Proposed Changes- Durable Medical Equipment, Prosthetics & Orthotics, & Supplies Medicaid Coverage & Payment JU

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1 1. If a procedure on the proposed fee schedule states Medicare-based, will providers receive Medicare fee schedule reimbursement for those services and equipment? 2. Medicare requires a face to face examination for hospital beds; will the department remove the service authorization request for these? 3. Is the face to face requirement (referenced in 7 AAC [9]) required on a pad prescription as well as a CMN? A face to face requirement for DME services will impose additional administrative burden on providers. Yes, if an item/service on the proposed fee schedule is listed as Medicare-based, providers will receive reimbursement based on the most current quarter s Medicare DMEPOS Fee Schedule available at: This is in compliance with 42 USC 1396b(i)(27). All other Medicaid regulations continue to apply, including 7 AAC A face-to-face examination does not eliminate the service authorization requirement for Alaska Medicaid. The date of the face-to-face is to be documented on the CMN when applicable. Please refer to the following document on the face-to-face encounter requirement. 1.pdf The face-to-face encounter is a federal requirement outlined in 42 CFR , effective July 1, 2017, and is applicable to those services required under the referenced federal regulation. Published 11/29/2017 Public Review Draft Date: 10/16/2017 Page 1

2 4. Why is the department using A6250 to identify skin cleansers? Certain primary payors use A4335 to identify skin cleansers. If the Department requires A6250 to be used, it will be difficult to bill with an appropriate denial. 5. Current claims containing additional product information require manual review which leads to a large number of suspended claims. How will the department ensure timely processing if the volume of manual review claims is increased? 6. What is the procedure for obtaining higher reimbursement on items such as specialty nutritional products? 7. What is the procedure for submitting the price research form and can this process be used for higher reimbursement on items such as specialty pediatric formulas? Utilizing the combination of the procedure code, product code, and any applicable modifiers is anticipated to decrease the volume of claims requiring manual review if billing guidance is followed. The department has identified specific products for coverage, as listed on the fee schedule, under A6250 (skin sealants, protectants, moisturizers, ointments) as this HCPCS most appropriately aligns with products assigned by the Medicare Pricing, Data Analysis and Coding (PDAC). When defined, providers will be required to select the correct HCPCS based on the PDAC HCPCS assignment for a given product. The PDAC does not at this time list skin cleanser products under A4335. The department will take the comment under consideration. Medicare Pricing, Data Analysis and Coding: Specific billing guidance will be provided for claims submissions once all comments are reviewed and regulations are finalized. Utilizing the combination of the procedure code, product code, and any applicable modifiers are anticipated to decrease the volume of claims requiring manual review if billing guidance is followed. The proposed reimbursement rate structure for enteral nutrition requires the product code/ndc on all enteral product claims. This in addition to applicable modifiers allows the system to calculate the higher reimbursement differential for specialty enteral products as compared to standard enteral products within the same HCPCS at the time of claim submittal. Providers will be allowed to submit a price research form to request formal research of state-based specific prices when no price is established by CMS. The department will research the pricing to determine if an updated fee schedule price for the specific product is warranted. Formal process guidance will be provided once all comments are reviewed and regulations are finalized. Published 11/29/2017 Public Review Draft Date: 10/16/2017 Page 2

3 8. Comment: Providers are concerned with the potential of increased volume of enteral nutrition products & incontinence supply products claims requiring specific manufacturer product code. 9. Enteral equipment supplies are no longer individually priced on the proposed fee schedule. Will these items be manually priced again or will the department follow a per diem similar to Medicare? 10. In regards to used equipment; if a provider dispenses used equipment, will the reimbursement be 25% less than the allowed amount? 11. Regarding dual eligible (Medicare-Medicaid) recipients, 7 AAC (h)2 indicates the department will not reimburse more than 20% of the Medicare allowed rate for community use only items. What does this mean? Utilizing the combination of the procedure code, product code, and any applicable modifiers is anticipated to decrease the volume of claims requiring manual review if billing guidance is followed. Claims submitted for enteral nutrition products and incontinence products following the billing guidance would no longer require manual pricing, thus making the claims processing for these items more timely and efficient. Thank you for identifying the missing notation on the fee schedule. The department will take this into consideration when finalizing these proposed regulations. The proposed regulations allow enrolled providers to request payment for used or refurbished durable medical equipment using the UE modifier at a rate of no more than 75% of the proposed reimbursement rate for new equipment in alignment with Medicare used equipment rates. Providers should also refer to 7 AAC In the event a recipient is unable to ambulate household distances and requires a wheelchair in the home, but the provider indicates the item will only be used in the community, the department shall be the secondary payer after Medicare. Under coinsurance and deductible rules, Medicaid s allowed amount would not exceed 20% of the Medicare allowed rate. Published 11/29/2017 Public Review Draft Date: 10/16/2017 Page 3

4 12. Regarding dual eligible (Medicare-Medicaid) recipients, 7 AAC (h)3 indicates the department will not reimburse DME services that Medicare has not deemed medically necessary for that recipient. What does this mean? To demonstrate alignment of medical necessity policies, the department shall recognize Medicare s determination of medical necessity as primary payer. In the event Medicare deems a Medicare covered service or product medically necessary, the department will reimburse accordingly. Please refer to guidance on Medicare Crossover Claims Processing: _In_Enterprise_ pdf In the event Medicare deems a Medicare covered service or product to not be medically necessary under Medicare rules, the service or product would not be determined to be medically necessary under Medicaid review AAC (b)2 is interpreted as the department will no longer reimburse 100% of the Medicaid fee schedule if the recipient is out of state for school or medical reasons. Would you please clarify? 14. In regards to the A9901/shipping reimbursement; will providers be given maps of service areas for other enrolled providers to determine eligibility for shipping outside of the 50 air mile radius? 15. How will the department assist providers in determining same/similar HCPC codes as well as how many months a recipient has rented a piece of equipment from what provider? Statutorily non-covered Medicare items and services will be reviewed by Medicaid for medical necessity. When the recipient is physically located outside of this state, the department s reimbursement will be based on 100% of the current quarter s Medicare DMEPOS Fee Schedule established by CMS for items and services in the state where the item or service was provided. The department thanks you for your question and will consider your inquiry when finalizing these proposed regulations. Resources will be available to aid providers during the transition period following adoption of final regulations. Additionally, a provider inquiry line is available to assist with provider-specific questions. Members who choose to switch providers while renting equipment shall provide the name of the existing provider to the new provider. Published 11/29/2017 Public Review Draft Date: 10/16/2017 Page 4

5 16. In what field is the product serial number to be submitted for claim submissions? 17. Comment: Providers are concerned with the potential of increased volume of miscellaneous coded claims requiring vendor invoices. 18. Medicare allows certain items (for example: complex rehab chairs, feeding pumps) to be purchased outright; will the Department allow these items to be purchased outright as well? 19. Medicare allows the E0562 as an initial purchase for patients; will the department allow an initial purchase for this item as well? 20. When shipping DME to rural Alaskan communities, will providers have the option to be reimbursed for items as a purchase rather than as a rental? 21. Are there plans to allow electric breast pumps (E0603) to be purchased? Specific billing guidance will be provided for claims submissions once all comments are reviewed and regulations are finalized. The department thanks you for your comment. Providers are encouraged to provide specific comments during the public comment period to further inform regulation development. The use of miscellaneous codes should be infrequent. Providers are encouraged to confirm whether or not a product specific code is available prior to using a miscellaneous code. Medicare Pricing, Data Analysis and Coding: Under the proposed regulations, 7 AAC (b)(15) and 7 AAC (c), the department considers direct purchase of specialized power wheelchairs on a case-bycase basis. The department will give consideration to additional items. The proposed regulations in 7 AAC (b)(15) and 7 AAC (c) considers direct purchase of specialized power wheelchairs on a case-by-case basis. At this time, E0562 (humidifier, heated) is not a direct purchase item however, the department will give consideration to additional items. The proposed regulations do not differentiate rental requirements based on region. The department will take your comment under advisement in the final version of the regulations. Electric breast pumps (E0603) are listed on the proposed fee schedule as a rental item at this time. The department will take your inquiry into consideration. Published 11/29/2017 Public Review Draft Date: 10/16/2017 Page 5

6 22. In regards to Group 4 Wheelchairs being considered optional upgrades, can the recipient be given the option to pay for the upgrade difference as Medicare recipients can? The department does not currently have specific regulations restricting a recipient from paying for optional upgrades; however, a provider may not influence a recipient to pay cash for upgrades. It is expected that providers would ensure compliance with all relevant Medicare and Medicaid rules for both Medicaid and Medicare-Medicaid dual eligible members. Published 11/29/2017 Public Review Draft Date: 10/16/2017 Page 6

7 23. Will the department follow Medicare s 36 month payment period for oxygen? AAC (d) indicates DME services now require, when applicable, manufacturer information, item description/number, GTIN, suggested list price, and serial number at the time of requesting a service authorization. Will providers be required to submit this information in addition to the HCPC, item description, list price, and NDC (if applicable)? 25. Why is the department requiring a service authorization request for hospital beds but not standard wheelchairs? Both are capped rental items. 26. DME providers are currently able to complete part A of the CMN; 7 AAC (v) indicates that the CMN may not be prepared by the supplier. Will DME providers still be able to complete part A of the CMN? 27. What guidelines will be in place for recipients needing supplies which exceed maximum quantity limits? 28. If proposed regulations are adopted, would existing service authorizations be honored? Yes, the department will align with Medicare s 36 month payment period for oxygen. Service authorization requests will continue to require all necessary information including procedure code (HCPCS), item description, list price/billed amount, etc. needed to appropriately authorize a medically necessary covered item/service. Proposed section 7 AAC (d) references a specific subset of durable medical equipment and medical supplies and will not apply to all circumstances. Under proposed 7 AAC (a)(2), service authorization is required for those capped rental items denoted on the fee schedule. The department will consider your suggestion of adding a service authorization requirement to the standard wheelchair. Section A of the current Certificate of Medical Necessity (CMN) is the patient clinical information including diagnosis code/description and estimated length of need which is to be filled out by the prescriber. DME providers may assist with adding the provider information and member insurance information in this section but may not provide pre-filled forms. Sections C and D will continue to be completed by the DME provider. Please refer to current CMN for additional information. The department will require service authorization as outlined in proposed 7 AAC (b)(2) to evaluate medical necessity. Service authorizations are effective based on the date they were authorized through the expiration date provided sufficient units remain. Published 11/29/2017 Public Review Draft Date: 10/16/2017 Page 7

8 29. Comment: Items on the proposed fee schedule coded as A9999 (miscellaneous DME supply or accessory, not otherwise specified) should be coded as A9900 (miscellaneous DME supply, accessory, and/or service component of another HCPC code). These items are used with a base piece of equipment so should be coded as such. Thank you for your comment. The department will take this into consideration in the final version of the regulations. Published 11/29/2017 Public Review Draft Date: 10/16/2017 Page 8

9 - for questions received through 11/10/17 1. There are items that state "Prosthetic and Orthotics Suppliers Only". Does that mean that a DME supplier is unable to provide these items? We have found a couple of items that are prefabricated off the shelf items but are marked for Prosthetic/Orthotics only. Example: L1930 & L Comment: The proposed Prosthetic & Orthotic regulations, fee schedule changes, service authorization requirements and unit quantities place additional responsibilities and adjudication burdens. 3. Comment: The proposed fee schedule refers to Medicare s LCD on almost every procedure code. 4. Is the enrollment of Ambulatory Infusion Centers included in the proposed DMEPOS regulations? The department thanks you for your question and for bringing this example to our attention. The department will review the Medicare defined prefabricated off the shelf items and procedure codes and determine if additional modifications may be necessary to more effectively align program rules and patient access considerations. If an update is necessary, the fee schedule would be updated accordingly to reflect the changes. The department thanks you for your feedback and welcomes additional specifics on the concerns you identified so that we may fully consider the impact to the public. The department thanks you for your comment. Under the proposed fee schedule, if a Medicare Local Coverage Determination (LCD) exists for a specific procedure code, Medicaid will use the LCD to conform its medical necessity criteria with that of Medicare. In such instances where an LCD for a specific procedure code is retired, rescinded, or no longer effective, the department would no longer consider the LCD. The department thanks you for your question. No; Ambulatory Infusion Center enrollment was not part of the original scope of this specific regulation package. Published 11/15/2017 Public Review Draft Date: 10/16/2017 Page 1