Center for Medicare Advocacy

Advancing Access to Medicare and Healthcare

CMS Releases Issue Brief on Access Challenges of DME for Duals

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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.

The Center for Medicare Advocacy has heard from state advocates that since Connecticut has allowed prior authorization in Medicaid for DME, dually eligible beneficiaries in the state have had access to DME without the delays seen in other states. The Center has advocated for this model to be implemented in other states.

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.

July 5, 2017 – K. Kertesz