NHIA Reimbursement Training Center

Payers

Knowing the source(s) of payment for drugs, services, and supplies is critical to the financial success of home and specialty infusion providers. Common payers include:

Medicare
Medicaid
Commercial (private) Insurance
Other Government Payers
Worker’s Compensation
Patient

Medicare

Medicare coverage of home and specialty infusion service is fractured and may be covered under different parts of the Medicare benefit.

Medicare Part A – Home Health Services Medicare Fee For Service will only allow home nursing services to be provided by a Part A certified home health agency (HHA) under an episode of care  Home infusion providers will often coordinate the nursing care for Medicare FFS patients with a (HHA).

Medicare Part B – Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) benefit offers limited coverage for home infused drugs. The few drugs that are covered are only covered when delivered via an infusion pump (the item of DME) and the patient meets strict medical necessity coverage criteria. The nursing component of care can only be delivered by a Medicare Part A Certified Home Health Agency, and only if the beneficiary meets qualifying criteria, which includes homebound status.

Medicare Part C- Medicare Advantage Plans often have an enhanced home infusion benefit that provides home infusion coverage that extends beyond the Medicare Part B DMEPOS limitations.

The Medicare Part D – Prescription Drug Program may cover infused medications that are not covered by Part B DMEPOS, but the services, supplies and equipment necessary for the safe provision of home infused therapies are not covered. The out of pocket cost for the services, supplies and equipment are often financially prohibitive and cause patients to choose more costly sites of care.

NHIA has long maintained that Medicare’s limited and fragmented coverage for home infusion therapy drives patients to more costly sites of care and puts patients at increases risk of infection when exposed to other patients in the inpatient setting or frequent trips to a physician’s office or hospital outpatient department for the administration of their IV medications. NHIA supports legislation that would expand Medicare coverage of home infusion therapy.

 

Medicaid

Medicaid programs’ coverage varies form state-to-state. It most cases Medicaid requires that infused drugs are billed through the prescription benefit (NCDPD). Some state utilize the S-code per diem for service, supplies and equipment while others require that A and E HCPCS codes are billed to the DME benefit for the supplies and equipment utilized in the provision of care.

The NHIA Payer Advocacy and Relations Committee (PARC) recently surveyed state Medicaid programs to document the varying coverage paradigms of the Medicaid programs, click here for details.

Commercial Insurance

Commercial payors have long understood the value of home infusion therapy and utilize the per diem HCPCS S-codes to pay home infusion providers for services, supplies and equipment. The S-code set includes about 50 HCPCS codes that are specific to the type of therapy being provided, as well as the volume of drug or frequency of dosing. Click link to access the NHIA National Per Diem Coding Standard for Home Infusion Claims.

Blue Cross Blue Shield Plans

Blue Card is a national program for BCBS that allows members to obtain services in areas outside their home plan’s state.

Home Plan:  refers to the BC plan that holds the benefit.  For group plans, it is usually where the employee’s headquarters are located.

Local Plan:  refers to the area where the member receives services.

A person may hold a BCBS policy originating out of Illinois (BCBS IL) but they reside in Kansas.  The home plan is BCBS IL and the local plan is BCBS KC

Providers verify benefits and eligibility through the home plan as well as obtain authorization for services as needed.  Claims are billed to the local plan and are subject to the contractual allowances of their local contract.  Claims management activities are conducted through the local to include collection efforts and payments.

Other Government Payers

Tricare:  formerly known as the Civilian Health and Medical Program of the Uniformed Services, is a health care program of the United States Department of Defense Military Health System.  Tricare provides civilian health benefits for U.S Armed Forces military personnel, military retirees, and their dependents, including some members of the Reserve Component. The Tricare program is managed by Tricare Management Activity (TMA) under the authority of the Assistant Secretary of Defense (Health Affairs). Tricare is the civilian care component of the Military Health System.

Tricare for life:  is a Medicare-wraparound coverage for Tricare eligible beneficiaries who have Medicare Part A & B.

Veteran’s Health Administration (VHA):  is the component of the United States Department of Veterans Affairs (VA) led by the Under Secretary of Veterans Affairs for Health that implements the medical assistance program of the VA through the administration and operation of numerous VA Medical Centers (VAMC), Outpatient Clinics (OPC), Community Based Outpatient Clinics (CBOC), and VA Community Living Centers (VA Nursing Home) Programs.

 

Worker’s Compensation

Worker’s compensation, also known as workman’s compensation or workers’ comp, is a specialized type of medical insurance that covers treatment for injuries incurred on the job. Commercial workers’ comp policies may be purchased by employers, though in some states, the policies and programs are administered by the states. An employee is assigned an adjuster, a specialist who coordinates the employee’s care, authorizes treatment and can direct the medical claim process. Providers must be aware of the workers’ comp plans in their states, the requirements and guidelines necessary for billing medical claims to these plans, and the plans’ limitations.

Patient

Patient high deductible plans and out of pocket cost have increased significantly over the past decade. Communicating up front with the patient regarding their estimate out of pocket costs is increasingly important. Some may require making payment arrangements prior to starting service.