7 AAC 145.425 - Home infusion therapy payment rates

(a) Except as otherwise provided in this section, when the only home infusion therapy service being provided is skilled nursing, the department will pay a provider of home infusion therapy services for skilled nursing services in accordance with 7 AAC 145.020, not to exceed 85 percent of the amount determined under 7 AAC 145.050 per visit.

(b) The department will pay a provider on a per diem basis, for the duration of the therapy period, for home infusion therapy services and specialty drug administration when the home infusion therapy includes the concurrent delivery of home infusion administrative services, professional pharmacy services, care coordination, and necessary supplies and equipment; the per diem amount is determined as follows:

(1) the department will pay a percentage of the maximum allowed amount under (2) and (3) of this subsection that is

(A) 100 percent for the first administered therapy;

(B) 80 percent for the second concurrently administered therapy; and

(C) 75 percent for the third and each subsequent concurrently administered therapy;

(2) the maximum allowed amount in CPT Fee Schedule for Home Infusion Therapy Servicestable and HCPC Fee Schedule for Home Infusion Therapy Servicestable, adopted by reference in 7 AAC 160.900;

(3) for services not listed on the fee schedule adopted by reference in (2) of this subsection, a maximum allowed amount that the department will establish based on 80 percent of the billed charges from enrolled providers in this state for the first nine billings that reflect a charge for a home infusion therapy service not already on the schedule established under this subsection; thereafter, the payment rate will be established based on the 50th percentile of the first 10 billings; the department will add new payment rates under this subsection each time the department receives 10 billings for a home infusion therapy service not already on the schedule; to be paid under this paragraph, a billing must reflect a charge that complies with the applicable standards in 7 AAC 145.020.

(c) For home infusion therapy services for which a payment rate has not been determined under (a) or (b) of this section, the department will pay a home infusion therapy provider at a reasonable per diem rate determined under (d) of this section for the duration of the therapy period.

(d) A reasonable per diem amount for a home infusion therapy service under (c) of this section is determined by the department based upon the specific circumstances of the service being offered. To determine a reasonable per diem amount, the department will

(1) add the total amount for the following costs, direct or indirect, that are associated with providing services to the recipient:

(A) administrative costs;

(B) professional pharmacy services, including drug compounding;

(C) care coordination;

(D) clinical monitoring of the recipient;

(E) purchase or lease of infusion-related equipment and supplies necessary to provide infusion in the recipient's home; and

(F) delivery and pickup of infusion-related equipment, supplies, and medications;

(2) subtract the cost of drugs and skilled nursing services; and

(3) if necessary, add an amount to provide a fair return to the home infusion therapy provider to ensure that home infusion therapy services continue to be available to that recipient.

(e) For drugs covered under 7 AAC 120.110 and used in home infusion therapy, the department will pay the rate determined under 7 AAC 145.400. A provider may not include compounding and dispensing fees paid under (a) of this section on the claim for drugs, unless the drugs are dispensed to a recipient in a long-term care facility.

(f) A home infusion therapy period begins the day home infusion therapy services are initiated and ends the day home infusion therapy services are discontinued and not anticipated to begin again. If home infusion therapy services resume after a therapy period has stopped, those services are considered to be a part of a new therapy period. The number of per diem payments made for a therapy period may not exceed the number of days authorized on the order or plan of care.

Notes

7 AAC 145.425

Eff. 7/7/2010, Register 195

Authority:AS 47.05.010

AS 47.07.030

AS 47.07.040