Medicare Limits on Coverage for Home Infusions Should Be Corrected

Individuals in traditional Medicare who require intravenous or injectable medications are often stunned to learn they have to leave home to obtain this necessary care. This is true even when they are receiving other Medicare-covered home health services.

Obtaining coverage for both the medication and the professional services necessary for the infusion or injections requires billing both Medicare Parts D and B.  However, Medicare Part B only pays for the administration of certain types of drugs that cannot be self-administered, and only when provided in an outpatient setting, such as a hospital, infusion center, or doctor’s office.  Medicare Part D will cover the intravenous or injectable medications covered under a beneficiary’s prescription drug plan, but not the skilled services and necessary supplies required to actually administer the medication.

When beneficiaries are unable to travel to an approved outpatient setting or need to receive their infusions at home, traditional Medicare will not cover the professional services, equipment or medication. Most beneficiaries are thus forced to travel to an outpatient setting in order to receive Part B coverage for the skilled services and equipment.

The outpatient requirement under Part B effectively denies Medicare coverage for home infusions and forces medically compromised beneficiaries to leave home in order to receive intravenous or injectable medications. This requirement puts vulnerable patients at risk of further illness, infection and injury. Further, the outpatient requirement adds to the overall cost of treating beneficiaries, creating unnecessary expenses to the Medicare program.

Medicare Advantage and Private Insurance Covers Home Infusion

Importantly, most private insurance and Medicare Advantage plans do cover both the medication and professional services in the home for some time. Unfortunately, traditional Medicare continues to lag behind in this regard.

The Centers for Medicare & Medicaid Services (CMS) takes the position that it does not have authority to cover home infusions under Part D. The National Home Infusion Association (NHIA) has spearheaded efforts to change the law and is actively supporting The Medicare Home Infusion Site of Care Act of 2015 (S.275/HR 605). This legislation would allow home infusions to be covered under traditional Medicare.

The Medicare Home Infusion Site of Care Act provides a pathway for reimbursement of services and equipment required for home infusions under Part B, while the drugs required for infusion would continue to be covered under Part D. The Bill would require the Secretary of the Department of Health and Human Services to develop safety, efficacy, and quality standards for home infusion. Infusion agencies would need to be accredited and demonstrate expertise in home infusion as well as meet uniform safety requirements established by the Secretary.  Under this Bill, infusion services and equipment would not be covered under Medicare’s home health benefit under Part A, but rather as a separate Part B service. Another approach would be to include such infusions as a covered skilled service under the Medicare Home Health benefit.

Conclusion

Providing necessary infusions and injections at home reduces the risk of infection and other health consequences for beneficiaries who are already medically compromised. These important services should be covered for beneficiaries in traditional Medicare.

10/27/15 – R. Robichaud