Ensuring DME Access for Dual-Eligible Beneficiaries

(June 27, 2018)—The Integrated Care Resource Center (ICRC) recently released a briefing titled “Facilitating Access to Medicaid Durable Medical Equipment for Dually Eligible Beneficiaries in the Fee-for-Service System.” As the title states, the brief explores the approaches of Connecticut, California and Illinois in ensuring dual-eligible beneficiaries receive the medical equipment they need.

Background

Dually eligible beneficiaries may face obstacles when they try to access services, such as durable medical equipment (DME), that are covered in varying degrees by Medicare and Medicaid. The rules for eligibility for these two programs vary in ways that can be difficult for beneficiaries, providers and even state Medicaid administrators to understand. To top it off, Medicaid is often the “payer of last resort.”

Medicare typically does not process a claim until an item is delivered, and Medicaid requires a Medicare denial prior to processing a claim for payment and delivery of the product. This causes delays in care for dually eligible beneficiaries.

State Approaches to Care

Currently fourteen states have implemented provisional prior authorization (PA) policies supported by lists of DME items that Medicare does not generally cover. The ICRC explored the policies of three states to better understand how PA improves access for dual-eligible individuals.

California, Connecticut and Illinois have slightly different DME billing policies. California and Illinois both implemented a feature that further facilitates the provisional PA approach. Each maintains an online list of DME items that Medicare generally denies as non-covered under Part B, but that Medicaid may cover. When it is clear from the list that Medicare will not cover the item, DME suppliers can submit their claims directly to Medicaid without first submitting them for a Medicare denial. In contrast, Connecticut developed a system that allows for prior authorization of DME before a Medicare denial.

Recommendation

The ICRC suggests that states compile a list of Medicaid DME that Medicare will not cover. According to the brief, CGS Administrators, LLC, the DME medicare administrative contractor (DMAC) for Jurisdictions B and C, and Noridian, the DMAC for Jurisdictions A and D, have posted identical lists of items not covered by Medicare that may be useful for states.

The ICRC is a national initiative of the CMS Medicare-Medicaid Coordination Office to help states improve the quality and cost-effectiveness of care for dually-eligible beneficiaries.  

Read the full brief here.

Visit integratedcareresourcecenter.com for more information.