Home Infusion Pharmacy

Home Infusion Pharmacy and Home Medical Update

Quarterly Release: October 2019

CAHSAH advocates and provides regular updates to its members on regulations that impact our industry. Some of the recent regulatory actions included:

Payment Rates and Policies Proposed for Medicare’s New Home Infusion Therapy Benefit: The Centers for Medicare & Medicaid Services (CMS) issued its proposed home health rate update rule which included further details about the implementation of the new home infusion therapy supplier benefit which becomes a permanent beneficiary program for Medicare Part B beneficiaries in 2021. This new benefit originated from the 21st Century Cures Act (Act) and allows professional services for beneficiaries receiving home infusion therapy through an authorized DME pump for specific types of drugs. Medicare will cover such drug infusions as: chemotherapy, inotropic medications, certain pain medications, immunoglobulin therapy, and anti-fungal medications. Additionally, the professional service associated with that home infusion therapy will be paid to the provider as a single payment for the day the clinician provides the infuse to the patient in their home.

Medicare has specified who a qualified home infusion therapy supplier is and has included the following suppliers: a pharmacy, physician, or other provider licensed by the state where services are provided and accredited to be a home infusion therapy supplier by a CMS approved accrediting organization. Home health care and hospice providers are eligible to be accredited as home infusion therapy suppliers.

There will be a transition period for the new benefit beginning in 2019 and 2020. Only licensed pharmacies enrolled as a DME supplier are eligible to offer the benefit during the transitional period. Once the home infusion therapy supplier benefit becomes permanent, coverage for Part B infusion services will be carved out of the home health benefit. Therefore, only accredited home infusion therapy suppliers will be able to provide and bill for these services. Home infusion therapy suppliers would need to enroll in Medicare Part B and bill the services on a professional claim. (1500/837P). CMS will permit a Medicare beneficiary to receive the new home infusion therapy benefit concurrently with the home health benefit and would require that the agency, if also an accredited home infusion therapy supplier, bill separately for the home infusion therapy services under a Part B professional claim.

The Part B drugs covered under the new benefit are divided into three categories based on variation in utilization of nursing services, patient acuity, and complexity of drug administration. payment amount (LUPA) add-on for home health services. The proposed rates for the professional services related to the infusion equal a five hour infusion on the physician fee schedule. This is the maximum payment allowed for home infusion therapy services by statute. In addition, CMS is proposing to set a higher payment amount for the initial infusion visit, like the low utilization.

Medi-Cal Contracted Tracheostomy Supplies: Effective for dates of service on or after July 1, 2019, products by Respiratory Therapeutics Group, LLC are added to the List of Contracted Tracheostomy Supplies eligible for reimbursement.

Medi-Cal DME-Protective Underwear Incontinence Supply: Effective for dates of service on or after September 1, 2019, an approved Treatment Authorization Request (TAR) is required for reimbursement of HCPCS code T4536 (incontinence product, protective underwear/pull-on, reusable, any size, each). The List of Incontinence Medical Supply Billing Codes has been updated. A completed Incontinence Supplies Prescription Form must accompany the TAR and should include an explanation, as documented in the recipient’s medical record that supports the following: There is a need for reusable protective underwear to be used with absorbent products for the recipient’s type of incontinence. Alternative products on the List of Contracted Incontinence Absorbent Products have been tried, have failed or are contraindicated. Alternative products on this list include the following: Liners, shields, guards, pads and undergarments, available in various shapes, sizes and absorbency levels used with regular underwear (household item) and Disposable protective underwear/pull-on (pants with a built-in pad).

Medi-Cal Removes Gerber Good Start Enteral Nutrition Products: The Department of Health Care Services has announced that effective for dates of service on or after August 1, 2019, the recently added Gerber Good Start Gentle and Gerber Good Start Soothe formulas are deleted from the List of Enteral Nutrition Products and will not be reimbursable, even with an approved Treatment Authorization Request (TAR) or Service Authorization Request (SAR). The MAC for these products is not guaranteed.

US Department of Labor’s Overtime Rule Sets New Thresholds: The US Department of Labor has issued a final rule which updates the earning thresholds necessary to exempt executive, administrative, or professional employees form the FLSA’s minimum wage and overtime pay requirements and allows employers to count a portion of certain bonuses and/or commissions toward meeting the salary level.


The California Legislature is currently adjourned for this year and will resume the 20192020 legislative session in January of 2020. For a complete list of new laws, please visit the Policy page on CAHSAH’s website.

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