New year, new benefit: An overview of Medicare’s permanent home infusion therapy services benefit
In 2019 and 2020, the home infusion industry worked under a transitional Medicare home infusion therapy services (HITS) benefit. The permanent HITS benefit went into effect January 1, 2021 and differs significantly from its predecessor. The following is a brief overview of the essential information that providers need to know about the permanent HITS benefit. For more details, you can reference the National Home Infusion Association’s (NHIA) Part B tool.
Pharmacies, physicians, home health agencies, and other state-licensed providers are eligible to enroll as home infusion therapy (HIT) suppliers to bill Medicare under the permanent HIT services benefit. Claims are submitted to — and providers are enrolled with — the A/B Medicare Administrative Contractors (MACs). The HIT suppliers must be appropriately licensed in each state where they provide infusion therapy services in the homes of patients, and they must obtain a separate accreditation from one of the six CMS-deemed accrediting organizations.
The benefit applies only to durable medical equipment (DME)-infused drugs administered intravenously or subcutaneously for greater than 15 minutes. The covered drugs list is slightly different from that of the transitional benefit, but the list is still divided into three categories home infusion (IV), subcutaneous (SC), and chemotherapy (see Table 2). Each category includes two HCPCS codes: one for an initial visit and subsequent visits, as shown in Table 1 directly below.
Table 1
HCPCS | Category | Short Description | 2021 Medicare Unadjusted Allowable |
G0088 | Category 1 | Adm IV drug 1st home visit | $194.81 |
G0068 | Category 1 | Adm IV infusion drug in home | $160.18 |
G0089 | Category 2 | Adm SC drug 1st home visit | $263.21 |
G0069 | Category 2 | Adm SC infusion drug in home | $216.43 |
G0090 | Category 3 | Adm IV chemo 1st home visit | $327.46 |
G0070 | Category 3 | Adm of IV chemo drug in home | $269.25 |
Geographically adjusted rates are available on the CMS website here: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Home-Infusion-Therapy/Overview
Claims are only payable when a skilled professional is in the patient’s home within 30 days of an applicable drug being dispensed. The skilled services must be so inherently complex that they can only be safely and effectively performed by (or under the supervision of) professional or technical personnel. All services must be within the practitioner’s scope of practice. Please see NHIA’s Part B tool for a full description of covered services.
Beneficiaries are not required to be homebound, and they must be under the care of an applicable provider — such as a physician, nurse practitioner, or physician’s assistant. Physicians are the only providers who can order services and must establish and periodically review a plan of care that prescribes the type, amount, and duration of infusion therapy services that are to be furnished. The plan of care must include the following elements:
- Medication name
- Dose
- Frequency
- Type
- Amount
- Duration
- Frequency of the services to be provided
- Healthcare professional performing each service
- A physician signature
The 2021 HITS benefit is a departure from past Medicare coverage because it creates an intersection with home health. HITS are wholly separate from Medicare Part A home health episodic care. Still, home health agencies can enroll as Part B HIT services suppliers and bill directly to Part B for infusion-related services. For patients receiving non-infusion-related Part A home health in addition to Part B infusion nursing, the Medicare-certified home health agency and the Part B HITS supplier must bill each service separately. If the home health agency and HITS supplier are the same entity, the services are billed separately to each benefit. Home health agencies enrolled as Part B HIT services suppliers may contract with the home infusion pharmacy for pharmacist professional services provided as part of the bundled payment paid when a skilled professional is in the home. Home infusion pharmacies enrolled as HITS suppliers can offer nursing services directly or subcontract with another state-licensed nursing agency.
It’s important to note that the HITS benefit is limited to the DME infused medications in Table 2. Home health agencies can continue to provide nursing under Part A episode of care model for drug therapies not in Table 2, which account for the majority of home infused therapies — namely antibiotics and parenteral nutrition.
Table 2
NHIA has been heavily involved in advocacy and education on this issue ever since the benefit was first created in 2016 by the 21st Century Cures Act. The association was concerned that throughout the rule-making process, and in the permanent benefit, home infusion providers are not paid for professional services each day that the drug is administered in the same way they are in commercial health plans. As NHIA has maintained, this was Congress’s intent when it passed the 21st Century Cures Act. NHIA will continue to work with industry stakeholders to advocacy for improved coverage.