NHIA says CMS proposal sharpens rules, not benefit

WASHINGTON – CMS’s proposal to expand Medicare coverage for certain external infusion pumps and associated drugs is a step forward but stops short of addressing the biggest gap in the benefit, stakeholders say: Medicare patients who need IV antibiotics remain largely unable to access home infusion.

The proposal, included in the Calendar Year 2027 Home Health Prospective Payment System proposed rule, would extend Medicare coverage to certain infusion drugs when they require professional supervision, are administered or supervised in the home by a qualified supplier and are provided at least monthly.

The National Home Infusion Association (NHIA) generally supports the proposed criteria but says CMS didn't go far enough, according to President and CEO Connie Sullivan.

“While we're certainly supportive of anyone gaining access to home infusion, I just don't think that this policy was ever intended to create broad access,” she said.

CMS estimates only one additional drug would qualify under the proposed criteria, although NHIA believes one or two others may also be eligible. Even so, the change would do little to improve access for Medicare beneficiaries who need IV antibiotics, the most common home infusion therapy used to support hospital discharge and avoid skilled nursing facility admissions.

“Every hospital in the country, every time they need to discharge someone with Medicare, they jump through hoops – ‘What do we do with this patient?’ – because we can’t do what we do for everybody else,” she said.

Sullivan also pointed out that CMS has not explained how newly eligible drugs would be treated under the Medicare home infusion therapy services benefit.

“Maybe that’s something they intend to address drug by drug as they come through, but we’ve already seen some drugs get added to the benefit where they have never addressed how the home infusion therapy services benefit should be applied,” she said. “We think that this is somewhat of a gap that needs to be addressed by CMS.”

NHIA has urged Congress to pass the Preserving Patient Access to Home Infusion Act, H.R. 2172 and S. 1058, which would extend Medicare coverage to certain non-pump IV antibiotics and other anti-infectives and would revise payment for the pharmacy and professional services needed to provide them at home, bringing the benefit more in line with commercial insurance. NHIA estimates that commercial health plans routinely cover more than 350 infused drugs administered safely in the home.

“It’s one of the most common-sense things that they could do,” Sullivan said. “CMS really doesn’t have the authority to fix this without legislation.”