Medicare is the federal insurance program that provides coverage for the elderly (people aged 65 and older) and people who are disabled. NHF advocates for Medicare policies that benefit the bleeding disorders community in part because Medicare is often seen as the model program that influences coverage by private insurers.
Skilled Nursing Facilities
Medicare beneficiaries with hemophilia and other bleeding disorders have been unable to access Skilled Nursing Facilities (SNFs) following an inpatient hospital admission largely due to how Medicare reimburses these facilities.
SNFs are paid a prospectively determined daily rate (per diem) for all SNF services provided to patients. This bundled payment includes nursing and therapy components (adjusted by case mix), drugs, supplies and equipment, in addition to a room/board and administration component. This payment is expected to cover all operating and capital costs of SNF facilities.
It is extremely difficult to find a SNF that will care for hemophilia patients due to the significant losses the SNF will incur as a result of clotting factor costs. Costs for a person with hemophilia will far exceed the per diem rate for the highest level SNF care.
If a SNF is unavailable, other options for patients include inpatient rehabilitation facilities (but many patients are not strong or healthy enough to meet admission and/or treatment requirements), keeping the patient in the acute inpatient setting longer than needed, or sending the patient home. None of these options allow for the level of coordinated, skilled care necessary for a successful recovery.
The Medicare SNF statute allows for certain costly, highly specialized services that SNFs do not typically provide to be billed separately under Medicare Part B. Services that can be billed separately include chemotherapy, radioisotopes, certain types of prosthetics and EPO for dialysis patients.
NHF seeks to add clotting factor therapies to the list of services that can be billed separately under Medicare Part B. The provision of clotting factor to patients is comparable in cost to the above-referenced specialized services where Medicare recognizes the need for separate treatment.
The Consolidated Omnibus Appropriations 2021 law included the enactment of the Hemophilia SNF Access Act. The Hemophilia SNF Access Act was a top priority at NHF’s Washington Days 2020. The measure has now become law and will take effect October 2021.
This section of the legislation adds blood clotting factors and items and services related to their furnishing to the categories of high-cost, low-probability services that are excluded from the skilled nursing facility per diem prospective payment system (PPS) and are separately payable. This change will allow people with bleeding disorders to access SNF care when it is the most appropriate setting rather than having to stay in the hospital for longer. NHF thanks our Congressional sponsors who helped champion this legislation, and our network of providers and patient advocates that shared their experiences and concerns to make this proposal a reality in 2021.