The Medicare-Medicaid Coordination Office’s Integrated Resource Center (ICRC) of the Center for Medicare & Medicaid Services recently released an issue brief addressing the challenges of access to durable medical equipment (DME) for dually eligible beneficiaries. The brief, Facilitating Access to Medicaid Durable Medical Equipment for Dually Eligible Beneficiaries in the Fee-for-Service System: Three State Approaches, cites the logistical problems created by the mismatch of Medicare and Medicaid processing rules as creating barriers in access to needed care that individuals enrolled in only one or the other of the programs do not have. ICRC researched examples of states that have implemented provisional prior authorization (PA) policies, supported by lists of DME that Medicare generally does not cover. Fourteen states – Alaska, California, Connecticut, Georgia, Idaho, Illinois, Indiana, Kansas, Minnesota, Nevada, New York, Ohio, Oregon, and Utah – all appear to authorize suppliers to bill Medicaid directly for DME items that Medicare generally does not cover. The brief examines DME policies in three states (Illinois, California and Connecticut) that have led to improved access.
- Illinois: Illinois enables
providers to use an online information system called Medical Electronic
Data Interchange (MEDI) that lets providers verify multiple elements of a
beneficiary’s eligibility, including QMB status, and an online table for
providers that specifies the services/items for which providers and
suppliers can bill Medicaid directly because Medicare generally does not
cover them under Part B. The table also includes other key information,
such as Medicaid prior authorization requirements and the maximum quantity
of DME items allowed.
- California: California
providers are allowed to submit claims directly to Medi-Cal (California’s
Medicaid program) when any of the following criteria apply: Medicare does
not cover the item or service; the beneficiary’s Medicare benefits have
been exhausted; or Medicare has denied the claim; or the recipient is not
Medicare-eligible.
- Connecticut: Connecticut
requires that the state consider preauthorization of a DME item before the
state receives a formal denial from Medicare. The state cannot deny dually
eligible beneficiaries access to prior authorization for new or rental DME
because Medicare has not yet made a coverage determination.
Federal Update
The brief cites a Medicare prior authorization process, implemented July 2017, which is in effect nationwide for two types of power wheelchairs. The aim is to make the authorization process easier for dually eligible beneficiaries and power wheelchair providers by enabling them to get an earlier Medicare decision on those DME items. Beginning September 1, 2018, thirty-one additional power mobility device codes will be subject to required prior authorization.
The Center for Medicare Advocacy has promoted a prior authorization system in Medicaid (as is the case in Connecticut) and will be monitoring the impact on access to DME of adding additional power mobility device codes to Medicare prior authorization. The Center urges advocates to contact us at DMEPOS@medicareadvocacy.org to update us about DME access for dually eligible beneficiaries.
- The
ICRC Issue Brief is available at: http://www.integratedcareresourcecenter.com/PDFs/ICRC_Access_to_DME_in_FFS_06-2018.pdf
- For
more information on the Center’s work on DME access for duals, please
visit: http://www.medicareadvocacy.org/cms-bulletin-moves-to-improve-access-to-durable-medical-equipment-for-dually-eligible-beneficiaries/;
and http://www.medicareadvocacy.org/cma-organizes-sign-on-letter-concerning-cms-request-for-information-regarding-dually-eligible-beneficiaries-access-to-dme/
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