Why CMS’s New Home Infusion Benefit Falls Short — And How to Fix It

The recently finalized home infusion benefit from the Centers for Medicare & Medicaid Services (CMS) has created moderate excitement within the home health community, with some providers seeing newfound opportunities to expand their business offerings.

Those who currently provide home infusion services, however, have called CMS’s new benefit “deeply flawed.” CMS finalized a permanent home infusion benefit that starts in 2021 within its final home health payment rule, released Oct. 31.

The problem, critics say, is that the currently structured home infusion benefit would only reimburse home infusion providers for services on the days when a nurse is present in a patient’s home. But nursing visits are just a small piece of the larger puzzle that is home infusion, meaning such a reimbursement model would be unsustainable.


These shortcomings must be addressed before the benefit can be of any real use to providers or patients, industry insiders say.

“The benefit sounds good, but, ultimately, all [CMS] did was carve out and create a nursing benefit for patients who aren’t homebound,” Connie Sullivan, president and CEO of the National Home Infusion Association (NHIA), told Home Health Care News in early October.

NHIA is trade association representing organizations that provide home infusion, which is the at-home delivery of a drug through a needle or catheter. Some examples of home infusion include chemotherapy, immune deficiency treatment and anti-infective treatment.


While NHIA opposed CMS’s initial home infusion proposal, it doubled down on its criticisms last week, noting that the organization is even pursuing legal remedies or Congressional intervention.

CMS first proposed the home infusion benefit in July as part of its proposed home health payment rule.

In many ways, the CMS final rule mirrors the transitional benefit already in place for Medicare-reimbursed home infusion, which is also problematic in that it only reimburses for nursing visits, Sullivan explained.

“Even though CMS claims the payment made on the nursing days also covers the pharmacist professional services, the rate is insufficient and will be consumed by the cost of the nurse,” she said. “And if a patient doesn’t have nursing services, it’s unclear how they would actually access this benefit because there’s no payment at all.”

For most patients, home infusion begins with a referral to a home infusion provider, which is usually a pharmacy. From there, the pharmacist verifies a patient’s coverage for services and does an assessment to determine whether the patient is a right for home infusion.

Then, the pharmacist comes up with a customized therapy plan for the patient. Once the treatment plan is in place, a nurse teaches that patient how to self-infuse his or her drugs and returns to the home minimally from there on out.

“Generally, once a patient is taught to self-infuse, the nurse might visit the home once a week for some patients,” Sullivan said. “But there are other patients that once they are independent in their therapies, the nurse may not go out unless there’s a problem.”

Meanwhile, the pharmacy that started the services generally acts as a case manager, filling new orders and working with a physician to alter treatments, medications and doses for patients when necessary.

But under CMS’s newly finalized benefit, no elements of the service beyond nursing visits are reimbursed. That’s unlike how things work in the commercial home infusion sector, according to Matt Deans, senior vice president of business development at Option Care Health.

Headquartered in Bannockburn, Illinois, Option Care Health is one of the country’s largest home infusion providers. It delivers more than 2 million home infusion doses per month to patients across 50 states.

“We [should] be appropriately reimbursed for the services we are providing, like every other insurance type pays for today,” Deans told HHCN. “Medicare is the only payer of home infusion services … that doesn’t pay for what we call a per-day infusion rate.”

That per-day infusion rate equates to payment for each day that a patient infuses the drug at home — not just the days when a nurse is present to oversee it.

While CMS’s home infusion benefit would not take effect until 2021, the industry is already seeing the harmful effects of the nursing-only reimbursement strategy. A very similar policy is currently in place to govern home infusion.

“The did make some minor adjustments [to the proposed rule],” Sullivan said. “They increased reimbursement slightly, tying it to the physician fee schedule. The [current] benefit maxes the payment at four hours, and the permanent benefit will increase it to five, but it’s a very, very minor increase.”

The major concern with the proposed benefit is that Medicare patients will be unable to receive home infusion services because the reimbursement rates are unsustainable.

The industry is already seeing that with the current Medicare home infusion policy.

“It is creating access issues,” Deans said. “Those patients are either staying in-patient or having to receive care in a skilled nursing facility.”

In an effort to avoid further access issues, NHIA has taken legal action.

In February, the association filed a complaint against CMS, challenging its interpretation of the infusion drug administration calendar day — or in other words, the agency’s decision to only reimburse for nursing visits.

“For [the benefit] to be successful, CMS should simply look to the commercial sector, where they’ve created an efficient, cost-effective and safe model for how patients can access home infusion services,” Sullivan said.

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