My friend is in rehab for infection after surgery. Will medicare pay for her to have infusions at home?

Does Medicare cover home infusion therapy?

Unfortunately, Medicare’s fee-for-service program (Parts A, B and D) is the only major health plan in the country that has not recognized the clear benefits of adequately covering provision of infusion therapies in a patient’s home. Because most Medicare beneficiaries are enrolled in the fee-for-service program, when seniors and the disabled find they may need infusion therapy they often find it unaffordable to receive this care in the comfort of their home.

Providing home infusion therapy involves not only the delivery of medication, but also requires professional services, specialized equipment and supplies to ensure safe and effective administration of the therapy. While most infusion drugs may be covered by the Medicare Part D prescription drug benefit, the Centers for Medicare & Medicaid Services (CMS) has determined that it does not have the authority to cover the infusion-related services, equipment and supplies under Part D. As a result, many Medicare beneficiaries are effectively denied access to home infusion therapy and are being forced into receiving infusion therapy in hospitals and skilled nursing facilities at a significantly higher cost to Medicare and at great inconvenience to the patients. NHIA is underway with a critical legislation initiative to rectify this situation.

In Medicare Part B, there is some coverage for certain therapies administered using durable medical equipment (a mechanical or electronic external infusion pump). Unfortunately, only a select few therapies are covered and only under very specific conditions. These include some anti-infective, some chemotherapy drug, some inotropic therapies (e.g., dobutamine), some pain management, immune globulin administered subcutaneously, and a few other therapies. For parenteral and enteral nutrition therapies, there can be coverage in Part B only if the need for the therapy is documented to be for at least 90 days and other coverage criteria are met. There may be coverage for intravenous immune globulin (IVIG) for primary immune deficiency patients but the supplies and equipment are not paid for. More specific information can be obtained by contacting the Medicare entities called Durable Medical Equipment Medicare Administrative Contractors (DME MACs). The coverage criteria for home infusion that all contractors follow are found from a DME MAC.

For home nursing visits needed for beneficiaries receiving infusion therapy, there can be Medicare Part A coverage under Medicare’s home health benefit only if the patients are serviced by a Medicare-certified home health agency, as well as considered to be homebound and in need of intermittent (not 24 hour) home nursing. NHIA’s Medicare legislation initiative is intended to broaden this gap in coverage too.

Some Medicare fee-for-service plan patients may have other insurance that will pick up some of the home infusion costs not covered by Medicare. A minority of the Medicare population is enrolled in the Medicare Advantage (Part C) program. Similar to most commercial health plans, many Medicare Advantage health plans cover home infusion because they recognize it will reduce their overall health care costs and achieve high levels of patient satisfaction.

Most home infusion therapy providers are familiar with Medicare’s coverage details and will advise prospective patients of their specific coverage and anticipated out-of-pocket obligations should they undertake home infusion therapy.