Who pays, and under what rules.

Medicare and home infusion. The Medicare mark on the home infusion row is specific to a benefit. Since January 1, 2021, Medicare Part B has paid a qualified home infusion therapy supplier for the professional services, including nursing, training and monitoring, that go with certain drugs given through a pump covered as durable medical equipment. CMS states that those services are excluded from the home health benefit, and that for other infused drugs the professional services at home may be covered under the home health benefit when the patient is eligible for it. Medicare Advantage plans are required to include Part B benefits and apply their own networks and authorization rules. Medicare does not pay for every infusion given at home. The Medicaid and VA marks are also conditional: state Medicaid programs must cover home health nursing, and whether and how each pays for home infusion nursing differs by state; the VA lists home infusion among the skilled home health care it purchases from contracted community agencies for veterans who are eligible for community care and meet the clinical criteria. Home infusion nursing, in full →

Read along a row and the point is plain. An infusion suite may be paid by a pharmacy, by Medicare, by a managed-care plan, by an insurer and by patients, all in the same week. Read down a column and it is equally plain: a Medicaid plan may be paying the same agency for skilled home health, private duty nursing and personal care.

The clinical work follows the row. The money follows the column. An agency that grows almost always grows along both.

Every service line, explained →   Medicaid home and community care →   VA community care →   Healthcare staffing →

A pharmacy under contract

The pharmacy dispenses the drug and is the agency’s customer. Its contract sets what a nursing visit is worth, commonly a flat amount for the first hours and an hourly rate after, with its own rules for travel, mileage, supplies and missed visits. Every pharmacy’s contract differs, and an agency serving several holds several sets of terms at once.

What it changes: the authority to visit is the pharmacy’s order, the bill is an invoice, and the pharmacy expects the nursing note back in its own form within a stated time. There is no adjudication, but there is a customer who checks every line against its own records.

Home infusion nursing →   Specialty pharmacy nursing →

Medicare

Original Medicare pays for home health by period of care and for hospice by the day, under federal payment systems whose rates and groupings are republished on a cycle. It does not approve visits one at a time. It requires that the patient be eligible, that a practitioner certify the need, that the standardized assessment be completed and that the agency meet the Conditions of Participation.

What it changes: payment depends on the assessment and the diagnosis as well as the visits; a notice is due at the start of care; the claim lists every visit while paying for the period; and the agency is surveyed against federal conditions. Operational events, such as a late start or a missed visit, have payment consequences while care is still under way.

How Medicare home health actually operates →   Hospice →

Medicare Advantage

A private plan administers the Medicare benefit for its members and sets its own authorization, rate and claim rules. An agency contracted with several plans works under several rulebooks for patients who are clinically alike.

What it changes: care is usually approved in advance for a number of visits and must be re-approved to continue; the plan, not Original Medicare, receives the claim; and payment is commonly per visit at a contracted rate. Checking which coverage is active at referral matters, because the same patient’s care is billed to an entirely different party depending on the answer. Hospice is the exception: when a plan member elects hospice, Original Medicare pays the hospice.

Medicaid and managed care

Medicaid is run by each state within federal rules, and most states deliver much of it through managed-care plans. Home and community-based services, private duty nursing and personal care are authorized in units or hours for a period, by service.

What it changes: there is no single national workflow. The service authorization, the billing code, the unit, the claim rules and the requirement to verify visits electronically are set by the state and often by the plan. An agency in one state under three plans may have three sets of rules for the same aide visit.

Medicaid home and community care →   Personal care and home care →

VA programs

When the VA cannot provide care itself, it may authorize a community provider to deliver it. The authorization names the services, the disciplines, the quantity and the period, and care outside those terms is not covered by it.

What it changes: the authorization is a set of lines by discipline, each with its own quantity and dates; continuing care requires a new authorization before the first one ends; and the approval of care and the document that permits billing for it are separate facts that software must be able to hold apart. Claims go through the VA’s contracted network or to the VA, in the form the service requires.

VA community care →

Commercial insurance

An employer-sponsored or individual health plan covers home care by its own policy. Coverage, limits and the patient’s share differ by plan. Long-term care insurance is a separate product that reimburses personal care or nursing once the policyholder meets the policy’s conditions.

What it changes: prior authorization is the insurer’s, by code and quantity; the bill is a professional or institutional claim sent through a clearinghouse; and the result is adjudicated by that insurer’s rules, with the patient often owing part.

Private pay

A person or family engages the agency directly under a service agreement that states the service, the rate, the schedule and the terms of payment.

What it changes: nobody adjudicates anything, and the customer reads every line. The record of each shift or visit has to be exact, the invoice has to match it, and payment, balance and refunds have to be handled as carefully as a claim.

Private duty and private pay →