Sec. 5. Ensuring beneficiary access to home infusion therapy
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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 to avoid the filing of duplicative or otherwise improper claims.
Specifically, the Secretary shall ensure that— the benefit is practical and workable with minimal administrative burden for beneficiaries, qualified home infusion therapy suppliers, 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; any prior authorization or utilization review process is expeditious, allowing Medicare beneficiaries meaningful access to home infusion therapy; medical necessity determinations for home infusion therapy will be made— except as provided in subparagraph (B), by Medicare administrative contractors under such part B and communicated to the appropriate prescription drug plans; or 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; except as otherwise provided in this section, the benefit is modeled on current private sector coverage and coding for home infusion therapy; and 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.
Not later than January 1, 2018, the Comptroller General of the United States shall submit a report to Congress on Medicare beneficiary access to home infusion therapy. Such report shall specifically address whether the objectives specified in subsection
(a)have been met and shall make recommendations to Congress and the Secretary of Health and Human Services on how to improve the benefit and better ensure that Medicare beneficiaries have timely and appropriate access to infusion therapy in their homes.