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Does Medicare Pay For Home Infusion Of Antibiotics

The 21st Century Cures Act

Medicare Basics: Parts A, B, C & D

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.

Congress Introduces New Legislation Designed For Medicare Patients In Need Of Part B Home Infusion Medications

A bipartisan coalition in Congress has introduced new legislation designed to ensure Medicare patients have access to Part B home infusion medications.

A bipartisan coalition in Congress has introduced new legislation, called the Preserving Patient Access to Home Infusion Act, designed to ensure Medicare patients have access to Part B home infusion medications, known as the Preserving Patient Access to Home Infusion Act.

The recent outbreak of the coronavirus has emphasized the importance of home-based treatments for vulnerable patients across the United States. Home infusion therapy keeps high-risk patients with serious infections, heart failure, immune diseases, cancer, and other conditions out of institutional settings, allowing them to receive treatment at home.

The Preserving Patient Access to Home Infusion Act has a goal of ensuring patients with Medicare access to infused medication covered under the Medicare B durable medical equipment benefit.

Despite Congress intent, the Center for Medicare and Medicaid improperly implemented the benefit by requiring a nurse to be physically present in the patients home in order for providers to be reimbursed, according to the NHIA.

In response, the NHIA has been working with stakeholders and legislators over the past several months to advocate for Congress intended implementation of the 21st Century Cures Act.

Reference

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Where Do I Find A List Of Drugs Covered By Medicare Part D

Medicare Part D drug coverage can vary from one plan to another. The list of drugs covered by a Part D plan is called a formulary.

Part D plans typically cover a wide range of drugs. And while the formularies can vary by plan, there are certain drugs that must be covered by every Part D plan, such as cancer drugs or HIV/AIDS medications.

Part D plans cover both generic and name brand drugs and typically do so at different tiers. Common generic drugs are typically placed into a lower tier and typically covered at a lower cost, while rare or brand name drugs are placed into a higher tier and may require more costs to the beneficiary.

Each plans formulary can usually be found along with its summary of benefits. When shopping for a Part D plan , the drug formulary should be listed alongside the other plan details.

Its important to note that a plans formulary can change every year as drugs may be added to or dropped from a particular plans benefits, or a drug may be moved to a different coverage tier.

If there is a specific drug you want to obtain coverage for, contact a licensed insurance agent and they will be able to gather up the plans available in your area that provide coverage for your medication.

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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.

Medicare And Home Infusion Ivig: What You Need To Know

Federal Register :: Medicare and Medicaid Programs  CY 2020 Home Health ...

Medicare is confusing thats a fact! Add the confusing Medicare system on top of a complex treatment for a rare disease, and its easy to feel overwhelmed. The Foundation is here to help all of our patients navigate health insurance headaches! For now this article explains the current Medicare situation for our friends living with CIDP and MMN who are on Medicare and want to access home infusion for their IVIG treatments.

Lets start with a quick review of Medicare and its parts:

  • Medicare Part A
  • Everyone is automatically enrolled in Part A when they apply for Medicare
  • Covers hospital costs
  • No monthly premium, but there is a high deductible
  • Considered part of the Original Medicare benefits
  • Medicare Part B
  • Everyone is automatically enrolled in Part B when they apply for Medicare, and most people pay a monthly premium for this coverage
    • Medicare pays 80% of Medical costs
    • You can purchase a Medigap plan to cover the other costs, including the 20% copay required by Medicare. The Foundation strongly recommends that people with Medicare purchase a Medigap plan
    • Note- Medigap plans are not always offered to people under 65 years old. Contact the Foundation for help with this situation.
    • Covers doctors visits, general outpatient services, and some prescriptions, and is considered one of the Original Medicare benefits
  • Medicare Part C
  • Medicare Advantage Plans
    • Provided by a private insurer that follows rules set by the Medicare office
  • Medicare Part D
  • Contact:

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    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.

    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.

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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.

    Q Does Medicare Cover Home Infusion

    Is Medicare Advantage Right For You? UnitedHealthcare

    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.

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    Medicare Reimbursement For Home Infusion Antibiotics Amidst A Pandemic

    ReTweet

    Abstract:

    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.

    Reference:

    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..

    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.

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    Will Medicare Pay For Infusion Therapy

    Full Question: My husband was recently in the hospital for a pacemaker implant. He was set to come home but developed a staph infection and a blood clot. He now has to receive an antibiotic infusion for six to eight weeks.Medicare would not pay for home infusion, so he has to travel 30 minutes to the infusion center every day. Is there anything we can do?

    Answer: Probably not. Infusion therapy means administering drugs intravenously, and although it can be done in settings such as outpatient centers, hospitals or nursing homes, many patients would prefer to receive their drugs at home. But even though most private health plans and some Medicare Advantage managed care plans pay for home infusion, the traditional Medicare fee-for-service program generally does not.

    Theres an exception for roughly 30 drugs that must be administered using an IV infusion pump. These are covered under Medicare Part Bs durable medical equipment benefit. But Medicare generally wont pick up the tab to intravenously administer other drugs such as antibiotics at home, even though the drugs themselves may be covered under Part D, Medicares prescription drug benefit. Its a basic flaw, says Russ Bodoff, president and CEO of the National Home Infusion Association, a trade group for home infusion providers. Every site of care is covered except the home.

    : Michelle Andrews, Seattle/LocalHealthGuide 8/12/2014

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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 Is Home Infusion Therapy

    Home infusion therapy is the term for receiving a drug intravenously at home. Depending on the type of medication, a needle or a catheter will be used. The therapy allows you to undergo treatment for a medical condition or illness at home rather than in a hospital setting. All home infusion therapy is done by a medical professional usually a registered nurse. Drugs that you can administer on your own via a simple injection don’t qualify as home infusion therapy.

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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.

    Section 5012 Of The 21st Century Cures Act

    Medicare & You: Different Parts Of Medicare

    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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    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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