Medicare and Medicaid

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Medicare and Medicaid

• Unlocking the Gate to Funding Assistive
  Technology

2
Whos 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

3
Common Product Categories
Orthoses Canes/Crutches Walkers
Enteral Nutrient Glucose Testing Nebulizer Drugs
Prostheses Manual W/C Nebulizer
Ostomy Supply Oxygen Equip. PMD
Refractive Lens Support Surface Beds
Bath/Safety Commodes Urologicals
Surgical Dress Patient Lifts Seating
Suction CPAP/BIPAP Ventilators
4
Standards for Coverage

• MD order to initiate Service (pad script)
• CMN Payer specific forms
• Supporting documentation from charts
• LMN or clinical specialists notes
• HCPCS Code appropriate to payer
• Qualifying ICD9 code

5
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

6
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

7
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

8
Medicares 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,
  Physicians Assistant, or Nurse Practitioner
• Bed or Chair Confined no longer needed
• Focus is now on MRADL independence

9
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 LMNs

10
Web Support

• www.cms.hhs.gov
• www.medicare.gov
• www.dhhs.state.sc.us
• www.palmettogba.com
• www.nrrts.org

• www.pridemobility.com
• www.invacare.com
• www.sunrisemedical.com
• www.snugseat.com
• www.resna.org

www.edssafeguardservices.eds-gov.com/providers/dm
e/medchecklists.html
Find a reputable website, with frequent updates
and get on their mailing list for up to date
changes on product or reimbursement.
11
Handy Laws to Know

• Medicaids 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. , 440.230, c)
• mustprovide 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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Appendix A
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Appendix B
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Appendix C
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