MHCP Equipment & Supplies and Waiver Specialized Equipment & Supplies. Minnesota Health Care Programs (MHCP) Minnesota Department of Human Services

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1 MHCP Equipment & Supplies and Waiver Specialized Equipment & Supplies Minnesota Health Care Programs (MHCP) Minnesota Department of Human Services

2 Overview and Goals Understand the authorization and reimbursement processes for: Equipment & supplies by Medical Assistance (MA) Waivers and the Alternative Care (AC) program

3 Overview and Goals (continued) Understanding how to determine the appropriate payers for equipment & supplies covered by MA, Medicare, other payers, third party liability (TPL) and Waiver and AC Program Understanding how and where to locate provider resources: MHCP Provider Manual MHCP Provider web site

4 Presentation Agenda Waiver and Alternative Care (AC) policies about specialized equipment and supplies Equipment and supplies covered by MA, Medicare, other payers or TPL & Waiver and AC Programs The authorization and reimbursement process and procedures roles & responsibilities Surveillance & Integrity Review Section (SIRS) - Payment enforcement and recovery

5 Waiver & AC Program Specialized Equipment and Supplies

6 Specialized Equipment & Supplies & Waiver Definition Devices, controls or medical appliances or supplies specified in the community support plan that enable the person to increase their ability to: Perform activities of daily living Perceive, control or interact with their environment or communicate with others Items necessary for life support or to address physical conditions and ancillary supplies and equipment necessary to the proper functioning of those items May cover the evaluation of the need for the equipment or device or both Equipment rental during trial period, training and technical assistance

7 Non-covered Specialized Equipment & Supplies Items that are not a direct medical or remedial benefit to the member Items covered by the MA state plan as durable medical equipment MA state plan medical equipment and supplies is defined under Minnesota Rules, parts

8 Waiver and AC Program A Few Waiver Specifics ADD ON basket to MA covered walker: If a person has an assessed need and goal in his or her support plan for the basket, the waiver may be used to pay for the basket UPGRADES: Waiver services can only pay for the upgrade if the person has an assessed need and goal in his or her support plan and the item supports all other goals as stated for waiver eligibility

9 Waiver and AC Program Service Authorization Guidelines Meet the individual s needs identified in the community support plan AND Assure health, safety and welfare AND Goods and services collectively provide an alternative to institutional placement AND Are the most cost efficient AND Are for the sole benefit of the person

10 Waiver and AC Program Service Authorization Guidelines Support any or all of the following consumer outcomes: Maintain community living Enhance family involvement and community inclusion Develop or maintain social, physical or work related skills Decrease dependence on formal support services Increase independence of the person Increase ability of unpaid family and friends to receive training and education needed to provide support

11 Waiver and AC Program Service Authorization Guidelines Within the allowable budget of the county, tribe or the case mix of the individual Help a person avoid institutionalization Help a person function with greater independence in the community Meet authorization guidelines set by the federally approved state waiver plans Not covered by any other funding source (Medicare, TPL or MA)

12 Waiver and AC Program Guidelines for Non-covered Items Available first through the state plan Covered by any other third party payer including Medicare, long term care insurance or state educational or vocational services agencies That is diversionary or recreational in nature That is for comfort or convenience That is an item or support normally furnished by the recipient s parents, family or spouse That does not meet an identified need Over the counter medications, compounds and solutions Not approved in the support plan

13 Waiver and AC Program Service Authorization Limits BI, CAC and CADI - Service agreements may not exceed the maximum of $3,909. ******************************** EW and AC Authorizations need to fit within client authorized budget and case mix cap Specific limits with Personal Emergency Response Systems (PERS)

14 Personal Emergency Response Systems (PERS) Can be authorized under the following codes: S5160 Emergency response system installation and testing. The maximum cost is $500. S5161 Emergency response system monthly service fee. The maximum cost is $110 per month. S5162 Emergency response system purchase. The maximum cost is $1,500. The maximum cost for all PERS codes is $3,000 per year.

15 Waiver and AC Program Provider Standards & Qualifications The provider must be a MA enrolled provider and have a signed provider enrollment application and provider agreement or Be a receipt-based provider approved by the lead agency Any necessary training or instruction on the use of specialized equipment and supplies are considered to be included in the purchase price

16 Alternative Care (AC) Specialized Equipment & Supplies All other private and public payers (private insurance, Medicare, client s cost sharing obligations, long term care insurance) must be exhausted prior to utilizing AC funds for coverage. The AC program does not provide payment for medical equipment and supplies that are not considered to be medically necessary, or provide items that address a client s acute, sub-acute or rehabilitative status that would otherwise be addressed through a client s primary or secondary payer coverage. In the absence of other payers to address those needs, the AC program does not provide any form of payment.

17 All Waivers & AC Non-covered Items Toothettes Shampoo caps Vinegar DVD player Chair lift (lift mechanism portion that is covered by Medicare or MA) Exercise equipment All prescription and over-the-counter medications, compounds and solutions and related fees including premiums and co-payments Experimental or investigative equipment (Foot Drop System) Animals, including service animals and their related costs (For CDCS please refer to the CDCS Lead Agency Manual Section 8.2 Excluded Services, Support and Items)

18 Oral & Enteral Nutritional Products Oral nutritional product: Commercially formulated substance taken by mouth that provides nourishment and affects the nutritive and metabolic processes of the body. Enteral nutritional product: Commercially formulated substance administered by tube that provides nourishment and affects the nutritive and metabolic processes of the body. There are differences in payment for nutritional products under the waiver programs and AC.

19 Oral & Enteral Nutritional Products MA may pay for nutritional products whether or not they are oral or tube fed. An authorization is required for individuals consuming their nutritional supplements orally. MA covers nutritional supplements when needed because solid foods and their nutrients cannot be properly absorbed by the person. No authorization is required if an individual is taking the product through a feeding tube or the individual has PKU, Hyperlysinemia or maple syrup urine disease. See MHCP Manual Nutritional Products and Related Supplies

20 Oral & Enteral Nutritional Products EW and AC EW and AC will pay for nutritional products with the following requirements: Addresses a documented chronic care need, and is not reimbursable through other payers. Product is necessary to meet nutritional needs and maintain strength for living in the community. It is not used as a convenience. There is a physician s order, including reason why the person cannot obtain their caloric intake without the supplement. The need and goal have been documented in the community support plan and verified by a physician or physician assistant. The doctor has established that the person needs the product to maintain body weight and strength in the community.

21 Oral & Enteral Nutritional Products BI, CAC and CADI BI, CAC and CADI waivers cover enteral tube nutritional products that exceed the limits and PA has been denied for MA state plan. However, lead agencies are required to: On the support plan, document the person s need for the product(s) and that the person exceeded the MA state plan coverage Authorize the enteral nutritional products on the service agreement

22 Oral & Enteral Nutritional Products BI, CAC and CADI (continued) BI, CAC and CADI waivers do NOT cover: Any oral nutritional products (Example: Boost or Ensure) Electrolyte products Foods including organic or special diet needs Over the counter food supplement products including vitamins not covered by MA state plan sources Thickening agents

23 MA Coverage Policies & Guidelines

24 General MA Coverage Guidelines MA covers services that are determined by prevailing community standards to be: Medically necessary Appropriate and effective for the medical needs of the recipient Cost effective Minnesota Rule

25 General MA Non-coverage Guidelines (Minnesota Rule ) MA does not cover: Separate charges for mileage for purpose other than medical transportation of a recipient (this includes travel for repairs) A health service or item provided without a physician s order A health service or item that is only for a vocational or educational purpose A health service for which required authorization is not obtained Services or items deemed investigative

26 MA Equipment and Supplies Durable medical equipment Meets all of the following requirements: Prescribed by a physician within the scope of his or her license Able to withstand repeated use Used primarily for a medical purpose Generally not useful in the absence of illness or injury Determined to be reasonable and necessary Represents the most cost-effective alternative

27 MA Prior Authorization Process 1. Ordering provider writes prescription 2. Recipient chooses supplier 3. Supplier gets needed documentation from recipient and ordering provider 4. Supplier requests authorization 5. Medical review agent has 30 days to process a complete request

28 Determining MA coverage MHCP Provider Manual Equipment and Supplies chapter:

29 MHCP Provider Manual Equipment and Supplies

30 Determining MA Coverage Medical Supply Coverage Guide includes medical supplies and some equipment:

31 Medical Supply Coverage Guide

32 MHCP Providers Webpage for Equipment and Supplies 1. Select Your Provider Type dropdown 2. Select Equipment and Supplies 3. Select Medical Supply Related Lists

33 Medicare & Other Insurance or TPL Potential coverage by Medicare and other insurance must be determined prior to billing MA. MHCP does not require Medicare billing if an item is known to never be covered by Medicare. Insurance policies that exclude or limit coverage for DME or medical supplies must be entered correctly into the DHS MMIS system to bypass.

34 Authorization Denial Reasons DO Matter Authorizations denied as not medically necessary, not the least costly alternative, duplication of services or similar can be treated as an effective denial. Authorizations denied for insufficient documentation, no doctor s order, included in another line or service or similar should prompt additional questions from the lead agency The lead agency can ask for a copy of the denial notice from the medical supplier

35 Claims Denial Reasons DO Matter Claims that MA denies as not a covered service, not covered for this diagnosis, exceeds quantity limits or similar may be treated as an effective denial. Claims that MA denies because pricing documentation missing, failure to bill Medicare/other insurance, procedure code/modifier conflict or similar should prompt additional questions from the lead agency The lead agency can ask for a copy of the denial from the medical supplier

36 MA Upgrades and Add-ons Add-on: A non-covered item that can be added to a piece of covered equipment. Upgrade: A piece of equipment with extra, more desirable features that substitutes for a less costly piece of equipment. Often, MA will cover the upgrade item for some recipients who meet medical necessity and least costly alternative criteria. If you could walk out of the store with the item, and return to get the desired item added, it s an add-on. If the desired features are an integral part of the equipment, it s an upgrade. Example: A basket for a walker is a non-covered add-on to a covered piece of equipment. Example: MA covers a manual hospital bed without authorization for recipients with positioning needs. A semielectric hospital bed would be an upgrade unless the recipient meets MA criteria.

37 A Few Specifics Electric patient lifts May be MA covered without authorization. Providers are challenged by the low MA rate. Wheelchairs or scooters Generally MA only covers one mobility device per person. Exceptions are made, however authorization is always required. Repairs MA covers repairs to any DME that meets MA criteria for purchase. If MA bought it, MA fixes it. If MA did not buy it, MA might fix it. Repairs over $400 require authorization.

38 Lift Chair Definition: A lift chair is a combination of the chair and the lift mechanism. MA may cover the lift mechanism with authorization, but not the chair Lead Agency should note on the SA: Cost of chair as lift mechanism covered by other payer Provider must note on claim: Cost of chair as lift mechanism covered by other payer If the lift chair is not covered by other payers, lead agency and provider should note: Noncovered by Medicare /TPL/ MA

39 The Authorization & Payment Process Select Manual on left hand navigation Select EW and AC or Select HCBS Waiver Services From either section, select Specialized Equipment & Supplies Authorization & Billing Responsibilities

40 Roles & Responsibilities Lead Agency Approve and authorize specialized equipment and supplies through the waiver and the AC programs Provider Request reimbursement to the appropriate payer(s) MHCP Process claims

41 Lead Agency Process Approve & Authorize Item or Service 1. Contact provider: Physician s orders Appropriate payer(s) 2. Determine coverage through the waiver and AC programs 3. Contact DHS: Clarification Special considerations 4. Document findings

42 Lead Agency Process Physician s Orders Contact the provider to find out if a physician s order is necessary when dispensing the item following health care industry standards. If: Yes Inform and assist the recipient with obtaining a doctor s order to purchase the item No Document findings into the DHS Comments section of the authorization

43 Lead Agency Process Clarification or Special Consideration Contact your Regional Resource Specialist (RRS): For questions about BI, CAC and CADI Clarification of allowable items For special considerations due to the person s situation Submit a Disability and Aging PolicyQuest question Document findings in case notes and the DHS comments screen on the SA

44 Lead Agency Process Appropriate Payer(s) Contact the provider to determine: Is the item covered through the person s: Medicare coverage Other insurance or TPL payer Medical Assistance (MA) state plan If no other payer exists, document findings in the DHS Comments section of the authorization

45 Lead Agency Process Approving the Item Through Waiver or AC Determine if the item is allowable through the waiver or AC program using the: Community-Based Services Manual (CBSM) BI, CAC, CADI & DD MHCP Provider Manual EW and AC Enter a specific description of the item(s) (no brand names) and the cost of the item(s) on the line of the SA or DHS Comments section of the authorization

46 Lead Agency Process SA Documentation DHS Comments Enter the following into the DHS Comments screen of the SA: Provider comments Need for physician orders Determination of appropriate payers Description of the item(s) authorized and cost(s) of the item(s) If authorizing based on policy approval, include the DSD & Aging Policy Quest question number

47 Provider Process 1. Informs lead agency of: Need for physician s orders Determination of appropriate payer 2. Requests physician s order from recipient prior to dispensing the item (when applicable) 3. Submits the claim following MHCP billing policies Maintain documentation showing determination of appropriate payer Itemize and enter a description of the item on the claim

48 Provider Notes on Claim Notes on claim must match notes on SA See slide 45 for Lead Agency process on notes When item is not covered by other payer (Medicare, TPL, MA) enter the statement Does not meet the coverage criteria for Medicare, TPL, MA

49 MHCP - Claims Process While processing the claim following all MHCP billing policies, MHCP reviews the claim: 1. For a specific description of the item or service 2. Determines if item or service can be paid by other payer, TPL, Medicare or MA; if: Yes Denies the claim unless note states Doesn t meet criteria for Medicare, TPL, MA No continue to step 3 3. Determine if the item or service: Is reported on the authorization Is allowed to be covered through the waiver

50 Enforcement & Recovery

51 Enforcement & Recovery Surveillance & Integrity Review Section (SIRS) SIRS is legislatively mandated to conduct post payment reviews Responsible for monitoring compliance with rules and regulations governing health care services Contact information: Hotline: , FAX:

52 Resources MHCP Webpage: MHCP Provider Manual: HCBS Waiver Services: Elderly Waiver (EW) and Alternative Care (AC) Program: Equipment and Supplies:

53 Additional Resources Community-Based Services Manual (CBSM): Waiver Oral and Enteral Nutritional Products: Specialized Supplies and Equipment: CDCS Lead Agency Manual Link: ublic/dhs-4270-eng