Durable Medical Equipment (DME) and Supplies

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Claud Gibson
10 years ago
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1 Durable Medical Equipment (DME) and Supplies June

2 Our Mission: Improving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources 2

3 60% Children & Adolescents under age 20 32% Adults ages Colorado Data 10% People with Disabilities in all age groups 8% Elderly ages 65 or older More than 1/3 of babies born in Colorado are born to mothers who are on Medicaid 15% live in rural areas 85% live in areas with populations above 100, % of overall Medicaid clients live in Denver County 3

born in Colorado are born to mothers who are on Medicaid 15% live in rural areas 85% live

4 Program Overview Durable Medical Equipment: equipment that can withstand repeated use and that generally would be of no values to the client in the absence of a disability, illness, or injury. Covered Benefits: supplies and DME must be medically necessary and prescribed by an authorized prescriptive authority for use by an eligible client 4

5 Providers Eligible Providers Providers must be enrolled as a Colorado Medical Assistance Program provider in order to: Treat Colorado Medical Assistance Program Submit claims for payment to the Colorado Medical Assistance Program Prescribing Providers Supplies and DME must be prescribed by a: Physician Physician assistant Nurse practitioner The prescription must be within the scope of the prescribing provider s license Supply/Equipment Providers May be either enrolled as pharmacy or DME supply company 5

Supplies and DME must be prescribed by a: Physician Physician assistant Nurse practitioner The prescription must be within the

6 DME Benefits The following DME and Supplies are benefits for clients regardless of age Ambulation devices and accessories including but not limited to canes, crutches or walkers Bath and bedroom safety equipment Bath and bedroom equipment and accessories including, but not limited to, specialized beds and mattress overlays Manual or power Wheelchairs and accessories Diabetic monitoring equipment and related disposable supplies Elastic supports/stockings Blood pressure, apnea, blood oxygen, Pacemaker and uterine monitoring equipment and supplies 6

limited to, specialized beds and mattress overlays Manual or power Wheelchairs and accessories Diabetic monitoring equipment and related

7 Continued DME Benefits Oxygen and oxygen equipment in the client s home, a nursing facility or other institution Transcutaneous and/or neuromuscular electrical nerve stimulators(tens/nmes) Trapeze, traction and fracture frames Lymphedema pumps and compressors Specialized use rehabilitation equipment Oral and enteral formulas and supplies Parenteral equipment and supplies Facilitative Devices -tablet technologies using E1399 with AV modifer Alternative and Augmentative Communication Devices (AACD) 7

pumps and compressors Specialized use rehabilitation equipment Oral and enteral formulas and supplies Parenteral equipment

8 DME Benefits The following Prosthetic or Orthotic Devices are benefits for clients regardless of age Artificial limbs Facial Prosthetics Ankle-foot/knee-ankle-foot orthotics Recumbent ankle positioning splints Thoracic-lumbar-sacral orthoses Lumbar-sacral orthoses Rigid and semi-rigid braces 8

Ankle-foot/knee-ankle-foot orthotics Recumbent ankle positioning splints

9 DME Benefits The following DME are benefits to only clients under the age of 21 Hearing aids and accessories Phonic ear Therapy balls for use in physical or occupational therapy treatment Selective therapeutic toys Computers and computer software when utilization to meet medical rather than educational needs Vision correction unrelated to eye surgery 9

therapy treatment Selective therapeutic toys Computers and computer software when

10 EPSDT Program Through EPSDT, each state s Medicaid plan must provide to any EPSDT recipient any medically necessary health care service, even if the service is not available under the State's Medicaid plan to the rest of the Medicaid population 10

care service, even if the service is not available under the

11 Medical Necessity It is a reasonable, appropriate, and effective method for meeting the client s medical need; The expected use is in accordance with current medical standards or practices (clinical guidelines exist); It is cost effective; and It provides for a safe environment or situation for the client 11

current medical standards or practices (clinical guidelines exist); It is

12 EPSDT exceptions Services not otherwise covered under Medicaid DME benefit will be considered for coverage for clients aged 20 and under even if the code is closed in our system Waiver exceptions DME Benefits Waivers may cover items outside of EPSDT ie; hippotherapy which is not a benefit under EPSDT but can be paid by the CES HCBS waiver dollars if available. 12

system Waiver exceptions DME Benefits Waivers may cover items outside of EPSDT ie;

13 Prior Authorization Requests (PARs) for Supplies and DME Some supply items and most DME items require prior authorization For detailed list of prior authorization requirements, please refer to the DME manual found on the Department s website PAR is not required for Medicare Crossover claims PAR is required for clients who have other primary insurance Approval of a PAR does not guarantee CO Medicaid payment Only assures that the approved service is a medical necessity 13

Department s website PAR is not required for Medicare Crossover claims PAR is required for clients who have other

14 PAR Process From a primary care physician or DME Provider Parents or family members are not able to submit their own PAR, but they may assist provider in language as they often understand better the need/use A PAR form MUST have a signed prescription from the medical provider A letter of medical necessity must accompany the completed PAR form A letter is not a prescription Additional documentation as needed WIKI information, clinical guidelines, flyer or marketing materials Letter approving, pending or denying request will be mailed to the requesting party as well as the client Pended PARs have 10 days for response 14

must accompany the completed PAR form A letter is not a prescription Additional documentation as needed WIKI information, clinical guidelines, flyer or

15 Medicaid DME Benefit YES Submit to Medicaid via DME provider N O Available under EPSDT YES Submit to Medicaid via DME provider N O Waiver covered services N O YES Request to be forwarded to the local waiver manager for final approval from State Waiver Manager Deny 15

Waiver covered services N O YES Request to be forwarded to the

16 Questions? 16 Colorado Department of Healthcare Policy and Financing Improving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources

17 17 Colorado Department of Healthcare Policy and Financing Improving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources

Medicare Coverage of Durable Medical Equipment and Other Devices. This official government booklet explains the following:

CENTERS FOR MEDICARE & MEDICAID SERVICES Medicare Coverage of Durable Medical Equipment and Other Devices This official government booklet explains the following: What durable medical equipment is Which