CMS Proposes Payment Rates, Policies for New Home Infusion Therapy Benefit
Monday, August 19, 2019
Posted by: Kyle Simon
Courtesy of the National Association for Home Care & Hospice (NAHC)
The Centers for Medicare & Medicaid Services (CMS) issued its proposed home health rate update rule on Monday, July 11, 2019. In addition, to updates for calendar year (CY) 2020 payment rates for home health agencies, CMS provided more detail on the implementation of the new home infusion therapy supplier benefit when it becomes a permanent program in 2021.
The 21st Century Cures Act (Act) included a provision that called for the development of new home infusion therapy benefit under Medicare Part B. The benefit would provide professional services for beneficiaries receiving home infusion therapy through a pump that is an item of Durable Medical equipment (DME). Medicare covers certain infusion drugs under Part B when the drug requires infusion by a pump. These drugs include chemotherapy, inotropic medications, certain pain medications, immunoglobulin therapy, and anti-fungal medications.
A qualified home infusion therapy supplier is a pharmacy, physician, or other provider licensed by the state where services are provided and accredited to be a home infusion therapy supplier by a CMS approved accrediting organization. Home health care and hospice providers are eligible to be accredited as home infusion therapy suppliers.
The new benefit will cover the professional service associated with home infusion therapy as single payment for the day the professional is in the home and the drug is infused.
Full implementation of the home infusion therapy benefit will begin in 2021 with a transition period in 2019 and 2020. Only licensed pharmacies enrolled as a DME supplier are eligible to offer the benefit during the transitional period.
Once the home infusion therapy supplier benefit becomes a permanent, coverage for Part B infusion services will be carved out of the home health benefit. Therefore only accredited home infusion therapy suppliers will be able to provide and bill for these services.
Home infusion therapy suppliers would need to enroll in Medicare Part B, and bill the services on a professional claim. (1500/837P).
CMS will permit a Medicare beneficiary to receive the new home infusion therapy benefit concurrently with the home health benefit and would require that the agency, if also an accredited home infusion therapy supplier, to bill separately for the home infusion therapy services under Part B professional claim.
In the proposed rule, CMS established the drugs that will be covered under the new benefit in 2021 and the payment categories for each drug. The Part B drugs covered under the new benefit are divided into three categories based on variation in utilization of nursing services, patient acuity, and complexity of drug administration. CMS is proposing to set the rates for the professional services related to the infusion to equal a five hour infusion on the physician fee schedule. This is the maximum payment allowed for home infusion therapy services by statute. In addition, CMS is proposing to set a higher payment amount for the initial infusion visit, similar to the low utilization payment amount (LUPA) add-on for home health services.
CMS is seeking comments on two proposed requirements for the physician ordering home infusion therapy services. A requirement to notify beneficiaries of the site options to receive home infusion services (physician office, home, or outpatient), and the specificity of orders and the frequency for physician review of the plan of care.
NAHC has concerns with the statutory requirement that prohibits beneficiaries from receiving Part B home infusion services under the home health benefit. The home infusion therapy benefit under Medicare Part B requires a20 % copay by the beneficiary that is not required under the home health benefit. In addition, some beneficiaries receiving home infusion therapy services could be prohibited from receiving any home heath services if the only qualifying skilled need is related to the infusion. Unfortunately, a change in the law is required to correct these concerns.
On the regulatory front, NAHC intends to request CMS provide home health agencies (HHAs) approved as infusion therapy suppliers with the option to bill for the services using their home health provider number under a type of bill 34x. HHAs bill for other Part B items and supplies, such as outpatient therapy, without having to enroll as a Medicare Part B supplier.
Comments on the proposed rule are due September 9, 2019.