Reimbursement FAQs: Patient Affordability Programs

Does Medicare reimburse for intravenous immune globulin (IVIG) when used to treat autoimmune hemolytic anemia (AIHA)?

Although it is not routine, Medicare does reimburse for IVIG in patients with refractory AIHA in some instances. Specifically, local coverage determination for at least one of the durable medical equipment (DME) Medicare administrative contractor (MAC) providers states:

“In this condition, intravenous immune globulin is indicated only for those patients who have failed to respond to other forms of therapy and/or require rapid cessation of hemolysis due to severe or lifethreatening manifestations of this condition. Duration of treatment is generally a short course of 3-5 weeks. Realizing dosage may vary based on patient’s individual situation, dosage must be in keeping with the recommended current literature and standard of practice.”

I have many patients who cannot afford the care they need. In addition, many do not qualify for entitlement programs because their income is not low enough. Are there any programs to help get my patients the care they need?

There are several programs that offer prescription and/or insurance premium assistance. To qualify for many of these programs, it is not necessary to be below the federal poverty level. In almost all cases, patients are required to give personal information such as proof of income and expenses to substantiate their need. In addition, healthcare providers need to be prepared to fill out forms validating the diagnosis.

Some of the programs that will assist patients:

Patient Services Inc. will offer premium and/or copay assistance help for patients with hereditary angioedema, bleeding disorders, chronic inflammatory demyelinating polyneuropathy, complement-mediated diseases, primary immunodeficiency and more. For a complete list of diseases or to refer patients, go to www.patient servicesinc.org.

Needy Meds provides a database of information on different assistance programs. It does not directly supply medications or provide financial assistance. Providers and patients using this free service can search the database by disease, drug name, program name or company name to find applicable assistance programs. To read more about Needy Meds, go to www.needymeds.org/index.htm.

The National Organization for Rare Disorders administers patient assistance programs for uninsured and underinsured patients with rare diseases such as chronic non-infectious uveitis, multiple sclerosis and primary immunodeficiency.Programs may include assistance for premiums, copayments, travel and lodging for certain clinical trials. The type of help a patient qualifies for depends on the disease and/or medication. To view a complete program list, go to www.rarediseases.org/patients-and-families/patient-assistance.

Is there any help for low-income seniors who rely on Medicare Part D plans to assist with out-of-pocket expenses for medications?

It is a well-known fact that patients who can afford their medications are likely to be more compliant and, as a result, have fewer complications. Seniors on a fixed income can become especially vulnerable to noncompliance because of an inability to afford their medications. Additionally, because they are on an entitlement program, they do not qualify for manufacturer assistance programs. However, there may be some assistance that many Medicare recipients are not accessing.

The Centers for Medicare and Medicaid Services (CMS) recently reported that they believe nearly two million people qualify for but are not enrolled in a subsidy assistance program for low-income Medicare recipients. Beneficiaries with limited resources and with incomes less than $16,335 a year for an individual or $22,065 for a couple may qualify for the Medicare Low Income Subsidy program. CMS reports that it is easier for beneficiaries to qualify than in years past. A person’s house, car and life insurance policies do not count as resources. For a full list of qualifications and to apply for assistance, patients can go to www.ssa.gov/prescriptionhelp.

Now that Gammagard Liquid has been added to the External Infusion Pump LCD as covered subcutaneous immune globulin, what billing codes must be used for reimbursement?

For reimbursement of Gammagard Liquid for dates of service on or after July 22, 2011, the existing Healthcare Common Procedure Coding System (HCPCS) code must be used: J1569 — Injection,Immune Globulin (Gammagard Liquid), Intravenous, Nonlyophilized (e.g. Liquid), 500 mg. For subcutaneous administration, only an E0779 infusion pump is covered, and a JB modifier must be added to each HCPCS code: J1569-JB. No modifier should be added for other routes of administration.

Gammagard Liquid is available in 1 gram (2 units of service [UOS]) and 2.5 gram (5 UOS) sizes. Suppliers must choose the package size that is appropriate for the dosage being administered to minimize waste. For example, one unit of service (1 UOS) is 500 mg. If 1,500 mg is prescribed (3 UOS), two 1 gram vials (4 UOS) must be used rather than one 2.5- gram vial (5 UOS). Excess waste due to non-optimal vial sizes will be denied as not reasonable and not necessary.

Gammagard Liquid will be added in a future revision of the Local Coverage Determination (LCD). Suppliers should refer to the LCD, policy article and supplier manual for additional information.

Editor’s Note: The content of this column is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.