Name of Bill to Come

Overview

Home infusion coverage in the Medicare program is split between Parts B and D. Under the Medicare Part B Durable Medical Equipment (DME) benefit, home infusion professional services, drugs and supplies are covered, but a gap still exists for the coverage of home infusion professional services and supplies for home infusion drugs in Part D. While approximatly 40 home infusion drugs are covered in the Medicare Part B DME benefit, approximatley 100 home infusion drugs in the Medicare Part D prescription drug program still need the same coverage for services and supplies. The majority of Part D home infusion drugs are infused antibiotics, which are necessary to treat vulnerable benficiaries with diabetic foot ulcers, cystic fibrosis, and post surgical infections. Importantly, the [NEW BILL TITLE] will use the same services reimbursement structure that already exists in Part B to bridge the services gap for home infusion drugs covered by Part D.

Background

Home infusion coverage consists of three elements of reimbursement:

  • Reimbursement for professional services;
  • Reimbursement for the drugs;
  • Reimbursement for the supplies to administer the drug (i.e. the pump and tubing)

Infusion therapy (services, drugs and supplies) is fully covered by Medicare in these sites of care:

  • hospitals,
  • skilled nursing facilities (SNFs),
  • hospital outpatient departments (HOPDs),
  • physician offices; and
  • for a select set of home infusion drugs that are part of the Part B DME program.

As a first step in providing full home infusion therapy coverage in the home, Congress passed a home infusion professional services reimbursement for Part B DME drugs as part of the 21st Century Cures Act. In February 2018, Congress accelerated the timeline of this benefit by passing legislation that created a transitional reimbursement for home infusion professional services starting in 2019. However, the home infusion drugs in the Medicare Part D program still lack a services and supplies reimbursement.

For the approximately 100 home infusion drugs in the Medicare Part D program, Medicare stands virtually alone among payers in the United States in not fully recognizing the clinical and cost benefits of providing infusion drug therapy to patients in their homes. In the private sector, the accepted standard of care and practice for over 30 years is to provide infusion therapy at home where medically indicated and when requested by the attending physician. Ironically, patients who have access to this benefit under their private plans often lose this coverage when they enroll in Medicare, and they must seek treatment in more expensive and less clinically optimal sites of care as a result.

Position

We urge Congress to pass [New BILL TITLE] to align the Medicare program with virtually all private payers, most Medicare Advantage plans, TRICARE and many state Medicaid programs by providing comprehensive coverage for home infusion therapy in Medicare Part D. All Medicare beneficiaries should have the option to receive infusion therapy in the home, which is often the most clinically appropriate, cost effective, and convenient site of care.

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