On January 13, 2017 the Centers for Medicare & Medicaid Services (CMS) posted a State Informational Bulletin encouraging states to adopt strategies to improve dual eligible beneficiaries’ access to Durable Medical Equipment (DME). The Bulletin addresses a serious and persistent obstacle to obtaining DME faced by people dually eligible for Medicare and Medicaid in many states because of the mismatch of processing rules in the two programs.
These problems often arise when beneficiaries transition from Medicaid-only status to dual Medicare-Medicaid status. In these instances, individuals who previously had no difficulty obtaining their DME through Medicaid may face vendors who refuse to deliver the same DME once they also become eligible for Medicare, because they are concerned that they will not receive payment from either Medicare or Medicaid.
The CMS Bulletin addresses these serious obstacles to needed equipment and outlines strategies for states to employ in order to improve timely DME access. The CMS Bulletin states that if Medicare does not allow for prior authorization of certain items, then the state Medicaid agency should do so as the means to prevent blocked access for duals to DME covered under Medicaid. The CMS Bulletin also reminds states that a recently amended regulation, 42 CFR §440.70, codifies long-standing agency policy that Medicaid must cover appropriate medical supplies, equipment and appliances suitable for use in any setting in which normal life activities take place, other than inpatient settings. The Bulletin states that coverage cannot be limited to the home setting, as long as the other coverage requirements are met.
The Center for Medicare Advocacy (Center) has been working in coalition with other advocacy organizations on behalf of dually eligible beneficiaries to obtain access to DME. In response to a request from CMS for information regarding DME access issues faced by individuals who are dually eligible for Medicare and Medicaid, the Center organized a sign-on letter submitted to CMS in August of 2016. The letter, signed by almost 80 organizations, stressed the logistical problems created by Medicare and Medicaid processing rules that lead to barriers in accessing needed care that individuals who are on only Medicaid or Medicare do not have. The Center applauds CMS for responding to these issues, and for taking action to improve access to DME for this vulnerable population.
The Center urges state advocates to press for application of the Bulletin. Then, please contact Center Attorney Kata Kertesz at email@example.com, to update us about whether the Bulletin is improving DME access for dually eligible beneficiaries in your state.