US sets 2027 home-care payments and widens infusion cover

US Medicare officials have finalised new payment rules for home-health agencies, estimating that payments across the sector will rise by $415 million in 2027 compared with 2026. The same rule extends coverage to certain home-infusion pumps and medicines from April, subject to conditions.

The projected 2.4% increase is an aggregate estimate, not a promise that every agency will receive 2.4% more. The rule also retains a temporary 3% reduction to a national base payment rate, a measure that home-care providers have criticised.

Home-health agencies provide eligible patients with care at home under the US Medicare programme. The annual payment rule sets the framework used to calculate what the programme pays those agencies, including adjustments that reflect patients’ needs and particularly costly periods of care.

How the payment estimate is calculated

The Medicare agency says the overall 2027 estimate includes a 2.1% home-health payment update, worth approximately $365 million, and a further estimated 0.3%, or $50 million, related to an updated threshold for unusually costly cases.

Those figures describe the expected change across agencies, rather than the income of an individual provider. Payments can vary with the type of care delivered and the patients an agency serves. The final estimate is $5 million lower than the $420 million projected in the proposal released in July, although the estimated percentage increase remains 2.4%.

The agency will continue to use a system introduced in 2020 that calculates payments around 30-day periods and takes account of patient characteristics. Under the final rule, it will update the weights used for different patient groups and other factors that affect payments.

The 3% temporary reduction applies to the national standardised base payment rate. The agency says it is continuing an approach used in 2026 to recover what it calculates were retrospective overpayments associated with the introduction of the 30-day system. It did not propose an additional permanent adjustment to that base rate for 2027, but says it will continue to review claims data.

A national association representing home-care providers welcomed the projected payment increase but said the temporary reduction did not adequately reflect the cost of care. It also questioned the data behind the adjustment. Those are the association’s concerns; the effect on any particular agency or patient is not established by the aggregate forecast.

Conditions for home infusion

From 1 April 2027, the rule implements a change in law allowing certain external infusion pumps, associated medicines and supplies to qualify for coverage under Medicare’s medical-equipment benefit. An infusion pump delivers a medicine over time, rather than relying on a single dose.

Coverage is not being extended to every infusion medicine. Among the requirements, the medicine’s approved prescribing information must say it should be administered by or under the supervision of a healthcare professional. A qualified home-infusion supplier must administer or supervise the treatment safely at the patient’s home.

The prescribing information must also call for the medicine to be infused at least 12 times a year, either into a vein or under the skin, or at a rate that requires an external pump. The final rule uses the annual frequency rather than requiring an infusion in each calendar month, as had been proposed. Other statutory conditions still apply.

Provider oversight and palliative care

The rule also changes Medicare provider-enrolment requirements beyond home-health agencies. The agency says it will be able to make enrolment revocations effective from the date non-compliance began, allowing it to recover payments made after that point. It is also adding or expanding grounds for denying or revoking enrolment.

The home-care association said it supported action against improper activity but was concerned that broad enrolment provisions could affect legitimate providers. The Medicare agency says the changes are intended to strengthen oversight and protect the programme.

For patients with serious illness, the agency clarified that eligible skilled palliative care can be provided under the existing home-health benefit. It said this does not create a new benefit and that eligibility continues to depend on a patient’s needs and the programme’s home-health criteria. Further examples are due to be set out in guidance.