Wednesday, January 18, 2017

WASHINGTON, D.C. (January 18, 2017)—CMS published guidance to the states on Friday, January 13, in an effort to give strategies to the state to ensure access to DMEPOS is available. This was issued due to comments from 2016 on CMS 1651-P and 2011 comments submitted in response to Federal Register Request for Comment on alignment under Medicaid and Medicare. While CMS cannot enforce these suggestions, we believe that they would benefit both states and providers. There were four strategies issued to states that they could use to ensure appropriate access to DMEPOS:

  • Recommend Prior Approval (PA) for dual eligible beneficiaries. Many states do not require PA if Medicare is the primary payer or require a denial from Medicare before they will issue PA. They are recommending that states evaluate the prior approval process for dual eligible beneficiaries for high cost DME and to not require a denial from Medicare for this PA to be issued. They recommend this due to many providers who are unwilling to provide products because they are uncertain if the beneficiary meets Medicare criteria. They recommend PA up front without Medicare denial, but then require providers to obtain a denial on claim submission from Medicare prior to billing Medicaid.
  • Ensure DME claims for dual eligible beneficiaries are assessed against Medicaid’s broader coverage criteria. 42 CFR §440.70 language states 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 in patient settings. This went into effect on 7/1/16, but states have up to two years to implement this depending on state legislative cycles.
  • Ensure Medicaid is only looking for Medicare PA on those items and in those states that Medicare requires it. Gives guidance on new codes for March 19, 2017.
  • Guidance that states should consider incorporating these requirements and strategies into contracts with Medicaid MCOs.

See the full text of CMS's informational bulletin on the issue.

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—Via AAHomecare