Medicare and Medicaid “Unlocking the Gate to Funding Assistive Technology”

Who’s Who?  CMS (Centers for Medicare and Medicaid Services)  Medicare –Part A: Hospital Insurance –Part B: Medical premiums cover DME, outpatient care –Divided into 4 regions (DMERCs)  Medicaid –General Hospital, nursing home, TEFRA –Optional state supplement –Aged, blind, and disabled –Partners for Healthy Children –Optional coverage for pregnant women and infants

Common Product Categories OrthosesCanes/CrutchesWalkers Enteral NutrientGlucose TestingNebulizer Drugs ProsthesesManual W/CNebulizer Ostomy SupplyOxygen Equip.PMD Refractive LensSupport SurfaceBeds Bath/SafetyCommodesUrologicals Surgical DressPatient LiftsSeating SuctionCPAP/BIPAPVentilators

Standards for Coverage  MD order to initiate Service (pad script)  CMN – Payer specific forms  Supporting documentation from charts  LMN or clinical specialist’s notes  HCPCS Code appropriate to payer  Qualifying ICD9 code

Responsibility of Referrals  Basic product knowledge for application  Understanding covered vs. non-covered  Aware of product cost vs. allowables  Access to willing MD for orders  Work with reputable Supplier –Must provide what is ordered –Competent from intake to service after delivery –CRTS recommended for Custom Rehab

Responsibility of Suppliers  Access to quality products  In depth knowledge of coverage criteria  On going education of staff  Dependable service with trained staff  Reputable billing department  Medicare claims assigned or non-assigned  Medicaid HMO or out of state  Service after the delivery

Funding Trends  Medicaid requires PA on most equipment  Medicaid is always the last payer  Medicaid pays for bath equip. up to age 21  Medicaid pays for augmentative communication devices  No coverage for ramps, lifts, transportation, or home modifications  Qualifications vary by payer

Medicare’s New Mobility Maze  Based on Algorithm (attachment A)  Medical chart must show need for device  More reliance on MD for objective data  Power requires face to face exam with MD, Physician’s Assistant, or Nurse Practitioner  “Bed or Chair Confined” no longer needed  Focus is now on MRADL independence

Helpful Tips  Expected life of equipment is 5 years  Medicaid allows new cushion every year  Once you go power, you stay in power  Headrest or chest strap ICD9 driven  April 1, 2006 expect more changes  Tie down options on mobility, not covered  Ask Manufacturers for sample LMN’s

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Handy Laws to Know  Medicaid’s purpose is clearly stated and backed up: –To furnish rehabilitation and other services to help such families and individuals attain or retain capability for independence or self care. (42 U.S.C., 1396, 2) –The Medicaid Act requires that each state medical assistance program be administered in the “best interest of the recipients.” (42 U.S.C., 1396a, a, 19) –The Medicaid Agency may not arbitrarily deny or reduce the amount, duration, or scope of a required service to an otherwise eligible beneficiary solely because of the diagnosis, type of illness or condition. (42 C.F.R., , c) –“must…provide that all individuals wishing to make application for medical assistance under the plan shall have opportunity to do so, and that such assistance shall be furnished with reasonable promptness to all eligible individuals.” (42 U.S.C., 1396a, a, 8) Hunter v. Chiles, 944 F. Supp.914 (S.D. Fla.1996). Adults sought ACDs which state conceded it would cover for child if unavailable from other sources. Citing Salgado, court held that “Medicaid funding cannot be denied on the basis of age.” Age as sole criterion is wholly unrelated to medical necessity and is unreasonable.

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