Medicaid plans vary from state to state and the home infusion provider faces the challenge of understanding the requirements from each state.  Some states provide robust home infusion guidance, while others have very limited instruction, thus home and specialty infusion providers must carefully analyze the material in order to maintain compliance.  Below are recommendations for the type of criteria the provider should research.


Coding requirements are predicated on the state.  Some will allow per diems (S codes), others follow the supply code (A and E HCPCS codes) methodology.  Some may use a combination depending upon the therapy.  The provider should thoroughly understand what codes are permitted by each state.

The NHIA Payer Advocacy and Relations Committee surveyed state Medicaid programs to get a sense of the prevailing reimbursement methodologies for infused drugs and parenteral nutrition.  Click here to access summary data as well as State specific information.  It is important to note that this survey was completed in July of 2015 and represents a snapshot in time.    


Billing for drugs and supplies is typically a bifurcated process because states participate in a drug rebate programs.  It is quite common for the supplies to be billed to Medicaid using a CMS 1500 Health Insurance Claim Form (paper or electronic) with the drugs billed separately on either a CMS 1500 or through the point-of-sale National Council for Prescription Drug Programs (NCPDP) claim format.  Some may exclusively use one or the other as a means to submit claims.  Upon review of the provider manual, be sure to explore the DME and pharmacy chapters.

When billing drugs, the HIT provider must be aware of the billing requirements in regards to HCPCS versus NDC unit billing.  Again, some may use a combination of the two which are very different from one another.


Many Medicaid programs have documentation requirements that include a certificate of medical necessity (CMN) and some type of IV implementation form.  Although the latter may not need to be sent in with the claim, it is expected to be on hand in the event of a post-payment review.  The provider manual will typically specify the required forms and whether they require the physician’s signature.


Authorization requirements vary but are often limited to high dollar drugs, the use of DME, enteral, or usage in excess of specified quantity limits.  The process may include a physician signature on a form or require the physician to initiate the authorization.  The provider must also be aware of the limitations on receiving back-dated authorizations because of the short turn-around time requirements of the referral source.


Medicaid programs have varying levels of coverage thus the provider must understand the coverage codes that are typically provided when verifying coverage.  The two most common categories that will impact the provider are children under 21 and dual-eligibles (Medicare/Medicaid) – for example, QMB (qualified Medicare beneficiary) is a term that is used to indicate that the state is paying for the Medicare premium.  Medicaid’s coverage may be limited to just paying the premiums or the beneficiary may have an extended plan that also pays for non-Medicare covered therapies.   Children under 21 may have extended benefits for therapies such as enteral thus the provider should be aware of the programs that may have additional coverage criteria. Click here for weblinks to State Medicaid programs.

Per the 2015 -2017 NHIA Strategic Plan NHIA is working to educate Medicaid plans on the value of home infusion and specialty infusion therapy services.  NHIA efforts are focused primarily on national organizations that represent numerous Medicaid plans, such as the National Association of Medicaid Directors (NAMD), Medicaid Health Plans of America (MHPA) and the Association for Community Affiliated Plans (ACAP).  The Payer Advocacy and Relations Committee created a document explaining home and specialty infusion therapy, the various payment methodologies, and highlighting what Medicaid plans can do to take full advantage of the cost saving associated with the home site of care.  Click here to review the document, which NHIA encourages members to use in their local Medicaid discussions.


States have traditionally provided Medicaid benefits using a fee-for-service system. However, in the past 15 years, states are increasing implementing managed care delivery systems for Medicaid benefits. In a managed care delivery system, people get most or all of their Medicaid services from an organization under contract with the state. Almost 50 million people receive benefits through some form of managed care, either on a voluntary or mandatory basis.

Enrollment in Medicaid managed care programs can be voluntarily, but more frequently it’s a state requirement. An increasing numbers of States are using Managed Long Term Services and Supports (MLTSS) as a strategy for expanding home- and community-based services, promoting community inclusion, ensuring quality and increasing efficiency.  When states implement a managed care program, it can use any one of the following types of entities:

  • Managed Care Organizations (MCOs) – like HMOs, these companies agree to provide most Medicaid benefits to people in exchange for a monthly payment from the state.
  • Limited benefit plans – these companies may look like HMOs but only provide one or two Medicaid benefits (like mental health or dental services).
  • Primary Care Case Managers – these individual providers (or groups of providers) agree to act as an individual’s primary care provider, and receive a small monthly payment for helping to coordinate referrals and other medical services.

The provider must be diligent about checking eligibility monthly to see whether the patient is in a managed care plan or whether they are “straight Medicaid.”   Some states are very flexible allowing their recipients to change managed care plans, so the provider must stay current on the existing benefit to ensure that authorizations are obtained and the correct payer is billed.  Finally, providers must be cognizant of patients who have spend- downs and manage their risks accordingly.