getting your equipment repaired under medical assistance managed care prepared by the disability...

Getting Your Equipment Repaired Under

Medical AssistanceManaged Care

Prepared by theDisability Rights Networkof Pennsylvania and the

Institute on Disabilities at Temple University

March 11, 2014

Learning Objectives

• List the types of durable medical equipment repair services that are covered

• Identify providers to make repairs• Describe the process for getting

equipment repaired

Copyright March 2014. Disability Rights Network of Pennsylvania. 2

Roadmap

• Medical Assistance overview• Managed care overview• Covered repairs

–Warranties• Providers• Process


Medical Assistance Overview

• “Medicaid”• Part state-funded and part

federally-funded health insurance program for low-income persons

• “State Plan”

• Must follow federal law and rules



• Eligibility– Temporary Assistance for Needy

Families (TANF)– SSI– Other categories

Note: If SSI-level of disability and under age 18, parental income and resources not counted



• Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)– Children under age 21

– All medically necessary health care services that are contained in federal Medicaid law whether or not covered under Pennsylvania’s State Plan


Managed Care Overview

• “HealthChoices”• “Managed Care Organizations”• Statewide as of March 1, 2013,

with some exceptions• Health plans and providers must

follow federal and state laws and rules



• Fee schedule–List of covered services and rates

–May cover more, but not less, than fee-for-service Medical Assistance• Remember Early and Periodic

Screening, Diagnosis, and Treatment (EPSDT)



• Provider network

• Special Needs Unit–Contact Member Services and ask

for “Special Needs Unit”

–Can request case management

9Copyright March 2014. Disability Rights Network of Pennsylvania.


• HealthChoices Agreement www.dpw.state.pa.us/ucmprd/groups/webcontent/documents/communication/s_002105.pdf– Exhibits to HealthChoices Agreement

www.dpw.state.pa.us/ucmprd/groups/webcontent/documents/communication/s_002106.pdf

• Department of Public Welfare Directory http://www.dpw.state.pa.us/cs/groups/webcontent/documents/communication/s_002108.pdf– Contract managers


http://www.dpw.state.pa.us/ucmprd/groups/webcontent/documents/communication/s_002105.pdf

http://www.dpw.state.pa.us/ucmprd/groups/webcontent/documents/communication/s_002105.pdf

What Repairs Are Covered?

• Repairs to medically necessary durable medical equipment (DME)



• Durable medical equipment–Item or device

• that can withstand repeated use

• is used primarily and customarily to serve a medical purpose

• customarily is not useful to a person in the absence of illness or injury, and

• is appropriate for home use12Copyright March 2014. Disability Rights Network of Pennsylvania.


• Medically necessary1. Compensable under the Medical Assistance

Program and will

2. Prevent illness, condition, injury, or disability; or

Reduce or ameliorate the effects of an illness, condition, injury, or disability; or

Help the person achieve or maintain maximum functional capacity in performing daily activities, like other Medical Assistance recipients of the same age



• Coverage cannot be less than fee-for-service Medical Assistance

• Get health plan coverage policy– Ask Special Needs Unit or Durable

Medical Equipment Unit of health plan



• Medically necessary–Repairs

–Replacement of a part

–Maintenance

–Replacement of entire item



• Repair– Example definition: “to fix or mend and to

put the equipment back in working condition after damage or wear”

– Example coverage: “Repairs to medically necessary DME, corrective appliances, and other devices are covered up to the replacement cost when necessary to make the equipment or device serviceable”



• Replacement of a part –Example definition: “the provision

of an identical or nearly identical item”

–Example definition: “putting something new in place of an irreparable item”



• Maintenance–Check with health plan for coverage

policy

–Batteries• Power wheelchair (all ages)• Hearing aid (under age 21)

–Wheelchair tires (all ages)



• Equipment rentals–Maintenance and repairs included

in rate paid to provider

–Contact provider to get maintenance and repairs done

–Contact Special Needs Unit for help



• Replacement of entire item–Example coverage: “If the expense

for repairs exceeds the estimated expense of purchasing or renting another item of equipment for the remaining period of medical need, payment shall be limited to the replacement cost”



• Replacement of entire item–Medically necessary equipment can be

replaced after certain period of time regardless of condition

–Frequency must at least match fee-for- service Medical Assistance coverage• Three years for power wheelchair and

speech generating device



• Warranties–Medical Assistance will not cover

repairs that warranty should cover• Manufacturer responsibility

–Consider registering equipment with manufacturer



• Warranties–Pennsylvania’s Motorized

Wheelchair Warranty Act• “Problems with Your New Motorized

Wheelchair? – Your Rights Under Pennsylvania’s Motorized Wheelchair Warranty Act” at www.drnpa.org/publications



• Warranties–Keep copy of warranty

–Document the problem

–Contact manufacturer• “Authorized dealer”

–Confirm and document in writing



• Warranties–Pennsylvania Attorney General’s

Bureau of Consumer Protection

–Ask health plan to cover needed repair

–Get legal help



• During repair, consider–Rental of equipment (through

Medical Assistance)• Ask doctor and provider

–Loaner equipment (no charge)• Ask provider or manufacturer


Identifying Providers

• Must use providers in health plan’s network, but

• Network must be adequate–Can ask for permission to go

out of network



• Special Needs Unit–Ask for list of providers

• Health plan website

• Department of Public Welfare contract managers



• Verify

• Case management from Special Needs Unit

• Seek approval to use out of network provider, if needed

• Provider can contact health plan’s Provider Services


Process for Getting Repairs

• Know health plan coverage policy• Ask health plan

– Is the provider in network?– Is a prescription needed?– Is prior authorization needed?– What else is needed to show medical

necessity of repair?– Is there a copay?



• Specific billing code–Code for specific part being

repaired or replaced–Provider evaluate the problem–Physician contact health plan or

health plan contact provider directly for billing code



• Program Exception request if needed service not on fee schedule or to exceed limits on fee schedule–Need physician’s help to do this



• Physician, provider of repair, and others submit any additional documentation requested by health plan

• Submit letters of medical necessity if needed



• Must first use primary insurance, such as Medicare or private health insurance



• Health plan payment to provider is “payment in full”–Provider cannot charge

supplemental payments or “balance bill”

–Provider can collect Medical Assistance copay, if any



• Right to appeal if coverage is denied–Fair Hearing AND

–Complaint or Grievance

• Meet appeal deadlines


Webinars in This Series

• The webinars in this series may be accessed at: http://disabilities.temple.edu/programs/assistive/fac/

– Webinar 1: “Getting Durable Medical Equipment from Medical Assistance Managed Care: The Basics”

– Webinar 2: “Getting Your Communication or Mobility Equipment: Evaluations”


Disability Rights Networkof Pennsylvania

• 1-800-692-7443 (voice)

1-877-375-7139 (TDD)

[email protected]

• Follow us on Facebook www.facebook.com/DRNPA.org

• Sign up for alerts at www.drnpa.org


Disability Rights Networkof Pennsylvania

• Publications on getting assistive technology from Medical Assistance can be found at www.drnpa.org/publications


Pennsylvania’s Initiative on Assistive Technology

• 1-800-204-7428 (voice)

1-866-268-0579 (TDD)

[email protected]

www.disabilities.temple.edu/piat

• Statewide network of regional Assistive Technology Resource Centers

• Device demonstrations


Pennsylvania’s Initiative on Assistive Technology

• Device loans: [email protected], www.disabilities.temple.edu/programs/assistive/atlend

• Device reutilization

• Telecommunication Device Distribution Program (TDDP)

• iCanConnectPA


Other Resources

• Pennsylvania Assistive Technology Foundation: 1-888-744-1938 (toll-free voice/TDD), www.patf.us

• Department of Public Welfare: 1-866-542-3015 or 1-800-433-1324 (toll-free voice), www.dpw.state.pa.us


Contact Information

• Chava Kintisch, Staff Attorney

Assistive Technology Project Director

1315 Walnut Street, Suite 500

Philadelphia, PA 19107

215-238-8070, extension 210 (voice)

1-877-375-7139 (TDD)

[email protected]


Contact Information

• Amy S. Goldman, Co-Executive Director Institute on Disabilities, Temple University

1755 N. 13th Street, Suite 411 South

Philadelphia, PA 19122

215-204-1356 (voice/TTY)

215-204-3862 (voice/direct)

[email protected]

http://disabilities.temple.eduCopyright March 2014. Disability Rights Network of Pennsylvania. 44

Webinar Survey

• Please fill out our survey at https://www.surveymonkey.com/s/JS6ZKDB–Contact Amy Goldman for a print

copy or alternative format of the survey if needed


Other Information

• IMPORTANT: This publication is for general informational purposes only. This publication is not intended, nor should be construed, to create an attorney-client relationship between the Disability Rights Network of Pennsylvania and any person. Nothing in this publication should be considered to be legal advice.


Other Information

• This project is partially funded by a grant to the Disability Rights Network of Pennsylvania under Protection and Advocacy for Assistive Technology from the Department of Education. However, the content does not necessarily represent the policy of the Department of Education, and endorsement by the Federal Government should not be assumed.



Thank you!

getting your equipment repaired under medical assistance managed care prepared by the disability...

Documents

rules copyright

service medical assistance

treatment epsdt copyright

durable medical equipment

necessary health care

contract managers copyright

federal law

state laws