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The ALS Association is pleased to partner with Option Care to provide the following information.

Home Infusion and Coverage Information for People Living with ALS

 

Webinars

Home Infusion Basics Webinar Series 1
As one of the nation’s leading home infusion service providers, Option Care, presents key concepts of home infusion therapy, from care planning and supplies required, to training and support services.

September 26th and 27th webinar:
View the Recording

Home Infusion Webinar Series 2
Dates and registration information coming soon.


 

Home Infusion Basics

  1. What is home infusion?
    Home infusion is a safe and effective option available to hospital patients involving the administration of intravenous medications in a patient’s home or other alternate treatment setting.

  2. Are there accreditation standards for home infusion?
    The vast majority of home infusion pharmacies are accredited by 1 of 3 organizations reflecting the highest standard of care expected. These include Accreditation Commission for Health Care (ACHC), Community Health Accreditation Program (CHAP) and The Joint Commission. In addition, most commercial insurance payers require voluntary accreditation by a nationally recognized accreditation organization such as URAC Specialty Pharmacy Accreditation or American Society of Health-System Pharmacists (ASHP) to confirm the home infusion pharmacy’s commitment to quality patient care.

  3. What is the care team approach and who is involved?
    Home infusion is a highly specialized service dependent on a dedicated team to provide quality, individualized patient care. The home infusion healthcare team is comprised of Infusion Nurses, Clinical Pharmacists, Registered Dietitians and support staff members such as insurance specialists and pharmacy technicians.

  4. What types of infusion therapies are provided in the home?
    Core medications that are typically provided in the home are antibiotics, chemotherapy, enteral/intravenous (parenteral) nutrition and pain management. Specialty medications that are commonly infused in the home include Immune globulin, enzyme replacement therapies, bleeding disorder therapies and heart failure therapy. The home infusion healthcare team is responsible for assessing the patient and their home to ensure they are an appropriate candidate. An individualized plan of care is then created where the patient is monitored and reassessed on an ongoing basis. The team also oversees the delivery of infusion medication and necessary supplies as well as provides the patient with proper education.

  5. Are there different types of infusion?
    There are several different types of infusion therapies administered in the home which include the following:

    • IV anti-infectives / anti-fungals / anti-virals
    • Nutrition (Enteral / TPN)
    • Inotropes (heart failure)
    • Chemotherapy
    • Pain management
    • Specialty therapies:
      • Bleeding disorders
      • Immunoglobulin
      • HAE
      • Enzyme replacement
  6. What medical conditions treated in the home through home infusion?
    • Infectious diseases
    • Nutritional / gastrointestinal disorders
    • Cancer / blood disorders
    • Primary immune deficiencies
    • Hemophilia
    • Autoimmune disorders
    • End-stage heart failure
    • Pre- / post-transplantation

 

IV Access and Infusion Supplies

What are the types of IV access and the supplies required for different devices?
There are four different types of IV access devices:

  • Short peripheral IV: This is the most common IV access device that can be used up to 3 days. It is less than 3 inches in length and often is inserted into a superficial vein of the hand or forearm.
  • Long peripheral IV: 3-8 inches in length and is typically inserted into the larger veins of the upper arm with the IV tip extending below the shoulder region. It can be used up to 30 days.
  • Peripherally Inserted Central Catheter (PICC): 18-20 inched in length and is inserted into the larger veins of the upper arm then threaded into the central circulation above the heart. It can be used up to 1 year.
  • Implantable port: An implanted IV access device which consists of a portal body (reservoir) and IV catheter surgically implanted beneath the skin, generally in the chest region with the catheter tip threaded to above the heart.

 

Pharmacy Services

  1. Care planning:
    The home infusion clinical pharmacist facilitates coordination and continuity of care by communicating with MDs, nurses and other health care providers to optimize patient care outcomes.

  2. Medication and supply delivery:
    Prescribed medications and supplies are delivered directly to the patient through either a courier service or by the visiting nurse depending on the therapy. If preferred, patients and/or caregivers may also elect to pick-up medication and supplies at the home infusion pharmacy location. The frequency of deliveries is largely dependent on the medication prescribed, but can range anywhere from weekly to monthly.

  3. What are the most important questions to ask your home infusion pharmacy provider?
    There are several important questions you will want to ask your home infusion provider. Listed are some key inquiries to discuss:

    • Do you provide [name of IV medication] for use in the home?
    • How large is your service area?
    • Do you provide benefit verification services to confirm my therapy is covered under my medical or pharmacy plan?
    • Will you discuss the cost of services with me prior to my first delivery?
    • Will you bill my insurance provider and what is the protocol if I have more than 1 insurance provider?
    • If I cannot afford the cost, what options can you provide me with?
    • What accreditation(s) does your home infusion pharmacy currently hold?
    • Is your specialty infusion pharmacy URAC accredited?
    • Do you have your own infusion nursing or do you subcontract this service out?
    • What type of pharmacy oversight does the infusion pharmacy provide me?
    • How are my medications delivered?
    • Do I contact you for follow-up deliveries?
    • Do you provide services 24 hours a day?
  4. How do I choose a home infusion provider?
    When choosing a home infusion provider, it is best to refer to the following check list to ensure you receive expert patient care:
  5. optioncare-checklist

    Download this checklist


 

Insurance Information and Infusion Therapy

  1. What types of insurance cover infusion therapy?
    Nearly every insurance payer (commercial, Medicare, Medicaid) covers home infusion to some extent, but every insurance plan is different. A good home infusion therapy provider will check your insurance benefits to find out what is covered and discuss the potential cost BEFORE therapy begins.

  2. What happens if my insurance doesn’t cover home infusion?
    For services that are not covered by insurance, there are several options. First, discuss with the home infusion therapy provider and identify the reason the service is not covered. The home infusion therapy provider may be able to appeal the insurance payer’s decision on your behalf or work with your physician to submit a letter-of-medical-necessity, which contains the information needed to convince the insurance payer that the requested service is necessary to meet your medical needs. Another option is to pay out of your own pocket. Although this may be a costly option, many home infusion therapy providers offer “self-pay” pricing, as well as payment plans and financial assistance programs.

  3. Do government and private insurance plans cover infusion therapy in the home and/or other care sites?
    As stated on NHIA.org, the range of variables that must be managed by the infusion pharmacy to ensure safe and appropriate administration has led nearly all commercial health plans to treat home infusion therapy as a medical service, reimbursed under their medical benefit (rather than the prescription drug benefit) and paid for using a per diem for clinical services, supplies and equipment with separate payments for the drugs and nursing visits. It also has led most commercial plans to require that infusion pharmacies by accredited by nationally recognized accreditation organizations. Commercial plans have used this model aggressively to reduce overall health care costs while achieving high levels of patient satisfaction.

    Government health plans such as Medicaid, TRICARE and the Federal Employees Health Benefits Program also reimburse for home infusion therapy, although for Medicaid in a few states the extent of coverage can have gaps. A major exception in completeness of coverage is the Medicare program.

    For infusion therapy provided in Ambulatory Infusion Suites, commercial insurers are fast recognizing the appropriateness of this infusion setting and its cost-competitiveness with other Ambulatory Infusion Center settings. Medicaid coverage varies by state. Medicare’s prescription drug plan (Part D) may cover the cost of the infusion drugs, but the costs of AIS services, supplies, equipment and nursing are not covered. The infusion therapy provider will ascertain coverage for patients and advise on the extent of coverage and patient obligations prior to start of service.

  4. Does Medicare cover home infusion therapy?
    As stated on NHIA.org, 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 senior and the disabled fine 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 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 cove 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.

    To learn more about home infusion coverage under Medicare, click HERE.

  5. Open enrollment – what is it and why is it important?
    Open enrollment is usually a few weeks to a few months during the year that allows insurance beneficiaries to make changes to their benefits plans. These changes usually cover benefits such as health insurance, vision, dental and life insurance. During this time, you have the option to enroll in benefits for the first time, change your current plans or coverage amounts or to drop coverage completely. The open enrollment period is important because it is one of the few times you can make changes to your insurance benefits.

    When considering open enrollment, it is important to take into account all aspects of the coverage and not just the cost. You’ll want to compare premiums, deductibles, co-pays and total out-of-pocket limits. A lower premium may seem like a big savings, but you could end up paying even more if the coverage is not as good, so choose wisely.

    For Medicare coverage, open enrollment is October 15th to December 7th. These specific dates changed in 2011, but have been the same ever since.


 

Home Infusion FAQs

  1. What is infusion therapy?
    Infusion therapy involves the administration of medication through a needle or catheter into the body.

  2. What is a home infusion therapy provider?
    A home infusion therapy provider most commonly is a “closed-door,” state-licensed pharmacy that specializes in providing infusion therapies in the home or alternate treatment setting (ATS). Home infusion therapy providers must follow licensing, regulatory and accreditation standards required by state pharmacy, nursing boards and insurance payers.

  3. Why are infusions performed at home?
    Infusions performed at home have been found to be safe, clinically effective and improve patient quality of life while being less costly as compared to infusion care provided in a hospital setting. Additionally, this leads to fewer disruptions in patient’s personal schedules and responsibilities.

  4. What is a home therapy provider?
    Home healthcare provides skilled care in the home such as nursing, physical therapy, wound care. A home therapy provider is an organization that has the ability to provide such services to the patients it serves.

  5. What alternate care settings are appropriate for infusion therapy?
    An alternate care setting appropriate for infusion therapy is and Alternate treatment setting (ATS). This on-site infusion suite is located in the home infusion pharmacy.

  6. Who provides the infusion nursing and what specializations do such nurses have?
    Infusions nurses are provided directly by the home infusion pharmacy or by and affiliated/separate nursing agency. Skills this specific type of nurse has includes experience in IV access, midline/PICC catheter placement, knowledgeable of the various IV medications/fluids and competent in working with different vascular access infusion devices and pumps.

  7. Are home infusion pharmacies accredited? What requirements must be met by accredited infusion providers?
    Home infusion pharmacies must follow licensing, regulatory and accreditation standards required by state pharmacy, nursing boards and insurance payers. Managing home infusion therapies requires specialized expertise, clinical and supportive services as well as specialized facilities.

  8. Do government and private insurance plans cover infusion therapy in the home and/or other care sites?
    As stated on NHIA.org, the range of variables that must be managed by the infusion pharmacy to ensure safe and appropriate administration has led nearly all commercial health plans to treat home infusion therapy as a medical service, reimbursed under their medical benefit (rather than the prescription drug benefit) and paid for using a per diem for clinical services, supplies and equipment with separate payments for the drugs and nursing visits. It also has led most commercial plans to require that infusion pharmacies by accredited by nationally recognized accreditation organizations. Commercial plans have used this model aggressively to reduce overall health care costs while achieving high levels of patient satisfaction.

    Government health plans such as Medicaid, TRICARE and the Federal Employees Health Benefits Program also reimburse for home infusion therapy, although for Medicaid in a few states the extent of coverage can have gaps. A major exception in completeness of coverage is the Medicare program.

    For infusion therapy provided in Ambulatory Infusion Suites, commercial insurers are fast recognizing the appropriateness of this infusion setting and its cost-competitiveness with other Ambulatory Infusion Center settings. Medicaid coverage varies by state. Medicare’s prescription drug plan (Part D) may cover the cost of the infusion drugs, but the costs of AIS services, supplies, equipment and nursing are not covered. The infusion therapy provider will ascertain coverage for patients and advise on the extent of coverage and patient obligations prior to start of service.

  9. Does Medicare cover home infusion therapy?
    As stated on NHIA.org, 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 senior and the disabled fine 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 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 cove 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.

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