Home infusion stakeholders push new legislation to fix coverage gap

WASHINGTON – Home infusion stakeholders believe they have a strong case for Congress passing legislation that would finally bring Medicare coverage in line with that of private insurers. 

Introduced June 14 in both the Senate and the House of Representatives, “The Preserving Patient Access to Home Infusion Act” would include pharmacy services as part of the home infusion therapy benefit under Medicare, covering everything from assessments to drug preparation and compounding to care coordination and documentation. The bills, S. 1976 and H.R. 4104, would also direct CMS to pay 50% of the nursing rate on days when home infusion is provided, even when a nurse is not present. 

“This legislation would ensure coverage for the full scope of home infusion services consistent with the successful model employed by nearly every other commercial plan in the United States,” said Connie Sullivan, president and CEO of the National Home Infusion Association. “(This will) achieve savings and improve patients’ quality of life consistent with the original intent of Congress in passing the 21st Century Cures Act.” 

The Cures Act, passed in 2016, created a professional services benefit for Medicare Part B home infusion drugs, but a final rule published in 2018 limits reimbursement for those services to only those days a “skilled professional is in the home.”  

Without payment, the NHIA argues providers can’t afford to offer services, something that is highlighted in CMS’s own data. There are fewer than 60 eligible providers participating in the benefit, according to the agency. 

“I have more than 100 pharmacy technicians involved in my own infusion department, and we don't get paid for that,” said Tim Affeldt, vice president of infusion for Fairview Health Services, a nonprofit academic health system that’s part of the University of Minnesota. “You cannot possibly do home infusion without pharmacy involvement and by having a benefit that simply doesn't pay for pharmacy services – it's just a huge miss in the benefit.” 

While the NHIA and others wait for a score from the Congressional Budget Office – they expect it to come in at a cost savings, as it has in the past, because it shifts patients from higher cost settings into lower cost settings – they're getting ready to launch several advocacy initiatives over the summer to boost support for the bills.  

“The key ask right now is to reach out to your members of Congress and make sure they're aware of this bill and the gap that exists in the Medicare program and ask for their support,” Sullivan said. “Our members are also going to be asked to try to invite members of Congress to visit their home infusion businesses over the summer and show them what's involved.”