Getting Your Equipment Repaired Under Medical Assistance Managed Care Prepared by the Disability Rights Network of Pennsylvania and the Institute on Disabilities at Temple University March 11, 2014

Learning Objectives List the types of durable medical equipment repair services that are covered Identify providers to make repairs Describe the process for getting equipment repaired Copyright March Disability Rights Network of Pennsylvania.2

Roadmap Medical Assistance overview Managed care overview Covered repairs –Warranties Providers Process Copyright March Disability Rights Network of Pennsylvania.3

Medical Assistance Overview “Medicaid” Part state-funded and part federally-funded health insurance program for low-income persons “State Plan” Must follow federal law and rules Copyright March Disability Rights Network of Pennsylvania.4

Medical Assistance Overview Eligibility –Temporary Assistance for Needy Families (TANF) –SSI –Other categories Note: If SSI-level of disability and under age 18, parental income and resources not counted Copyright March Disability Rights Network of Pennsylvania.5

Medical Assistance Overview Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) –Children under age 21 –All medically necessary health care services that are contained in federal Medicaid law whether or not covered under Pennsylvania’s State Plan Copyright March Disability Rights Network of Pennsylvania.6

Managed Care Overview “HealthChoices” “Managed Care Organizations” Statewide as of March 1, 2013, with some exceptions Health plans and providers must follow federal and state laws and rules Copyright March Disability Rights Network of Pennsylvania.7

Managed Care Overview Fee schedule –List of covered services and rates –May cover more, but not less, than fee-for-service Medical Assistance Remember Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Copyright March Disability Rights Network of Pennsylvania.8

Managed Care Overview Provider network Special Needs Unit –Contact Member Services and ask for “Special Needs Unit” –Can request case management 9Copyright March Disability Rights Network of Pennsylvania.

Managed Care Overview HealthChoices Agreement t/documents/communication/s_ pdf t/documents/communication/s_ pdf –Exhibits to HealthChoices Agreement ent/documents/communication/s_ pdf ent/documents/communication/s_ pdf Department of Public Welfare Directory t/documents/communication/s_ pdf t/documents/communication/s_ pdf –Contract managers Copyright March Disability Rights Network of Pennsylvania.10

What Repairs Are Covered? Repairs to medically necessary durable medical equipment (DME) 11Copyright March Disability Rights Network of Pennsylvania.

What Repairs Are Covered? Durable medical equipment –Item or device that can withstand repeated use is used primarily and customarily to serve a medical purpose customarily is not useful to a person in the absence of illness or injury, and is appropriate for home use 12Copyright March Disability Rights Network of Pennsylvania.

What Repairs Are Covered? Medically necessary 1.Compensable under the Medical Assistance Program and will 2.Prevent illness, condition, injury, or disability; or Reduce or ameliorate the effects of an illness, condition, injury, or disability; or Help the person achieve or maintain maximum functional capacity in performing daily activities, like other Medical Assistance recipients of the same age Copyright March Disability Rights Network of Pennsylvania.13

What Repairs Are Covered? Coverage cannot be less than fee-for-service Medical Assistance Get health plan coverage policy –Ask Special Needs Unit or Durable Medical Equipment Unit of health plan 14Copyright March Disability Rights Network of Pennsylvania.

What Repairs Are Covered? Medically necessary –Repairs –Replacement of a part –Maintenance –Replacement of entire item 15Copyright March Disability Rights Network of Pennsylvania.

What Repairs Are Covered? Repair –Example definition: “to fix or mend and to put the equipment back in working condition after damage or wear” –Example coverage: “Repairs to medically necessary DME, corrective appliances, and other devices are covered up to the replacement cost when necessary to make the equipment or device serviceable” 16Copyright March Disability Rights Network of Pennsylvania.

What Repairs Are Covered? Replacement of a part –Example definition: “the provision of an identical or nearly identical item” –Example definition: “putting something new in place of an irreparable item” 17Copyright March Disability Rights Network of Pennsylvania.

What Repairs Are Covered? Maintenance –Check with health plan for coverage policy –Batteries Power wheelchair (all ages) Hearing aid (under age 21) –Wheelchair tires (all ages) 18Copyright March Disability Rights Network of Pennsylvania.

What Repairs Are Covered? Equipment rentals –Maintenance and repairs included in rate paid to provider –Contact provider to get maintenance and repairs done –Contact Special Needs Unit for help 19Copyright March Disability Rights Network of Pennsylvania.

What Repairs Are Covered? Replacement of entire item –Example coverage: “If the expense for repairs exceeds the estimated expense of purchasing or renting another item of equipment for the remaining period of medical need, payment shall be limited to the replacement cost” 20Copyright March Disability Rights Network of Pennsylvania.

What Repairs Are Covered? Replacement of entire item –Medically necessary equipment can be replaced after certain period of time regardless of condition –Frequency must at least match fee-for- service Medical Assistance coverage Three years for power wheelchair and speech generating device 21Copyright March Disability Rights Network of Pennsylvania.

What Repairs Are Covered? Warranties –Medical Assistance will not cover repairs that warranty should cover Manufacturer responsibility –Consider registering equipment with manufacturer 22Copyright March Disability Rights Network of Pennsylvania.

What Repairs Are Covered? Warranties –Pennsylvania’s Motorized Wheelchair Warranty Act “Problems with Your New Motorized Wheelchair? – Your Rights Under Pennsylvania’s Motorized Wheelchair Warranty Act” at 23Copyright March Disability Rights Network of Pennsylvania.

What Repairs Are Covered? Warranties –Keep copy of warranty –Document the problem –Contact manufacturer “Authorized dealer” –Confirm and document in writing 24Copyright March Disability Rights Network of Pennsylvania.

What Repairs Are Covered? Warranties –Pennsylvania Attorney General’s Bureau of Consumer Protection –Ask health plan to cover needed repair –Get legal help 25Copyright March Disability Rights Network of Pennsylvania.

What Repairs Are Covered? During repair, consider –Rental of equipment (through Medical Assistance) Ask doctor and provider –Loaner equipment (no charge) Ask provider or manufacturer 26Copyright March Disability Rights Network of Pennsylvania.

Identifying Providers Must use providers in health plan’s network, but Network must be adequate –Can ask for permission to go out of network Copyright March Disability Rights Network of Pennsylvania.27

Identifying Providers Special Needs Unit –Ask for list of providers Health plan website Department of Public Welfare contract managers 28 Copyright March Disability Rights Network of Pennsylvania.

Identifying Providers Verify Case management from Special Needs Unit Seek approval to use out of network provider, if needed Provider can contact health plan’s Provider Services 29 Copyright March Disability Rights Network of Pennsylvania.

Process for Getting Repairs Know health plan coverage policy Ask health plan –Is the provider in network? –Is a prescription needed? –Is prior authorization needed? –What else is needed to show medical necessity of repair? –Is there a copay? Copyright March Disability Rights Network of Pennsylvania.30

Process for Getting Repairs Specific billing code –Code for specific part being repaired or replaced –Provider evaluate the problem –Physician contact health plan or health plan contact provider directly for billing code Copyright March Disability Rights Network of Pennsylvania.31

Process for Getting Repairs Program Exception request if needed service not on fee schedule or to exceed limits on fee schedule –Need physician’s help to do this Copyright March Disability Rights Network of Pennsylvania. 32

Process for Getting Repairs Physician, provider of repair, and others submit any additional documentation requested by health plan Submit letters of medical necessity if needed Copyright March Disability Rights Network of Pennsylvania.33

Process for Getting Repairs Must first use primary insurance, such as Medicare or private health insurance Copyright March Disability Rights Network of Pennsylvania.34

Process for Getting Repairs Health plan payment to provider is “payment in full” –Provider cannot charge supplemental payments or “balance bill” –Provider can collect Medical Assistance copay, if any Copyright March Disability Rights Network of Pennsylvania.35

Process for Getting Repairs Right to appeal if coverage is denied –Fair Hearing AND –Complaint or Grievance Meet appeal deadlines Copyright March Disability Rights Network of Pennsylvania.36

Webinars in This Series The webinars in this series may be accessed at: –Webinar 1: “Getting Durable Medical Equipment from Medical Assistance Managed Care: The Basics” –Webinar 2: “Getting Your Communication or Mobility Equipment: Evaluations” Copyright March Disability Rights Network of Pennsylvania.37

Disability Rights Network of Pennsylvania (voice) (TDD) Follow us on Facebook Sign up for alerts at Copyright March Disability Rights Network of Pennsylvania.38

Disability Rights Network of Pennsylvania Publications on getting assistive technology from Medical Assistance can be found at Copyright March Disability Rights Network of Pennsylvania.39

Pennsylvania’s Initiative on Assistive Technology (voice) (TDD) Statewide network of regional Assistive Technology Resource Centers Device demonstrations Copyright March Disability Rights Network of Pennsylvania.40

Pennsylvania’s Initiative on Assistive Technology Device loans: /assistive/atlend /assistive/atlend Device reutilization Telecommunication Device Distribution Program (TDDP) iCanConnectPA Copyright March Disability Rights Network of Pennsylvania.41

Other Resources Pennsylvania Assistive Technology Foundation: (toll- free voice/TDD), Department of Public Welfare: or (toll-free voice), Copyright March Disability Rights Network of Pennsylvania.42

Contact Information Chava Kintisch, Staff Attorney Assistive Technology Project Director 1315 Walnut Street, Suite 500 Philadelphia, PA , extension 210 (voice) (TDD) Copyright March Disability Rights Network of Pennsylvania.43

Contact Information Amy S. Goldman, Co-Executive Director Institute on Disabilities, Temple University 1755 N. 13th Street, Suite 411 South Philadelphia, PA (voice/TTY) (voice/direct) Copyright March Disability Rights Network of Pennsylvania.44

Webinar Survey Please fill out our survey at JS6ZKDB JS6ZKDB –Contact Amy Goldman for a print copy or alternative format of the survey if needed Copyright March Disability Rights Network of Pennsylvania.45

Other Information IMPORTANT: This publication is for general informational purposes only. This publication is not intended, nor should be construed, to create an attorney-client relationship between the Disability Rights Network of Pennsylvania and any person. Nothing in this publication should be considered to be legal advice. Copyright March Disability Rights Network of Pennsylvania.46

Other Information This project is partially funded by a grant to the Disability Rights Network of Pennsylvania under Protection and Advocacy for Assistive Technology from the Department of Education. However, the content does not necessarily represent the policy of the Department of Education, and endorsement by the Federal Government should not be assumed. Copyright March Disability Rights Network of Pennsylvania.47

Copyright March Disability Rights Network of Pennsylvania.48 Thank you!