Managed Care - July 2010 - (Page 8)
NEWS & COMMENTARY
Home Infusion Therapy Covered Well by Insurers
t’s not often that commercial insurers get a pat on the back, but a recent Government Accounting Office study that compared home infusion coverage for Medicare beneficiaries and commercial insurers comes pretty close. The GAO study examined the
When it comes to utilization, the commercial insurers in the study report using standard industry practices to manage utilization and to ensure quality of care. Specifically, most commercial insurers require that infusion providers submit patient information in advance to support a request for coverage and receive payment authorization. Insurers also report that they review samples of claims after payment to determine if they were billed and paid appropriately. None stated that they have had significant problems with improper payments or quality for home infusion therapy services. In addition, commercial insurers report taking various steps to ensure the quality of services delivered in the home, including developing a limited provider network of infusion pharmacies and home health agencies, requiring provider accreditation, coordinating care by providers, and monitoring patient complaints.
extent of Medicare fee-for-service coverage for this therapy. It found that coverage depends on whether the beneficiary is homebound and on other factors related to the beneficiary’s condition and needs. In particular, there was a distinct difference in how commercial insurers and Medicare cover this therapy. Commercial insurers provided comprehensive coverage of home infusion therapy under network-based MA plans, which may provide benefits beyond those required under feefor-service (FFS) Medicare. Nationwide, nearly 1 of 5 MA beneficiaries has comprehensive coverage through an MA plan that offers home infusion therapy as a supplemental benefit. Some homebound Medicare FFS beneficiaries receive comprehensive coverage of home infusion therapy, which includes drugs, equipment and supplies, and skilled nursing when needed. On the other hand, for beneficiaries who are not homebound, Medicare FFS is limited to the necessary drugs, equipment, and supplies, excluding nursing services. For nonhomebound beneficiaries, Medicare FFS is further limited: Infusion drugs may be covered for those enrolled in a prescription drug plan, but neither equipment and supplies, nor nursing services is covered. This group of people would need to obtain infusion therapy in a hospital, nursing home, or physician’s office to have all therapy components covered.
Individual Premiums Rise 20 Percent
People who buy nongroup or individual insurance say their premiums have increased an average of 20 percent, according to a survey by the Kaiser Family Foundation. This increase has spurred 16 percent of them to search high and low for a better price for the coverage they want, but they’re coming up short.
Buyers who bought a cheaper policy still ended up paying 13 percent more than their original premium — and are now getting less comprehensive coverage. The survey found that those who switched are more than four times as likely to say their new plan offers worse benefits than their previous plan (49 percent) than they are to say their new plan’s benefits are better (11 percent). The majority of people get health insurance through their employer, but about 14 million under age 65 have coverage through the nongroup or individual market, which has come under scrutiny for steep rate increases. This market will be subject to reform under the Patient Protection and Affordable Care Act. People with individual insurance report an average annual premium of $3,606, less than the average $4,824 reported in 2009 for employersponsored coverage, which is typically more comprehensive. Insurers also typically vary premiums by age in the nongroup market, with older people reporting higher premiums than their younger counterparts, both for the individual and for family policies. The survey notes that those who pay for their own coverage are much more likely to worry about being able to pay for health care or for a major illness than those with employer coverage: • Forty percent who buy their own insurance say they are “not too confident” or “not at all confident” that they will be able to pay their medical bills. • Only 17 percent say they are “very confident” they could pay these
MANAGED CARE / JULY 2010
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