[Congressional Bills 112th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2195 Introduced in House (IH)]

112th CONGRESS
  1st Session
                                H. R. 2195

  To amend title XVIII of the Social Security Act to provide for the 
     coverage of home infusion therapy under the Medicare Program.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             June 15, 2011

 Mr. Engel (for himself, Mr. Murphy of Pennsylvania, and Ms. Baldwin) 
 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 provide for the 
     coverage of home infusion therapy under the Medicare Program.

    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 ``Medicare Home Infusion Therapy 
Coverage Act of 2011''.

SEC. 2. FINDINGS.

    Congress finds the following:
            (1) The Medicare program is presently the only major health 
        care payer in the country that does not provide comprehensive 
        coverage of home infusion therapy.
            (2) As a result of the Medicare program not providing for 
        comprehensive coverage of home infusion therapy, many Medicare 
        beneficiaries are unable to obtain infusion therapy in the most 
        cost-effective and convenient setting of their homes.
            (3) The Medicare program is paying for institutional care 
        for the provision of infusion therapy in many instances when 
        such institutional care could be avoided if the Medicare 
        program provided coverage for home infusion therapy.
            (4) The Government Accountability Office found in a 2010 
        report that home infusion therapy is utilized widely by private 
        payors providing health insurance coverage for individuals 
        enrolled under such coverage and that such private payors 
        generally are satisfied with the quality of care and the 
        savings they achieve through avoided institutionalizations.

SEC. 3. MEDICARE COVERAGE OF HOME INFUSION THERAPY.

    (a) In General.--Section 1861 of the Social Security Act (42 U.S.C. 
1395x) is amended--
            (1) in subsection (s)(2)--
                    (A) by striking ``and'' at the end of subparagraph 
                (EE);
                    (B) by adding ``and'' at the end of subparagraph 
                (FF); and
                    (C) by adding at the end the following new 
                subparagraph:
            ``(GG) home infusion therapy (as defined in subsection 
        (iii)(1));''; and
            (2) by adding at the end the following new subsection:

                        ``Home Infusion Therapy

    ``(iii)(1) The term `home infusion therapy' means the following 
items and services furnished to an individual, who is under the care of 
a physician, which are provided by a qualified home infusion therapy 
provider under a plan (for furnishing such items and services to such 
individual) established and periodically reviewed by a physician, which 
items and services are provided in an integrated manner in the 
individual's home in conformance with uniform standards of care 
established by the Secretary (after taking into account the standards 
commonly used for home infusion therapy by Medicare Advantage plans and 
in the private sector and after consultation with all interested 
stakeholders) and in coordination with the provision of covered 
infusion drugs under part D:
            ``(A) Professional services other than nursing services 
        provided in accordance with the plan (including administrative, 
        compounding, dispensing, distribution, clinical monitoring and 
        care coordination services) and all necessary supplies and 
        equipment (including medical supplies such as sterile tubing 
        and infusion pumps, and other items and services the Secretary 
        determines appropriate) to administer infusion drug therapies 
        to an individual safely and effectively in the home.
            ``(B) Nursing services provided in accordance with the 
        plan, directly by a qualified home infusion therapy provider or 
        under arrangements with an accredited homecare organization, in 
        connection with such infusion, except that such term does not 
        include nursing services to the extent they are covered as home 
        health services.
    ``(2) For purposes of paragraph (1):
            ``(A) The term `home' means a place of residence used as an 
        individual's home and includes such other alternate settings as 
        the Secretary determines.
            ``(B) The term `qualified home infusion therapy provider' 
        means any pharmacy, physician, or other provider licensed by 
        the State in which the pharmacy, physician, or provider resides 
        or provides services, whose State authorized scope of practice 
        includes dispensing authority and that--
                    ``(i) has expertise in the preparation of 
                parenteral medications in compliance with enforceable 
                standards of the U.S. Pharmacopoeia and other 
                nationally recognized standards that regulate 
                preparation of parenteral medications as determined by 
                the Secretary and meets such standards;
                    ``(ii) provides infusion therapy to patients with 
                acute or chronic conditions requiring parenteral 
                administration of drugs and biologicals administered 
                through catheters or needles, or both, in a home; and
                    ``(iii) meets such other uniform requirements as 
                the Secretary determines are necessary to ensure the 
                safe and effective provision and administration of home 
                infusion therapy on a 7 day a week, 24 hour basis 
                (taking into account the standards of care for home 
                infusion therapy established by Medicare Advantage 
                plans and in the private sector), and the efficient 
                administration of the home infusion therapy benefit.
        A qualified home infusion therapy provider may subcontract with 
        a pharmacy, physician, provider, or supplier to meet the 
        requirements of this subsection.''.
    (b) Payment for Home Infusion Therapy.--Section 1834 of the Social 
Security Act (42 U.S.C. 1395m) is amended by adding at the end the 
following new subsection:
    ``(p) Payment for Home Infusion Therapy.--The payment amount under 
this part for home infusion therapy is determined as follows:
            ``(1) In general.--The Secretary shall determine a per diem 
        schedule for payment for the professional services, supplies, 
        and equipment described in section 1861(iii)(1)(A) that 
        reflects the reasonable costs which must be incurred by 
        efficiently and economically operated qualified home infusion 
        therapy providers to provide such services, supplies, and 
        equipment in conformity with applicable State and Federal laws, 
        regulations, and the uniform quality and safety standards 
        developed under section 1861(iii)(1) and to assure that 
        Medicare beneficiaries have reasonable access to such therapy. 
        The Secretary shall update such schedule from year to year by 
        the percentage increase in the consumer price index for all 
        urban consumers (United States city average) for the 12-month 
        period ending with June of the preceding year.
            ``(2) Nursing services.--The Secretary shall develop a 
        methodology for the separate payment for nursing services 
        described in section 1861(hhh)(1)(B) provided in accordance 
        with the plan under such section which reflects the reasonable 
        costs incurred in the provision of nursing services in 
        connection with infusion therapy in conformity with State and 
        Federal laws, regulations, and the uniform quality and safety 
        standards developed pursuant to this Act and to assure that 
        Medicare beneficiaries have reasonable access to nursing 
        services for infusion therapy. The Secretary shall update such 
        schedule from year to year by the percentage increase in the 
        consumer price index for all urban consumers (United States 
        city average) for the 12-month period ending with June of the 
        preceding year.''.
    (c) Conforming Amendments.--
            (1) Payment reference.--Section 1833(a)(1) of the Social 
        Security Act (42 U.S.C. 13951(a)(1)) is amended--
                    (A) by striking ``and'' before ``(Z)''; and
                    (B) by inserting before the semicolon at the end 
                the following: ``, and (AA) with respect to home 
                infusion therapy, the amounts paid shall be determined 
                under section 1834(p)''.
            (2) Direct payment.--The first sentence of section 
        1842(b)(6) of such Act (42 U.S.C. 1395u(b)(6)) is amended--
                    (A) by striking ``and'' before ``(H)''; and
                    (B) by inserting before the period at the end the 
                following: ``, and (I) in the case of home infusion 
                therapy, payment shall be made to the qualified home 
                infusion therapy provider''.
            (3) Exclusion from durable medical equipment and home 
        health services.--Section 1861 of such Act (42 U.S.C. 1395x) is 
        amended--
                    (A) in subsection (m)(5), by inserting ``and 
                supplies used in the provision of home infusion 
                therapy'' after ``excluding other drugs and 
                biologicals''; and
                    (B) in subsection (n), by adding at the end the 
                following: ``Such term does not include home infusion 
                therapy, other than equipment and supplies used in the 
                provision of insulin.''.
            (4) Application of accreditation provisions.--The 
        provisions of section 1865(b) of the Social Security Act (42 
        U.S.C. 1395bb(b)) apply to the accreditation of qualified home 
        infusion therapy providers in the manner they apply to other 
        suppliers.

SEC. 4. MEDICARE COVERAGE OF HOME INFUSION DRUGS.

    (a) In General.--Section 1860D-2(e)(1) of the Social Security Act 
(42 U.S.C. 1395w-102(e)(1)) is amended--
            (1) in paragraph (1)--
                    (A) by striking ``or'' at the end of subparagraph 
                (A);
                    (B) by striking the comma at the end of 
                subparagraph (B) and inserting ``; or''; and
                    (C) by inserting before the flush matter following 
                subparagraph (B) the following new subparagraph:
                    ``(C) an infusion drug (as defined in paragraph 
                (5)),''; and
            (2) by adding at the end the following new paragraph:
            ``(5) Infusion drug defined.--For purposes of this part, 
        the term `infusion drug' means a parenteral drug or biological 
        administered via an intravenous, intraspinal, intra-arterial, 
        intrathecal, epidural, subcutaneous, or intramuscular access 
        device inserted into the body, and includes a drug used for 
        catheter maintenance and declotting, a drug contained in a 
        device, vitamins, intravenous solutions, diluents and minerals, 
        and other components used in the provision of home infusion 
        therapy.''.
    (b) Infusion Drug Formularies.--For the first 2 years after the 
date of the enactment of this Act, notwithstanding any other provision 
of law, prescription drug plans and MA-PD plans under title XVIII of 
the Social Security Act shall maintain open formularies for infusion 
drugs (as defined in section 1860D-2(e)(5) of such Act, as added by 
subsection (a)). The Secretary of Health and Human Services shall 
request the United States Pharmacopeia to develop, in consultation with 
representatives of qualified home infusion therapy providers and other 
interested stakeholders, a model formulary approach for home infusion 
drugs for use by such plans after such 2-year period.
    (c) Part D Dispensing Fees.--Section 1860D-2(d)(1)(B) of the Social 
Security Act (42 U.S.C. 1395w-102(d)(1)(B)) is amended by inserting 
after ``any dispensing fees for such drugs'' the following: ``, other 
than for an infusion drug''.

SEC. 5. ENSURING BENEFICIARY ACCESS TO HOME INFUSION THERAPY.

    (a) Objectives in Implementation.--The Secretary of Health and 
Human Services shall implement the Medicare home infusion therapy 
benefit under the amendments made by this Act in a manner that ensures 
that Medicare beneficiaries have timely and appropriate access to 
infusion therapy in their homes and that there is rapid and seamless 
coordination between drug coverage under part D of title XVIII of the 
Social Security Act and coverage for home infusion therapy services 
under part B of such title. Specifically, the Secretary shall ensure 
that--
            (1) the benefit is practical and workable with minimal 
        administrative burden for beneficiaries, qualified home 
        infusion therapy providers, physicians, prescription drug 
        plans, MA-PD plans, and Medicare Advantage plans, and the 
        Secretary shall consider the use of consolidated claims 
        encompassing covered part D drugs and part B services, 
        supplies, and equipment under such part B to ensure the 
        efficient operation of this benefit;
            (2) any prior authorization or utilization review process 
        is expeditious, allowing Medicare beneficiaries meaningful 
        access to home infusion therapy;
            (3) medical necessity determinations for home infusion 
        therapy will be made--
                    (A) except as provided in subparagraph (B), by 
                medicare administrative contractors under such part B 
                and communicated to the appropriate prescription drug 
                plans; or
                    (B) in the case of an individual enrolled in a 
                Medicare Advantage plan, by the Medicare Advantage 
                organization offering the plan;
        and an individual may be initially qualified for coverage for 
        such benefit for a 90-day period and subsequent 90-day periods 
        thereafter;
            (4) the benefit is modeled on current private sector 
        coverage and coding for home infusion therapy; and
            (5) prescription drug plans and MA-PD plans structure their 
        formularies, utilization review protocols, and policies in a 
        manner that ensures that Medicare beneficiaries have timely and 
        appropriate access to infusion therapy in their homes.
    (b) Home Infusion Therapy Advisory Panel.--In implementing such 
home infusion therapy benefit and meeting the objectives specified in 
subsection (a), the Secretary shall establish an advisory panel to 
provide advice and recommendations. Such panel shall--
            (1) be comprised primarily of qualified home infusion 
        therapy providers and their representative organizations; and
            (2) also include representatives of the following:
                    (A) Patient organizations.
                    (B) Hospital discharge planners, care coordinators, 
                or social workers.
                    (C) Prescription drug plan sponsors and Medicare 
                Advantage organizations.
    (c) Report.--Not later than January 1, 2014, and every 2 years 
thereafter, the Comptroller General of the United States shall submit a 
report to Congress on Medicare beneficiary access to home infusion 
therapy. Each such report shall specifically address whether the 
objectives specified in subsection (a) have been met and shall make 
recommendations to Congress and the Secretary on how to improve the 
benefit and better ensure that Medicare beneficiaries have timely and 
appropriate access to infusion therapy in their homes.

SEC. 6. EFFECTIVE DATE.

    The amendments made by this Act shall apply to home infusion 
therapy furnished on or after January 1, 2012.
                                 <all>