Nursing homes may deny admission to a Medicare beneficiary who needs expensive drugs, often as a result of financial concerns. Because of “consolidated billing,” nursing homes must pay for whatever medications, therapies, and services a resident in a Medicare Part A stay needs and receives. However, nursing homes may not know that there are exclusions from consolidated billing for five specified categories that are extremely expensive but not frequently needed by residents (“high-cost, low-probability”) – including certain chemotherapy items and chemotherapy administration services. The Centers for Medicare & Medicaid Services tightly regulates the exclusions lists, although it asks the public each year if additional drugs (HCPCS codes) within the five categories should be excluded (see, e.g., proposed rule at 90 Fed. Reg. 18590, 18600-18602 (Apr. 30, 2025), final rule at 90 Fed. Reg. 37310, 37326-37328 (Aug. 4, 2025)).
Recently, the Center worked with a local ombudsman whose client was admitted to a nursing home on the condition that she forego chemotherapy. Successful advocacy focused on identifying the resident’s chemotherapy drugs and determining that they are expressly excluded from consolidated billing (and have been excluded since 2008). After a temporary hospitalization, the resident is now back in the nursing home under Medicare Part A and she is getting the chemotherapy she needs.
If someone is being denied admission to a nursing home chemotherapy, check the list of exclusions.
Resources:
- “Billing Challenges for Residents of Skilled Nursing Facilities,” PubMed Central (originally published in the Journal of Oncology Practice, Sep. 2008) describes consolidated billing; Table 1 provides an alphabetical list of drugs and services commonly provided in oncology practices and identifies whether they are reimbursed by Medicare or by the skilled nursing facility)
- See quarterly updates, e.g., “HCPCS Codes Used for Skilled Nursing Facility Consolidated Billing Enforcement: July 2025 Quarterly Update (effective July 1, 2025)
- 2025 Part A MAC Update, listing seven additional chemotherapy drugs that are excluded from consolidated billing and two chemotherapy drugs that are terminated
December 11, 2025 – T. Edelman