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What Are the Changes to Medicare Covered Home Infusion Services?

The 21st Century Cures Act (2018) expanded access to care and put patients over paperwork. One of the results was a new Medicare benefit: home infusion. An introductory period for the new service concluded with 2020, and the Home Health Final Rule for FY-2021 finalized the benefit changes. Changes to Medicare-covered home infusion services, or home infusion therapy (HIT), include a new Part B benefit category with an accompanying payment beginning January 1, 2021. Patients can now be covered for in-home infusions and required professional services for certain drugs and biologicals administered through a pump that is considered durable medical equipment (DME).

Changes to Medicare Covered Home Infusion Services

Firstly, let’s define what home infusion means. The Centers for Medicare and Medicaid Services (CMS) describes infusion services as “the intravenous (IV) or subcutaneous administration of drugs or biologics to an individual at home.”

Infusion requires DME such as an infusion pump, supplies, such as IV tubing, and professional nursing services for teaching, monitoring, and hands-on dressing changes.

What Is Covered by Medicare?

Medicare benefits consist of two parts. Part A coverage is for hospital services. Part B benefits are medical insurance that covers many medically necessary services such as:

●      Doctors’ services

●      Lab tests

●      Outpatient services

●      Preventative care

●      Durable Medical Equipment (DME)

●      Home Health services

Home Health services include in-home nursing visits, patient and caregiver training and instruction, and nursing observation and assessment. Before HIT was established as a separate covered benefit, the home infusion was provided either by Home Health, or in an outpatient clinic setting.

Medicare beneficiaries must meet certain requirements to qualify for Home Health, such as being homebound. Individuals who could not qualify had to travel to outpatient infusion centers for treatments. IV medications can be dosed up to four times per day.

If a patient were on multiple drugs, you can see how difficult such a treatment plan would be. It would be costly in terms of time and money.

New Medicare Coverage for 2021

The calendar year (CY) 2021 Final Rule, found here on the Federal Register, clarified the following related to HIT benefits:

●      Home infusion therapy is excluded from coverage under the Home Health benefit.

●      Providers must apply to become “suppliers” (complete CMS form 855B, pay an application fee)

●      HIT services must be furnished by a “qualified home infusion therapy supplier,” which is defined to mean “a pharmacy, physician, or another provider of services or supplier licensed by the State.”

●      Three new payment categories are established for payment.

●      The infusion pump and supplies, including the drug, are still covered under the Part B DME benefit; the administration and nursing services will be covered under the new Part B HIT benefit category.

●      Services for medications or biologicals not covered under the definition of “home infusion drugs” may still be provided and paid for under the Medicare Home Health benefit.

Medicare HIT Benefit Requirements

To qualify for home infusion therapy, a Medicare beneficiary must:

●      Have Part B coverage

●      Be under the care of a licensed physician, nurse practitioner, or physician assistant

●      Have a plan of care (POC) established and periodically reviewed by a physician prescribing the type, amount, and duration of infusion therapies

For individuals that meet these requirements, Medicare will now pay for the infusion at home. This change is also a huge cost-savings. Patients can avoid additional days in the hospital if infusion can be continued at home.

How Much Does Infusion Therapy Cost?

The economic burden is one part of the picture. Home infusion may cost up to $200 per day. This price is a fraction of a $4,000 hospital day.

But other costs are mitigated as well, including lost productivity. Individuals can return home and to their responsibilities sooner.

Other Medicare Changes for 2021

The HIT benefit was just one of a handful of major changes that CMS rolled out this year.

Among the Final Rule updates, were changes to the Home Health Prospective Payment System (PPS). A new case-mix model, called the Patient-Driven Groupings Model (PDGM), was put into effect. This new structure changes the pay for home health services and focuses on patient needs by relying heavily on patient characteristics rather than the care provided.

Additionally, CMS eliminated a home health pre-payment known as the Request for Anticipated Payment (RAP) in CY-2021. Home health companies once received their reimbursement in installments, including a portion up-front to start their care. However, now agencies are paid only at the submission of the final claim. CMS said that they believed eliminating the RAP would serve to mitigate fraud.

In the Home Health Final Rule 2021, Medicare made sweeping changes to home care coverage. One of the biggest updates was the addition of a HIT service category under Part B benefits. Medicare now covers in-home infusion and any associated services for approved drugs administered through a pump under this newly created service line. This welcomed change to the program has expanded access to care for those in need.

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