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Understanding the Benefits of Medicare Part B Coverage for PI Diagnoses

August 6, 2019

The Centers for Medicare and Medicaid (CMS) added more diagnoses of primary immunodeficiency diseases (PI) to be covered under the Medicare Part B benefit for immunoglobulin (Ig) replacement therapy in the home setting, as recently shared on the Immune Deficiency Foundation (IDF) blog: “More PI Diagnoses Covered for Home Ig Replacement Therapy under Medicare Part B.” This is great news for the PI community because now more people with PI can afford to receive Ig replacement therapy in a home setting. For those who have questions, we want to explain how this works and why it is helpful to our community.

  1. Before this change, individuals who had one of the 10 recently added PI diagnoses were not eligible to receive Medicare Part B coverage for their home infusions.
  2. Medicare Part B is a medical benefit and allows coverage for intravenous immunoglobulin replacement therapy (IVIG) because it was typically administered in a hospital or facility setting. CMS makes medical determinations as to the PI diagnoses that are covered under Part B for home infusions. The IVIG list is used as a reference for coverage of subcutaneous immunoglobulin replacement therapy (SCIG), which is covered under the Medicare Part B durable medical equipment (DME) benefit for external pumps.
  3. Individuals with PI who have diagnoses not on the Medicare list for home coverage were able to receive home infusions through the Medicare Part D pharmacy benefit. For most people with PI, however, this option is much more expensive. Under Part B, individuals over 65 may purchase supplemental insurance plans that will cover the 20% that is not covered by Medicare. For our community, whenever possible, IDF recommends purchasing a supplemental plan, but supplemental plans may not be used to cover the coinsurance requirements under a Part D plan. Depending on the plan, this could be up to 40%. In addition, within a year, once your plan has reached the coverage gap or donut hole ($3,820 in 2019), an individual will need to cover 25% of the costs until they reach the catastrophic out-of-pocket costs ($51,000). Once they reach that, individuals will still owe 5%. With the price of Ig replacement therapy being up to $10,000 per month, Part D coverage is not sufficient to make it affordable for most people. Given that many people struggle to make their basic monthly living expenses, getting to the point of reaching catastrophic coverage is not a realistic option. An article in the Hill highlights the challenges to people when medications that should be covered by Part B are only covered by Part D.
  4. Because of the challenges with Part D coverage, in the past, IDF has advised individuals who have had a PI diagnosis that was not covered under Part B for home infusions to receive treatment at a hospital or infusion center that would allow for Part B coverage. This was a challenge for many people who had received IVIG or SCIG at home under their private insurance but now had to go to a facility for treatment.
  5. In order to address the challenges that people with PI have faced for a number of years, IDF requested that CMS review the Medicare codes. We argued that it made no sense that individuals with some conditions could receive coverage for Ig replacement therapy under Part B in one setting but not in another. At our request, the medical team at CMS reviewed the list of covered diagnoses and determined there were 10 additional diagnoses that should be added. 

As this home coverage has opened opportunities for people with PI to have home infusions, we recognize that some providers are concerned about adequate reimbursement for these services. We support adequate reimbursement to providers, but access to treatment is IDF’s priority. People with PI—or any people with any diagnosis—should never be used to make up the difference in costs. The new codes will be implemented on August 13, 2019 and will ensure increased access to home Ig replacement therapy to more people who depend upon this lifesaving therapy.

Questions about Medicare Part B coverage for PI diagnoses? Click here to Ask IDF, or call 800-296-4433.  

 

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