The In’s and Out’s of DME
Florida Medicaid’s Durable Medical Equipment and Medical Supplies Program
June 13, 2008 Dan Gabric- DME Medical Health Care Analyst
Durable Medical Equipment and Medical Supplies Services Program
The Florida Medicaid Durable Medical Equipment and Medical Supplies Services Program (DME Program) is available to promote, maintain, or restore health and minimize the effects of illness, disability, or a disabling condition.
What are Durable Medical Equipment and Medical Supplies Services?
Durable medical equipment: Equipment that can withstand repeated use, serves a medical purpose, and is appropriate for use in the home. Example: Wheelchairs Medical supplies: Medical or surgical items that are consumable, expendable, disposable, or non-durable. Example: Ostomy supplies
Examples of covered services:
Augmentative and Alternative Communication Systems (AAC’s) Enteral Products/ Nutritional Supplements Hospital Beds, Mattress, and Rails Infusion Pumps Oxygen and Oxygen Related Equipment Patient Lifts Wheelchairs
Payment Hierarchy- Who pays first?
Medicaid reimbursement is considered the last resort. This means that all other resources, such as Medicare or third party insurance, must be billed first.
A provider who bills Medicaid for reimbursement of a Medicaid covered service must accept payment from Medicaid as payment in full. This does not include co-payments or co-insurance.
Eligibility for DME Services
The beneficiary must first be eligible for Medicaid Certain services are available to any age beneficiary, other services are only covered when the beneficiary is under the age of 21. DME services are not covered when a beneficiary is residing in a hospital, nursing home or an intermediate care facility for the developmentally disabled (some exceptions) Medically needy recipients will become Medicaid eligible on different days of the month depending on their ability to meet their share of cost
Exceptions for Beneficiaries Under The Age of 21
If a beneficiary lives in a nursing facility or intermediate care facility, and is preparing to be discharged to his home, AHCA may pay for DME items such as customized orthotics and prosthetics, customized wheelchairs, and assistive communication devices.
AHCA Determines Medical Necessity
Medicaid makes the final determination whether a service is medically necessary or not The fact that a provider has prescribed, recommended, or approved medical or allied care, goods or services does not, in itself, make such care, good or services medically necessary or a covered service.
Most DME and medical supplies must be prior authorized by the beneficiary's MediPass primary care provider, if the beneficiary is enrolled in MediPass.
Prior Authorization Requests
Prior authorization requests are required for certain DME equipment, for example: customized wheelchairs; hospital beds; enteral products, in some cases; and substantial repairs, modifications, or replacement of parts for medical equipment owned by the beneficiary.
Augmentative/Assistive (AAC) Communication Devices
Augmentative/assistive (AAC) communication devices are available to Medicaid beneficiaries of all ages. These “speech-generating devices” help people of all ages and abilities communicate meaningful and functional messages, opening up a world of new possibilities — and increased independence.
Enteral nutrition is the delivery of nutrients orally or by feeding tube. For patients under five years of age: The Women, Infants, and Children program (WIC) must be the primary provider of enteral products, if patient is WIC eligible.
Medicaid may reimburse for hospital beds, mattresses, and rails. Some types of beds are: Standard Beds Variable Height Beds Heavy Duty, Extra Wide Beds
Oxygen And Oxygen-related Equipment
Medicaid may reimburse oxygen and oxygenrelated equipment, such as: Continuous Positive Airway Pressure (CPAP) devices, nebulizers, oxygen concentrators, and ventilators for beneficiaries with hypoxia.
Medicaid may pay for a standard wheelchair if the beneficiary is confined to a bed or chair: a narrow wheelchair a lightweight wheelchair a motorized wheelchair other models if the features and accessories are medically necessary; or a customized wheelchair that is specially constructed and not available from manufacturers. 15
Customized wheelchairs are available to Medicaid beneficiaries of all ages with prior authorization.
Custom Wheelchair Review Process
There are five major parties involved in the DME prior authorization process: the beneficiary, the prescribing physician, the beneficiary’s physical therapist, the DME provider, and the Agency.
Steps in the custom wheelchair review: 1. The beneficiary’s treating practitioner prescribes a wheelchair or wheelchair evaluation. 2. The physical therapist conducts assessment and recommends type of wheelchair and components.
Custom Wheelchair Review Process continued..
3. The DME provider collects the required documentation and mails prior authorization request to the Agency. 4. The Agency’s physical therapist consultant reviews for medical necessity: When the documentation does not support a requested item, the therapist may ask why an identified less costly item/alternative could not meet the beneficiary’s needs. This is a very complex and specialized field. Florida is one of the few states to have physical therapist review wheelchair requests. The Agency takes about 30 days to review a custom wheelchair request.
Repairs to Equipment
Medicaid may pay DME providers for general repairs and service of equipment owned and used by a beneficiary, including DME, medical supplies, orthotics, and prosthetics. No repair will be reimbursed for equipment within the first year of service. This is because all equipment must have a 1-year warranty that covers repairs.
Maintenance Routine The beneficiary or caregiver is responsible for performing routine maintenance described in the manufacturer’s operating manual, including: testing; cleaning; regulating; and lubricating the equipment as needed. Non-routine Medicaid may pay DME providers for nonroutine maintenance and repair needed to keep durable medical equipment functional.
A beneficiary may rent certain equipment with the option to purchase. Example: Hospital Beds Rent-to-purchase is for ten months, as long as medically necessary; The item becomes the property of the beneficiary after the tenth month.
Rental Only Items
Rental only (RO) items remain the property of the provider Example: Stationary Oxygen Systems
Rental Equipment Agreements
A rental agreement between a provider and beneficiary may not be discontinued: without the consent of the beneficiary or caregiver; unless medical necessity ends; unless the beneficiary is no longer eligible for Medicaid; or the rent-to-purchase period has ended.
Call your local Medicaid Office for more information. Or visit the Agency for Health Care Administration’s website at: http://ahca.myflorida.com
For Medicaid's Durable Medical Equipment and Medical Supply Coverage and Limitations handbook and fee schedules, please visit our fiscal agent's website at http://floridamedicaid.acs-inc.com. Click on “Provider Support."
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