As of October 2021, nearly 64 million Americans were enrolled in Medicare, and since the agency’s beginnings in 1965, many have come to rely on Medicare services to cover their treatments. Patients undergoing infusion therapy are covered under Medicare. However, new guidelines for Medicare coverage, which went into effect in 2021, could still have some enrollees confused about how much of their home infusion is covered. Today, we’re taking a detailed look at Medicare coverage and home infusion.
Medicare covers quite a lot of expenses related to home infusion. Original Medicare specifically covers home infusion under Medicare Part B, where plans pay for 80% of therapy costs. Medicare Advantage plans must cover at least as much as Original Medicare; however, the actual percentage covered varies by case. Unfortunately, Medicare Supplement plans which are the plans that pay for out-of-pocket costs not covered by Medicare, do not usually cover home infusion.
Before beginning the enrollment process, it’s essential to know whether or not you qualify for Medicare coverage. To qualify, you must meet these requirements:
You must have a condition requiring home infusion and an established diagnosis of that condition.
Have a referral from your doctor.
The home infusion provider you choose must be Medicare-approved.
Any equipment purchased for home infusion must be from a Medicare-approved supplier.
You must pay your Medicare monthly premiums and satisfy any deductible your plan may have.
In 2016, Medicare announced that home infusion therapy would be covered under Medicare Part B effective January 1, 2021. Medicare Part B, which we mentioned previously, covers all of the supplies used for home infusion, such as IV poles, tubing, pumping, etc. Medicare also announced that they would now cover some of the drugs used for home infusion under the guidelines that they were intravenous or IV treatments with infusions lasting for at least fifteen minutes. Part B also covers the fees from your infusion provider for at-home infusion treatments.
At ContinuumRx, we work with patients to ensure they get the maximum coverage for their infusion therapy, whether it be from home or one of our comfortable infusion suites. If you have questions about your Medicare coverage for home infusion, contact your ContinuumRx Patient Care Representative or contact Medicare directly. Are you interested in starting infusion therapy? Contact us today to learn more!
https://www.continuumrx.com/wp-content/uploads/2022/06/crx-medicare-coverage-blog.jpg423843Joseph Malatesta/wp-content/uploads/2014/09/crx-logo-340-156.pngJoseph Malatesta2022-06-22 14:54:132022-06-30 13:59:19Understanding Medicare Coverage and Home Infusion
On average, approximately 34,000 patients in the United States receive parenteral nutrition (PN) each year1 for critical ailments. For patients 65+ who are on Medicare, the worst news that a physician or case manager has to deliver is, “I’m sorry, you don’t meet the Medicare criteria for home parenteral nutrition.”
For over 20 years, parenteral nutrition has fallen under the prosthetic device benefit under Medicare Part B. There are seven gastrointestinal conditions (GI) that are considered by Medicare before providing coverage. And when it can be proven that a patient permanently (beyond three months) cannot absorb nutrients that are needed to maintain their weight and strength, is when Medicare may cover the accessories or supplies that are needed for long-term home infusion therapy. Patients with short bowel syndrome, GI fistulas, bowel obstructions, acute pancreatitis, and/or nutritional complications from cancer are typical candidates. It goes without saying that the nutritional mix of protein, carbohydrate, fat, minerals and electrolytes, vitamins and other trace elements and are received through parenteral nutrition can reduce complications, and even more so, reduce the risk of rehospitalization. As a result, regardless of insurance coverage or not, if there is any possibility that a patient may require parenteral nutrition (PN) at home after being discharged, the planning and documentation process needs to start immediately. By starting right away, it ensures that the physician, case manager, infusion provider, as well as the patient, are aware of what is required to attempt to secure coverage.
Understanding what Medicare covers and does not cover will ensure speed, efficiency, and uninterrupted quality of care on behalf of the patient. Utilize and implement the guidelines and quick-reference chart below to maximize effectiveness.
Medicare Does Not Cover Parenteral Nutrition For
Patients with a functioning gastrointestinal tract whose need for parenteral nutrition is only due to any of the following conditions:
Temporary defect in gastric emptying such as a metabolic or electrolyte disorder
Psychological disorder impairing food intake such as depression
Metabolic disorder inducing anorexia such as cancer
Physical disorder impairing food intake such as the dyspnea of severe pulmonary or cardiac disease
Side effect of a medication
Renal failure or dialysis
Medicare DOES Cover Parenteral Nutrition
(Parenteral Nutrition is approved on an individual, case-by-case basis initially and at periodic intervals of no more than three months by a Medicare Administrative Contractor (A/B MAC (B)) medical consultant or specially trained staff. It is expected that the patient’s medical records will reflect the need for the care provided. These records are not routinely submitted but must be available upon request.)
7 Gastrointestinal Conditions for Medicare Consideration
Severe Short Bowel Resection: Surgery within the past three months, leaving less than 5 feet of small bowel beyond the ligament of the Treitz.
Severe Short Bowel Syndrome: The patient has a short bowel syndrome that is severe enough that the patient has significant gastrointestinal fluid and electrolyte malabsorption.
Bowel Rest for at Least 3 Months: The patient requires bowel rest for at least three months for treatment of:
A proximal enterocutaneous fistula where tube feeding distal to the fistula isn’t possible.
Complete Mechanical Small Bowel Obstruction: The patient has complete mechanical small bowel obstruction where surgery is not an option.
Malabsorption and Malnutrition: The patient is significantly malnourished (10% weight loss over three months or less and serum albumin less than or equal to 3.4 gm/dl) and has severe fat malabsorption.
Motility Disturbance and Malnutrition: The patient is significantly malnourished (10% weight loss over 3 months or less and serum albumin less than or equal to 3.4 gm/dl) and has severe motility disturbance of the small intestine or stomach which is unresponsive to prokinetic medication.
Malnourished and Proven Condition: The patient is malnourished (10% weight loss over three months or less serum albumin less than or equal to 3.4 gm/dl) and disease and the clinical condition has been documented as being present and it has not responded to altering the manner of delivery of appropriate nutrients (e.g., slow infusion of nutrients through a tube with the tip located in the stomach or jejunum).
The information provided is meant to be a guide for your information only. Each health care provider’s office is responsible for providing accurate information to ContinuumRx for verifying codes, coverage and payment policies used for individual patients to ensure that they are exact and appropriate for the services and items provided.
Contact a ContinuumRx Medicare qualifying expert or trained clinician to assess your patient’s eligibility.
1 Trends in Parenteral Nutrition, By Kristi L. King, MPH, RDN, CNSC, LD, Today’s Dietitian Vol. 21, No. 1, P. 36, January 2019.
https://www.continuumrx.com/wp-content/uploads/2020/07/July-PN-Medicare-Blog-Feature-Image-843x321-1.jpg321843ContinuumRx/wp-content/uploads/2014/09/crx-logo-340-156.pngContinuumRx2020-07-29 08:27:532020-09-16 08:19:39Parenteral Nutrition: Medicare Coverage for Home Infusion Therapy