Section 50401 Of The Bipartisan Budget Act Of 2018
On February 9, 2018, the Bipartisan Budget Act of 2018 was signed into law. Section 50401 amended section 1834 of the Act, by adding a new paragraph that establishes a home infusion therapy services temporary transitional payment for eligible home infusion suppliers for certain items and services furnished in coordination with the furnishing of transitional home infusion drugs beginning January 1, 2019. This temporary payment covers the cost of the same items and services, as defined in section 1861 and of the Act, related to the administration of home infusion drugs. The temporary transitional payment would begin on January 1, 2019 and end the day before the full implementation of the home infusion therapy benefit on January 1, 2021, as required by section 5012 of the 21st Century Cures Act.
Does Medicare Cover Home Infusion Therapy
- Get the facts about Medicare coverage for home infusion therapy. Learn about the guidelines, and find out what parts of therapy Medicare is unlikely to cover.
The National Home Infusion Association reports that 3.2 million people receive home infusion therapy each year. In 2021, new guidelines for Medicare coverage for this commonly used at-home treatment went into effect. If you’re enrolled in Medicare, understanding the rules will help you better anticipate the cost of your care and increase the chances that your therapy will be covered by your plan.
Medicare Reimbursement For Home Infusion Antibiotics Amidst A Pandemic
The Centers for Medicare and Medicaid Services should immediately update current policies to include reimbursement for Medicare patients receiving intravenous antibiotics at home. The majority of these patients are over the age of 65 and at increased risk for severe illness due to severe acute respiratory syndrome coronavirus-2 . Requiring them to travel to an infusion center, stay in a skilled nursing facility or remain in the hospital longer than necessary to receive treatment results in avoidable risk of exposure amidst a pandemic. Current policy has significant implications for increased cost and harm to both these patients and the US healthcare system.
Streifel, A. C., and Sikka, M. K. The Urgent Need for Medicare Reimbursement for Home Infusion Antibiotics amidst a Pandemic. Clinical Infectious Diseases. May 28th. https://doi.org/10.1093/cid/ciaa658..
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Home Infusion Services Medicare Benefit Effective January 1 2021
Federal Register Vol 84, No. 217 released November 8, 2019
Section 4: Home Infusion Therapy Provisions
- The new Medicare home Infusion services benefit is provided in a Medicare beneficiarys home. The beneficiary must be currently under the care of a physician, nurse practitioner or physicians assistant. ).
- CMS defines which drugs are approved for home infusion. The medication must be a parenteral drug or biological administered intravenously or subcutaneously for an administration period of 15 minutes or more using an external pump that is a CMS-approved item of durable medical equipment.
- The requirement of an external infusion pump excludes insulin pump systems and any drugs or biologicals on the DME MAC local coverage decision self-administered drug exclusion list. This list can and does change.
- Self-administered = a drug that is self-administered by more than 50% of Medicare beneficiaries based on MAC analysis of Medicare claims data.
Reduced Utilization: A Red Flag
In the larger scheme of things, Medicare only offers home infusion benefits for a limited subset of drugsabout 30 medications that require an external infusion pump to administer. These drugs are covered under the Part B Durable Medical Equipment, Prosthetics, Orthotics and Supplies benefit. However, there are more than 100 medicationsincluding antibiotics, hydration and monoclonal antibodiescovered under Part D that are routinely administered at home using simple methods . Because they do not require a pump, these drugs are not eligible for Medicares Part B coverage of home administration supplies and services.
Among the medications for which home infusion services are covered, severely limited reimbursement and an improper interpretation of legislation intended to increase beneficiary access to care under the Part B benefit has actually worked to reduce the utilization of services. New data from the Centers for Medicare and Medicaid Services shows that utilization of Part B DMEPOS infusion drugs declined 2% from 2018 to 2019 and 31.3% from a six-year high in 2015 . In addition, provider participation in the program declined to its lowest point in five years . All this despite a new reimbursement model that includes payment for nursing services under the home infusion transitional benefit, which went into effect Jan. 1, 2019. A permanent benefit that included some modifications went into effect Jan. 1, 2021.
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Sound The Alarm: Home Infusion Utilization Dips
The COVID-19 crisis has reinforced the need to treat the most vulnerable patients at home. Home infusion pharmacies have been safely and effectively providing a wide range of intravenous medications to patients in their homes for more than 40 years. And, as in home nursing services, there has been a significant uptick in home infusion referrals for patients who are best served by avoiding facility-based care during and after the pandemic.
Home infusions proven model of care is overwhelmingly preferred by patients and is also cost effective compared to other sites of care. A 2017 study published in the journal Healthcare shows that up to 95% of patients who are dependent on IV medications prefer to be treated at home, and nearly 98% of patients indicated in a 2020 study in Infusion that they are highly satisfied with their home infusion services.
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Medicare And Home Infusion Therapy
Original Medicare covers part of the cost of home infusion therapy. However, you still have to cover your coinsurance under Medicare Part B.
In most cases, home infusion therapy means administering a drug intravenously through a needle or catheter in your home. But it may also include administering medicines or biologics through other nonoral such as injections into your muscles or the membranes surrounding your spinal cord.
In 2022, the global market size for home infusion therapy is $45.4 billion. The home infusion therapy market is projected to be worth $65.2 billion by 2030, according to Precedence Research.
Examples of Conditions Treated with Home Infusion Therapy
- Congestive heart failure
- Rheumatoid arthritis
Medicare has determined that certain infusion treatments can be safely and effectively performed at peoples homes. But it points out that home infusion therapy presents challenges different to those found at health care facilities.
Home infusion therapy requires medical coordination reaching well beyond your home. It requires patients, their doctors, home infusion pharmacies and the people who plan your hospital discharge to work together to guarantee you receive appropriate care.
In some cases, home health agencies may also have to be involved in your therapy.
Home Infusion Therapy Services
Home infusion therapy involves the intravenous or subcutaneous administration of drugs or biologicals to an individual at home. The components needed to perform home infusion include the drug , equipment , and supplies . Likewise, nursing services are necessary to train and educate the patient and caregivers on the safe administration of infusion drugs in the home. Visiting nurses often play a large role in home infusion. Nurses typically train the patient or caregiver to self-administer the drug, educate on side effects and goals of therapy, and visit periodically to assess the infusion site and provide dressing changes. The home infusion process typically requires coordination among multiple entities, including patients, physicians, hospital discharge planners, health plans, home infusion pharmacies, and, if applicable, home health agencies.
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Q What Is The Difference Between My Geisinger Home Infusion Services Nurse And My Home Health Nurse
A. The Geisinger Home Infusion Services nurse will contact you and/or your caregiver at the start of care. They will do the initial teaching regarding your home infusion therapy and will contact you and/or your caregiver periodically throughout the course of the prescribed therapy.Your home health nurse visits your home to assist with your therapy needs and continues teaching you and/or your caregiver, until you are comfortable with the infusion procedures. Your home health nurse should be the first person you call with questions regarding your therapy.
What Is Home Health Care
Home health care refers to services that are provided in the home to assist a person with a medical condition. These services can be “skilled” or “unskilled” .
Homecare is for people who are homebound. If you are able to get out of the house for needed medical care, your insurance company may not cover home care services. Homebound is defined as:
- Due to illness or injury, the patient requires the aid of supportive devices such as crutches, canes, wheelchairs, or walkers the use of special transportation or the assistance of another person in order to leave their place of residence.
- Leaving the patients home is medically contraindicated.
- The individual should be unable to leave home or leaving home must require a considerable and taxing effort.
However, there are some exceptions. You may still be considered homebound if you only leave home temporarily for medical care, such as attending a senior day program, going to dialysis, or receiving chemotherapy/radiation. Also, occasional absences from the home such as a trip to the hairdresser, a walk around the block, attendance at a wedding, funeral, or other infrequent or unique events are permitted while receiving homecare under homebound status.
Skilled services are typically covered by insurance. Non-skilled services are only covered if and when you have a skilled need for which you are receiving care.
Skilled needs include
- Physical/occupational/speech therapy.
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Which Part Of Medicare Covers Home Infusion Therapy
With Original Medicare, home infusion therapy falls under Medicare Part B. Medicare classifies the supplies needed for treatment as durable medical equipment. Under Medicare Part B, your plan pays for 80% of the cost of home infusion therapy. The remaining 20% of expenses related to home infusion therapy are your responsibility.
What Is Durable Medical Equipment
Durable medical equipment is any type of device that aids the patient in the home that improves quality of life. Examples of DME include walkers, wheelchairs, commodes, shower chairs, power scooters, oxygen, and hospital beds.
As with infusion and home care services, payment for medical equipment by insurance companies varies greatly. Any request for equipment submitted to the insurance company for payment must be medically necessary. Your healthcare team should order the equipment and is responsible for providing the equipment company with any necessary documentation to facilitate payment. You may be responsible for a monthly rental fee for some types of equipment. Most insurances will not cover two types of assistive devices i.e. you cant get a walker and a wheelchair covered by the insurance company at the same time.
You can privately purchase some DME, like canes, shower chairs, adult diapers, and commodes at local drug stores or online. This can also be cost-effective as you may actually pay less to buy the equipment rather than paying monthly rental fees.
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Q Do I Get My Wound Care Supplies From Geisinger Home Infusion Services
A. No. Geisinger Home Infusion Services only supplies those items required for your home infusion therapy.
If a home health agency is coming into your home for services, they may provide the wound care supplies to you.
Otherwise, you will need to contact your insurance company to assist you regarding coverage through a durable medical supplier in your area.
What Will Medicare Part B Cover For Home Infusion Therapy
Medicare Part B typically covers all the supplies required for home infusion therapy, such as:
In addition, Medicare Part B will usually cover the drugs used for home infusion therapy, provided they are administered under the skin or with an IV over a period of at least 15 minutes. Some covered drugs include:
- Antivirals like acyclovir and foscarnet sodium for treating viruses
- Antifungals like amphotericin for treating fungal infections
- Cancer drugs like doxorubicin hydrochloride and bleomycin sulfate
- Cardiovascular drugs like dobutamine hydrochloride and milrinone lactate
- Deferoxamine mesylate for treating high levels of iron in people who have undergone blood transfusions
- Immune globulin, which are antibodies that help your body fight infections
- Pain medications like hydromorphone and morphine
Your Medicare Part B plan also typically covers the fees that the supplier charges for each visit to perform home infusion therapy.
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Q How Often Will I Talk To Someone From Geisinger Home Infusion Services
A. You will talk to Geisinger Home Infusion Services personnel at the start of care and at least weekly if you are to receive IV medications.If you are receiving monthly growth hormone, enteral formula/supplies or catheter care supplies, you will speak to Geisinger Home Infusion Services personnel monthly. A Geisinger Home Infusion Services pharmacist, nurse and administrator are on call 24 hours a day to assist you, too
Addressing The Core Issues
Congress included provisions in the 21st Century Cures Act and the Bipartisan Budget Act of 2018 to create a professional services benefit for Medicare Part B home infusion drugs. The intent in establishing this benefit was to maintain patient access to home infusion by covering professional services, including assessments education on administration and access device care monitoring and remote monitoring coordination with the patient, caregivers and other health care providers and nursing visits. Despite Congresss intent, CMS improperly implemented the benefit by requiring a nurse to be physically present in the patients home for providers to be reimbursed. As a practical matter, the current home infusion therapy benefit only acknowledges face-to-face visits from a nurse and fails to account for the extensive clinical and administrative services that are provided remotely by home infusion clinicians.
The Cures Act also broadened the definition of a home infusion therapy services supplier to include physicians, home health agencies and othersin addition to infusion pharmacies. However, as of March 2021, fewer than than 250 total suppliers have enrolled nationwide. If CMSs goal was to recruit nursing agencies to the benefit, the effort appears to be falling short. Only 41 nursing agencies in 12 states have enrolled to provide services, and 59% of the 41 are located in just three states.
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Do Medicare Advantage Plans Cover Home Infusion Therapy
Medicare Advantage Plans must cover at least as much as Original Medicare. Your plan is likely to pay for the same supplies, medications and services for home infusion therapy described above. Plans may opt to cover more than Original Medicare. Normally, your Medicare Advantage Plan pays for most of the cost of covered services, and you are responsible for a copay or coinsurance.
The 21st Century Cures Act
On December 13, 2016, the 21st Century Cures Act was enacted into law. Section 5012 of this new law amended sections 1861 and 1861 of the Act, and established a new Medicare home infusion therapy benefit. The Medicare home infusion therapy benefit is for coverage of home infusion therapy-associated professional services for certain drugs and biologicals administered intravenously, or subcutaneously through a pump that is an item of DME, effective January 1, 2021. Section 1861 of the Act defines home infusion therapy to include the following items and services: the professional services , furnished in accordance with the plan, training and education , remote monitoring, and other monitoring services for the provision of home infusion therapy furnished by a qualified home infusion therapy supplier in the patients home.
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Q Does Medicare Cover Home Infusion
A. Certain therapies are covered when administered using a mechanical or electronic infusion pump.
Only a select few therapies are covered and only under very specific conditions. These include antiviral therapies, some chemotherapies, some ionotropic therapies and some pain management therapies.
For more information, visit What Medicare Covers on the Medicare web site.
Medicare Coverage For Home Infusion
Ah, election timehow I love the hordes of direct mailers, the nasty negative campaign ads, and the elusive non-answers given to moderator questions at the debates. But yet there is hope at election time. Hope that there can still be change for the better, that our elected officials will overcome their political biases and work together for the better of all Americans. One easy fix for the slew of problems facing our nations health care system is to change Medicare guidelines to expand coverage for home infusion patients. We recently published an article explaining in detail how the lack of Medicare funding increases patient costs, puts patients at risks, and how it can be addressed by our lawmakers. We encourage you to reach out to your elected officials and let them know about this issue. Read on for the full text of the article.
FULL TEXT OF ARTICLE
Sadly, the patient in Blaine was covered by Medicare. This means that he would not have access to home infusion services, because Medicare does not pay for a majority of the costs associated with the care. Medicare Part D will help cover the costs of the drugs involved, but not the supplies, equipment, and pharmacy-related services that make up more than half the cost of the therapy. This patient now had three choices: travel to and from the hospital out-patient facility everyday for his medicine check into a skilled nursing home for 6-8 weeks or pay us out-of-pocket for our services.
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