BILL REQ. #:  S-5096.1 

Read first time 02/07/2006.   Referred to Committee on Ways & Means.

     AN ACT Relating to providing continuing coverage for medicare part D beneficiaries; and adding a new section to chapter 74.09 RCW.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

NEW SECTION.  Sec. 1   A new section is added to chapter 74.09 RCW to read as follows:
     (1) Only to the extent that funds are appropriated for this purpose, the department shall provide drug benefits to a full-benefit dual eligible beneficiary who is not able to obtain drug benefits from his or her medicare drug plan only when one or more of the following conditions are met:
     (a) The pharmacy has submitted a claim for the provision of drug benefits to the full-benefit dual eligible beneficiary's medicare drug plan and the claim has been denied payment for reasons other than processing errors or omissions made by the pharmacy, lack of medical necessity, or health or safety reasons.
     (b) The pharmacy is unable to submit a claim for the provision of drug benefits solely due to the unavailability of complete or accurate medicare drug plan enrollment information from the full-benefit dual eligible beneficiary's medicare drug plan, the federal centers for medicare and medicaid services, or entities under contract with the centers for medicare and medicaid services to provide enrollment information.
     (c) The medicare drug plan provides information that the full-benefit dual eligible beneficiary's deductible or copayment amount is higher than the copayment amounts that are established by medicare for full-benefit dual eligible beneficiaries.
     (d) The full-benefit dual eligible beneficiary cannot pay, in whole or in part, the copayment amounts that are established by medicare for full-benefit dual eligible beneficiaries.
     (2) The secretary may impose a preservice or postservice prepayment or postpayment review or audit to determine whether a pharmacy has accurately and in good faith established the existence of any condition certified by the pharmacy pursuant to subsection (1)(a), (b), (c), or (d) of this section in support of a submitted claim to the department.
     (3) If the claim submitted by the pharmacy to the medicare drug plan meets the circumstances described in subsection (1)(c) of this section, the department shall pay the medicaid rate less the medicare drug plan reimbursement amount.
     (4) To obtain reimbursement from the department, a pharmacy must be an enrolled provider in the medicaid program and certify on its claims under penalty of perjury that one of the conditions specified in subsection (1) of this section exists.
     (5) The department shall seek reimbursement from the federal government of all funds spent to comply with the provisions of this section.
     (6) To the extent that the department reimburses a pharmacy for claims authorized under this section, the secretary may recover or recoup the full cost expended by the state for that reimbursement from the full-benefit dual eligible beneficiary's medicare drug plan.
     (7) Any drug benefits made available to full-benefit dual eligible beneficiaries under the authority of this section shall be limited to the funds appropriated by the legislature to the department for this purpose. These drug benefits shall not be deemed to be an entitlement.
     (8) Drug benefits under this section shall be available only until the secretary declares that operational problems associated with the implementation of the medicare drug plan have been resolved.
     (9) For the purposes of this section:
     (a) "Full-benefit dual eligible beneficiary" means an individual who meets both of the following criteria:
     (i) The beneficiary is eligible or would be eligible for coverage for the month for covered part D drugs under a prescription drug plan under part D of Title XVIII of the social security act (42 U.S.C. Sec. 1395w-101 et seq.) or under a MA-PD plan under part C of Title XVIII of the social security act (42 U.S.C. Sec. 1395w-21 et seq.).
     (ii) The beneficiary is determined eligible for full scope services, including drug benefits, for which federal financial participation is available.
     (b) "Medicare drug plan" means a prescription drug plan under part D of Title XVIII of the social security act (42 U.S.C. Sec. 1395w-101 et seq.) or under a MA-PD plan under part C of Title XVIII of the social security act (42 U.S.C. Sec. 1395w-21 et seq.).