subsection,
in computing actuarial rates there shall not be taken into account
benefits and administrative costs that are attributable to the
prescription drug coverage provided under section 1845.''.
(2) Government contribution.--Section 1844(a)(1) (42 U.S.C.
1395w(a)(1)) is amended--
(A) by striking ``plus'' at the end of subparagraph
(A);
(B) by striking ``; plus'' at the end of
subparagraph (B) and inserting ``, plus''; and
(C) by adding at the end the following new
subparagraph:
``(C) a Government contribution equal to the aggregate
amounts expended from the Trust Fund for benefits and
administrative expenses attributable to the prescription drug
coverage provided under section 1845; plus''.
(c) Medicare as Primary Payor.--Section 1862(b) (42 U.S.C.
1395y(b)) is amended by adding at the end the following new paragraph:
``(7) Exception for outpatient prescription drug benefit.--
The previous provisions of this subsection shall not apply to
benefits provided under section 1845.''.
TITLE II--BENEFITS FOR LOW-INCOME BENEFICIARIES
SEC. 201. BENEFITS FOR LOW-INCOME BENEFICIARIES.
(a) In General.--Section 1845, as inserted by section 101(b), is
amended by adding at the end the following new subsection:
``(g) First Dollar Coverage for Certain Low-income Individuals.--
``(1) In general.--In the case of a subsidy eligible
individual (as defined in paragraph (2)), this section shall be
applied as if the annual deductible were equal to zero but,
with respect to costs incurred before the amount of the annual
deductible otherwise applicable, the following copayment
amounts shall apply:
``(A) 20 percent copayment for individuals with
incomes up to 135 percent of poverty.--For subsidy
eligible individuals with income that does not exceed
135 percent of the poverty line, the copayment amounts
shall be the copayments amounts specified in subsection
(a)(3), which reflects an average benefit percentage of
80 percent.
``(B) 30 percent copayment for individuals with
incomes between 135 and 150 percent of poverty.--For
subsidy eligible individuals with income that exceeds
135 percent (but does not exceed 150 percent) of the
poverty line, the copayment amounts shall be the
copayments amounts specified in subsection (a)(3)
increased by 50 percent, which reflects an average
benefit percentage of 70 percent.
``(C) 50 percent copayment for individuals with
incomes above 150 percent of poverty.--For subsidy
eligible individuals with income that exceeds 150
percent of the poverty line, the copayment amounts
shall be the copayments amounts specified in subsection
(a)(3) increased by 150 percent, which reflects an
average benefit percentage of 50 percent.
``(2) Determination of eligibility.--
``(A) Subsidy eligible individual defined.--For
purposes of this subsection, subject to subparagraph
(D), the term `subsidy eligible individual' means an
individual who--
``(i) is enrolled under this part;
``(ii) has income below 150 percent (or
such higher percent, not to exceed 200 percent,
as a State may specify under subparagraph (B))
of the Federal poverty line; and
``(iii) is not eligible for medical
assistance with respect to prescription drugs
under title XIX.
For purposes of this section, an individual shall not be
treated as eligible for medical assistance with respect to
prescription drugs under title XIX (including under a waiver
under section 1115) only if, with respect to such assistance,
the individual is charged a copayment greater than a nominal
amount (as described in section 1916(a)(3)) and there is no
monthly or similar dollar limit established for the amount of
such assistance over any period of time.
``(B) Coverage of individuals with income up to 200
percent of poverty at state option.--One of the 50
States or the District of Columbia may, at its option
and subject to section 1935(c), specify a percent of
income, that exceeds 150 percent but does not exceed
200 percent, that will apply for purposes of this
subsection to individuals residing in the State.
``(C) Determinations.--The determination of whether
an individual residing in a State is a subsidy eligible
individual shall be determined under the State medicaid
plan for the State under section 1935(a) or by the
Social Security Administration. There are authorized to
be appropriated to the Social Security Administration
such sums as may be necessary for the determination of
eligibility under this subparagraph.
``(D) Income determinations.--For purposes of
applying this subsection--
``(i) income shall be determined in the
manner no less restrictive than the manner
described in section 1905(p)(1)(B); and
``(ii) the term `Federal poverty line'
means the official poverty line (as defined by
the Office of Management and Budget, and
revised annually in accordance with section
673(2) of the Omnibus Budget Reconciliation Act
of 1981) applicable to a family of the size
involved.
``(E) Treatment of territorial residents.--In the
case of an individual who is not a resident of the 50
States or the District of Columbia, the individual is
not eligible to be a subsidy eligible individual but
may be eligible for financial assistance with
prescription drug expenses under section 1935(f).
``(3) Administration of subsidy program.--The Secretary
shall provide a process whereby, in the case of an individual
who is determined to be a subsidy eligible individual and who
is enrolled in a medicare-approved prescription drug plan--
``(A) the Secretary provides for a notification of
the entity offering the plan that the individual is
eligible for a subsidy under paragraph (1);
``(B) such entity adjusts the benefits for
prescription drug coverage accordingly and submits to
the Secretary information on the amount of such
benefits provided; and
``(C) the Secretary periodically and on a timely
basis reimburses the entity for the amount of such
benefits (including reasonable related administrative
costs) that are provided only because of the
application of this subsection.
``(4) Relation to medicaid program.--
``(A) In general.--For provisions providing for
eligibility determinations, and additional financing,
under the medicaid program, see section 1935.
``(B) Coordination.--The Secretary shall develop
and implement a plan for the coordination of
prescription drug benefits under this part with the
benefits provided under the medicaid program under
title XIX, with particular attention to insuring
coordination of payments and prevention of fraud and
abuse. In developing and implementing such plan, the
Secretary shall involve the States, the data processing
industry, pharmacists, and pharmaceutical
manufacturers, and other experts and representatives of
low-income medicare beneficiaries.
``(C) Exemption.--Section 1902(n) shall not apply
with respect to coverage of cost-sharing imposed under
paragraph (1) or under subsection (a)(3).''.
(b) Medicaid Amendments.--
(1) Determinations of eligibility for low-income
subsidies.--
(A) Requirement.--Section 1902(a) (42 U.S.C.
1396a(a)) is amended--
(i) by striking ``and'' at the end of
paragraph (64);
(ii) by striking the period at the end of
paragraph (65) and inserting ``; and''; and
(iii) by inserting after paragraph (65) the
following new paragraph:
``(66) provide for making eligibility determinations under
sections 1845(g) and 1935(a).''.
(2) New section.--Title XIX of such Act is further
amended--
(A) by redesignating section 1935 as section 1936;
and
(B) by inserting after section 1934 the following
new section:
``special provisions relating to medicare prescription drug benefit
``Sec. 1935. (a) Requirement for Making Eligibility Determinations
for Low-Income Subsidy.--
``(1) In general.--As a condition of its State plan under
this title under section 1902(a)(66) and receipt of any Federal
financial assistance under section 1903(a), a State shall--
``(A) make determinations of eligibility for
subsidies under (and in accordance with) section
1845(g);
``(B) inform the Secretary of such determinations
in cases in which such eligibility is established; and
``(C) otherwise provide the Secretary with such
information as may be required to carry out section
1845.
``(2) State option for coverage of additional low-income
individuals.--A State may elect under paragraph (2)(B) of
section 1845(g) to cover additional low-income medicare
beneficiaries under the prescription drug subsidy program
provided under such subsection, subject to contribution under
subsection (c).
``(b) Payments for Additional Administrative Costs.--
``(1) In general.--The amounts expended by a State in
carrying out subsection (a) are, subject to paragraph (2),
expenditures reimbursable under the appropriate paragraph of
section 1903(a); except that, notwithstanding any other
provision of such section, the applicable Federal matching
rates with respect to such expenditures under such section
shall be increased as follows (but in no case shall the rate as
so increased exceed 100 percent):
``(A) For expenditures attributable to costs
incurred during 2005, the otherwise applicable Federal
matching rate shall be increased by 10 percent of the
percentage otherwise payable (but for this subsection)
by the State.
``(B)(i) For expenditures attributable to costs
incurred during 2006 and each subsequent year through
2013, the otherwise applicable Federal matching rate
shall be increased by the applicable percent (as
defined in clause (ii)) of the percentage otherwise
payable (but for this subsection) by the State.
``(ii) For purposes of clause (i), the `applicable
percent' for--
``(I) 2006 is 20 percent; or
``(II) a subsequent year is the applicable
percent under this clause for the previous year
increased by 10 percentage points.
``(C) For expenditures attributable to costs
incurred after 2013, the otherwise applicable Federal
matching rate shall be increased to 100 percent.
``(2) Coordination.--The State shall provide the Secretary
with such information as may be necessary to properly allocate
administrative expenditures described in paragraph (1) that may
otherwise be made for similar eligibility determinations.
``(c) State Contribution at SCHIP Matching Rate Towards Additional
Low-Income Subsidies for Optional Subsidy Eligible Individuals Covered
Under State Option.--In the case of a State that specifies a percent of
income under section 1845(g)(2)(B) for a quarter, the amount of payment
made to the State under section 1903(a)(1) for the quarter shall be
reduced by the product of--
``(1) 100 percent less the enhanced FMAP described in
section 2105(b) for that State and quarter; and
``(2) the additional amount of payment made under section
1845 because of the application of such specification.''.
(b) Phased-In Federal Assumption of Medicaid Responsibility for
Cost-Sharing Subsidies for Dually Eligible Individuals.--
(1) In general.--Section 1903(a)(1) (42 U.S.C. 1396b(a)(1))
is amended by inserting before the semicolon the following: ``,
reduced by the amount computed under section 1935(d)(1) for the
State and the quarter''.
(2) Amount described.--Section 1935, as inserted by
subsection (a)(2), is amended by adding at the end the
following new subsection:
``(d) Federal Assumption of Medicaid Prescription Drug Costs for
Dually-Eligible Beneficiaries.--
``(1) In general.--For purposes of section 1903(a)(1), for
a State that is one of the 50 States or the District of
Columbia for a calendar quarter in a year (beginning with 2005)
the amount computed under this subsection is equal to the
product of the following:
``(A) Medicare benefits for medicaid eligibles.--
The total amount of payments made in the quarter
because of the operation of section 1845 that are
attributable to individuals who are residents of the
State and are eligible for medical assistance with
respect to prescription drugs under this title.
``(B) State matching rate.--A proportion computed
by subtracting from 100 percent the Federal medical
assistance percentage (as defined in section 1905(b))
applicable to the State and the quarter.
``(C) Phase-out proportion.--The phase-out
proportion (as defined in paragraph (2)) for the
quarter.
``(2) Phase-out proportion.--For purposes of paragraph
(1)(C), the `phase-out proportion' for a calendar quarter in--
``(A) 2005 is 90 percent;
``(B) a subsequent year before 2014, is the phase-
out proportion for calendar quarters in the previous
year decreased by 10 percentage points; or
``(C) a year after 2013 is 0 percent.''.
(3) Medicaid providing wrap-around benefits.--Section 1935,
as so inserted and amended, is further amended by adding at the
end the following new subsection:
``(e) Medicaid as Secondary Payor.--In the case of an individual
who is entitled to benefits under part B of title XVIII and is eligible
for medical assistance with respect to prescribed drugs under this
title, medical assistance shall continue to be provided under this
title for prescribed drugs to the extent payment is not made under such
part B, without regard to section 1902(n)(2).''.
(d) Treatment of Territories.--
(1) In general.--Section 1935 of such Act, as so inserted
and amended, is further amended--
(A) in subsection (a) in the matter preceding
paragraph (1), by inserting ``subject to subsection
(f)'' after ``section 1903(a)'';
(B) in subsection (c)(1), by inserting ``subject to
subsection (f)'' after ``1903(a)(1)''; and
(C) by adding at the end the following new
subsection:
``(f) Treatment of Territories.--
``(1) In general.--In the case of a State, other than the
50 States and the District of Columbia--
``(A) the previous provisions of this section shall
not apply to residents of such State; and
``(B) if the State establishes a plan described in
paragraph (2) (for providing medical assistance with
respect to the provision of prescription drugs to
medicare beneficiaries under section 1845(g)), the
amount otherwise determined under section 1108(f) (as
increased under section 1108(g)) for the State shall be
increased by the amount specified in paragraph (3).
``(2) Plan.--The plan described in this paragraph is a plan
that--
``(A) provides medical assistance under section
1845(g) with respect to the provision of covered
outpatient drugs to low-income medicare beneficiaries
whose income does not exceed an income level specified
under the plan; and
``(B) assures that additional amounts received by
the State that are attributable to the operation of
this subsection are used only for such assistance.
``(3) Increased amount.--
``(A) In general.--The amount specified in this
paragraph for a State for a year is equal to the
product of--
``(i) the aggregate amount specified in
subparagraph (B); and
``(ii) the amount specified in section
1108(g)(1) for that State, divided by the sum
of the amounts specified in such section for
all such States.
``(B) Aggregate amount.--The aggregate amount
specified in this subparagraph for--
``(i) 2005, is equal to $25,000,000; or
``(ii) a subsequent year, is equal to the
aggregate amount specified in this subparagraph
for the previous year increased by annual
percentage increase specified in section
1845(a)(2)(B) for the year involved.
``(4) Report.--The Secretary shall submit to Congress a
report on the application of this subsection and may include in
the report such recommendations as the Secretary deems
appropriate.''.
(2) Conforming amendment.--Section 1108(f) (42 U.S.C.
1308(f)) is amended by inserting ``and section 1935(f)(1)(B)''
after ``Subject to subsection (g)''.
SEC. 202. IMPROVING ENROLLMENT PROCESS UNDER MEDICAID.
(a) Automatic Reenrollment Without Need To Reapply.--
(1) In general.--Section 1905(p) (42 U.S.C. 1396d(p)) is
amended--
(A) by redesignating paragraph (6) as paragraph
(9); and
(B) by inserting after paragraph (5), the following
new paragraph:
``(6) In the case of an individual who has been determined to
qualify as a qualified medicare beneficiary or to be eligible for
benefits under section 1902(a)(10)(E)(iii), the individual shall be
deemed to continue to be so qualified or eligible without the need for
any annual or periodic application unless and until the individual
notifies the State that the individual's eligibility conditions have
changed so that the individual is no longer so qualified or
eligible.''.
(2) Conforming amendment.--Section 1902(e)(8) (42 U.S.C.
1396a(e)(8)) is amended by striking the second sentence.
(b) Use of Simplified Application Process.--Such section 1905(p) is
further amended by adding at the end the following new paragraph:
``(7) A State shall permit individuals to apply to qualify as a
qualified medicare beneficiary or for benefits under section
1902(a)(10)(E)(iii) through the use of the simplified application form
developed under section 1905(p)(5)(A) and shall permit such an
application to be made over the telephone, the Internet, or by mail,
without the need for an interview in person by the applicant or a
representative of the applicant.''.
(c) Role of Social Security Offices.--
(1) Enrollment and provision of information at social
security offices.--Such section is further amended by adding at
the end the following new paragraph:
``(8) The Commissioner of Social Security shall provide, through
local offices of the Social Security Administration--
``(A) for the enrollment under State plans under this title
for appropriate medicare cost-sharing benefits for individuals
who qualify as a qualified medicare beneficiary or for benefits
under section 1902(a)(10)(E)(iii); and
``(B) for providing oral and written notice of the
availability of such benefits.''.
(2) Clarifying amendment.--Section 1902(a)(5) (42 U.S.C.
1396a(a)(5)) is amended by inserting ``as provided in section
1905(p)(10)'' before ``except''.
(d) Outstationing of State Eligibility Workers at SSA Field
Offices.--Section 1902(a)(55) (42 U.S.C. 1396a(a)(55)) is amended--
(1) by striking ``subsection (a)(10)(A)(i)(IV),
(a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), or (a)(10)(A)(ii)(IX)''
and inserting ``paragraph (10)(A)(i)(IV), (10)(A)(i)(VI),
(10)(A)(i)(VII), (10)(A)(ii)(IX), or (10)(E)''; and
(2) in subparagraph (A), by inserting ``and in the case of
applications of individuals for medical assistance under
paragraph (10)(E), at locations that include field offices of
the Social Security Administration''.
<all>
Introduced in House
Introduced in House
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.
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.
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.
Referred to the Subcommittee on Health.
Referred to the Subcommittee on Health.
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