H.R. 1845: Medicare IVG Access Act, as amended

H.R. 1845

Medicare IVG Access Act, as amended

Date
December 19, 2012 (112th Congress, 2nd Session)

Staff Contact
Communications

Floor Situation

On Wednesday, December 19, 2012, the House is scheduled to consider H.R. 1845, as amended, under a suspension of the rules requiring a two-thirds majority vote for passage. The bill was introduced by Rep. Kevin Brady (R-TX) on May 11, 2011, and referred to the Committee on Energy and Commerce and the Committee on Ways and Means. The bill also includes language from H.R. 1063, the Strengthening Medicare and Repaying Taxpayers (SMART) Act of 2011, which was introduced on March 14, 2011, and referred to the Committee on Energy and Commerce and the Committee on Ways and Means. The Committee on Energy and Commerce Subcommittee on Health held a markup on September 11, 2012, and reported the bill, as amended, to the full committee. The full committee held a markup on September 20, 2012 and ordered the bill, as amended, to be reported by voice. The following Legislative Digest is based on the text of the bill as posted on the House Majority Leader’s website.

Bill Summary

H.R. 1845 as amended, would create a demonstration project to provide in-home coverage of intravenous immune globulin (IVIG) services and supplies. In addition, the bill would reform Medicare secondary payer requirements (the same provision contained in H.R. 1063, as amended, the SMART Act).

Title I: Medicare IVIG Access

The bill would establish a three-year demonstration project providing comprehensive Part B coverage, including items and services, for up to 4,000 Medicare beneficiaries with primary immune deficiency disease (PIDD). Under the demonstration project, the Centers for Medicare and Medicaid Services (CMS) will establish a Part B payment amount, based on what Medicare pays home health agencies for similar services, for the IVIG home administration items and services. The bill would require CMS to submit an interim evaluation to Congress within three years of the bill’s enactment. The bill would also require CMS to submit a final evaluation to Congress no later than one year after the date of completion of the demonstration project.

Title II: Strengthening Medicare Secondary Payer Rules

The bill would direct CMS to maintain a web portal whereby individual beneficiaries can access claims paid. The bill would require parties to notify CMS 120 days from settlement. CMS would then have 65 days to ensure the website is up to date with the latest claims paid (CMS would be required to update no later than 15 days after receipt). Parties would then be able to draw down the final amount from the website for use in settlement.  The bill would require final notice to be drawn down no more than 3 days from date of settlement.

The bill would also introduce a threshold below which Medicare Secondary Payer (MSP) rules will not apply to ensure that the federal government does not spend more money pursuing an MSP claim then it could recover from that claim. The bill would require the Secretary to calculate the threshold annually with GAO review to equal the amount of settlement likely to yield an MSP collection at or below the government’s recovery cost.

H.R. 1845 would also direct CMS to develop an alternative to Social Security Numbers (SSNs) when filing. The bill would establish a statute of limitations for all MSP claims. The bill would clarify that the three-year MSP statute of limitations (measured from the date of reporting) covers all MSP claims.

Background

According to the bill’s sponsor, there are approximately 10,000 Medicare beneficiaries living with PIDD, a disease that leaves the patient unable to produce protective antibodies or to develop immunity to help the body fight serious infections. Regular infusions of IVIG allow PIDD patients to maintain their health and fight disease. According to the Committee on Ways and Means, Medicare Part B provides comprehensive coverage for these components when IVIG is administered in a physician’s office or a hospital outpatient department, however, it only covers the IVIG itself when it is administered in a beneficiary’s home (leaving the beneficiary to pay the full cost of the needed items and services).  These out-of-pocket costs deter beneficiaries from receiving IVIG in their home. As a result, PIDD patients must go to a hospital to receive IVIG treatment, which can further compromise their already weakened immune systems.

The SMART Act would modify the process through which the Medicare program is reimbursed when another payer is responsible for a beneficiary’s medical costs. According to the Committee on Ways and Means, the Medicare Secondary Payer (MSP) program prohibits Medicare payments for any item or service when payment has been made or can reasonably be expected to be made by a third-party payer. The MSP process is designed and intended to make sure the taxpayer and Medicare trust funds are protected from paying for care that is the responsibility of other parties. A provision in the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) requires insurers to report to CMS every settlement or other payment made to a beneficiary. A penalty of $1,000 perday perclaim applies for failure to report properly. The reporting and reimbursement obligations are complicated, and CMS does not provide a repayment amount until after parties have settled, so cases involving beneficiaries are difficult to settle. The bill would make it easier for other payers to repay Medicare, thus reducing program costs.

Cost

A CBO score of H.R. 1845, as amended, was not available as of press time. CBO has provided a cost estimate for H.R. 1063, the SMART Act, stating that enacting the bill would reduce Medicare spending by $45 million over the 2013-2022 period.