Home Infusion and Coverage Information for People Living with ALS

The Federal Drug Administration (FDA) recently approved a new drug to treat ALS, which uses intravenous (IV) infusion for administration. IV therapy can be administered in multiple sites of care: your doctor’s office, a clinic, a hospital, or your own home. Whether you receive treatment will be a decision based on clinical input from your physician, your insurance coverage, and personal preference. The following information focuses on home infusion therapy: the basics, the team members involved, the supplies required for home infusion, and where to get them; and finally, coverage options for home infusion therapy.

Home Infusion Basics
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. 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. This also leads to fewer disruptions in patients’ personal schedules and responsibilities.

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. This 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.

There are several types of medications that are typically provided in the home, including 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.

IV Access and Infusion Supplies
There are four different types of IV access devices, including short peripheral IV, long peripheral IV, Peripherally Inserted Central Catheter (PICC), and implantable port. The short peripheral IV is the most common IV access device. The type of device chosen will vary based on the type of medication a patient is receiving and the timeframe during which the medication is being administered.

Pharmacy Services
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. 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.

Insurance Information and Infusion Therapy
Nearly every insurance payer (e.g. commercial, Medicare, and 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.

Many patients with ALS may be eligible for Medicare, and the coverage for the different sites of care may vary depending on the type of Medicare plan. Original Medicare (also known as “traditional” or “fee-for-service” Medicare) has a limited home infusion benefit, and the new ALS drug is not covered under this benefit. If receiving infusion therapy at home is your goal, understanding how home infusion therapy services are covered by Medicare will help inform your Medicare plan selection during the Open Enrollment process.

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 will 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 beneficial, 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.

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.

More Information and Resources
For additional details and frequently asked questions about home infusion, click HERE.

A webinar, presented by Option Care, one of the nation’s leading home infusion service providers, is also available to view on-demand. This webinar presents key concepts of home infusion therapy, from care planning and supplies required, to training, and support services. View the recording HERE.

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

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