Center for Medicare Advocacy

Advancing Access to Medicare and Healthcare

CMA Alert – DME Access Issues for Dual-Eligibles; Proposed HH Rules will Harm Access to Care; Sabotage and Spin

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  1. CMS Releases Issue Brief on Access Challenges of DME for Duals
  2. Medicare Home Health Rules Proposed by CMS to "Improve Access to Solutions" Will Further Reduce Patient Access to Care
  3. Health Care Sabotage: Impact of Sabotage on the Exchanges
  4. Free Webinar: Enhancing the Promise of Medicare – Oral Health, Audiology, Vision Benefits

CMS Releases Issue Brief on Access Challenges of DME for Duals

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The Medicare-Medicaid Coordination Office’s Integrated Resource Center (ICRC) of the Center for Medicare & Medicaid Services recently released an issue brief addressing the challenges of access to durable medical equipment (DME) for dually eligible beneficiaries. The brief, Facilitating Access to Medicaid Durable Medical Equipment for Dually Eligible Beneficiaries in the Fee-for-Service System: Three State Approaches, cites the logistical problems created by the mismatch of Medicare and Medicaid processing rules as creating barriers in access to needed care that individuals enrolled in only one or the other of the programs do not have. ICRC researched examples of states that have implemented provisional prior authorization (PA) policies, supported by lists of DME that Medicare generally does not cover. Fourteen states – Alaska, California, Connecticut, Georgia, Idaho, Illinois, Indiana, Kansas, Minnesota, Nevada, New York, Ohio, Oregon, and Utah – all appear to authorize suppliers to bill Medicaid directly for DME items that Medicare generally does not cover. The brief examines DME policies in three states (Illinois, California and Connecticut) that have led to improved access.

  • Illinois: Illinois enables providers to use an online information system called Medical Electronic Data Interchange (MEDI) that lets providers verify multiple elements of a beneficiary’s eligibility, including QMB status, and an online table for providers that specifies the services/items for which providers and suppliers can bill Medicaid directly because Medicare generally does not cover them under Part B. The table also includes other key information, such as Medicaid prior authorization requirements and the maximum quantity of DME items allowed.
  • California: California providers are allowed to submit claims directly to Medi-Cal (California’s Medicaid program) when any of the following criteria apply: Medicare does not cover the item or service; the beneficiary’s Medicare benefits have been exhausted; or Medicare has denied the claim; or the recipient is not Medicare-eligible.
  • Connecticut: Connecticut requires that the state consider preauthorization of a DME item before the state receives a formal denial from Medicare. The state cannot deny dually eligible beneficiaries access to prior authorization for new or rental DME because Medicare has not yet made a coverage determination.

The Center for Medicare Advocacy has heard from state advocates that since Connecticut has allowed prior authorization in Medicaid for DME, dually eligible beneficiaries in the state have had access to DME without the delays seen in other states. The Center has advocated for this model to be implemented in other states.

Federal Update

The brief cites a Medicare prior authorization process, implemented July 2017, which is in effect nationwide for two types of power wheelchairs. The aim is to make the authorization process easier for dually eligible beneficiaries and power wheelchair providers by enabling them to get an earlier Medicare decision on those DME items. Beginning September 1, 2018, thirty-one additional power mobility device codes will be subject to required prior authorization.

The Center for Medicare Advocacy has promoted a prior authorization system in Medicaid (as is the case in Connecticut) and will be monitoring the impact on access to DME of adding additional power mobility device codes to Medicare prior authorization. The Center urges advocates to contact us at DMEPOS@medicareadvocacy.org to update us about DME access for dually eligible beneficiaries.

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Medicare Home Health Rules Proposed by CMS to "Improve Access to Solutions" Will Further Reduce Patient Access to Care

The announcement on July 2, 2018, that CMS seeks to “modernize” Medicare home health care is filled with patient-oriented rhetoric, but will actually further gut the Medicare home health benefit – which is already being implemented in a way that doesn't work for many patients who are most in need.

New payment policies, such as those in the proposed rule, will continue to make it impossible to effectively implement Medicare coverage laws for millions of beneficiaries who qualify for care under the law. Medicare beneficiaries who meet home health coverage criteria will be forced to go without necessary care or enter institutions because home health agencies consider Medicare payments inadequate to cover their care. 

Under the current payment system, for example, Medicare home health aide visits to provide patients with covered personal care services have declined from 48% to less than 10% over the past two decades[1] despite no change in home health aide coverage laws. Changes in payment policies have driven the decline. The new proposed rule will further erode the lawful Medicare benefit and decrease delivery of home health aide services.

In the coming weeks, the Center for Medicare Advocacy will comment on these proposed rules. We urge others to participate by sharing or signing on to these comments. The crisis in access to home care is growing. This proposed rule would only exacerbate that trend and must be stopped. CMS must instead create a payment system that allows equal access to legal Medicare coverage, not a payment system that further illegally limits access to care and destroys lives.

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Health Care Sabotage: Impact of Sabotage on the Exchanges

This week, the Centers for Medicare and Medicaid Services (CMS) released their reports on the performance of the exchanges and individual health insurance market. These reports include the Early 2018 Effectuated Enrollment Snapshot, Exchange Trends Report and the Trends in Subsidized and Unsubsidized Enrollment. In the press release for these reports, CMS makes a few unfortunate statements and draws some troubling conclusions based on the data in these reports.

CMS concludes:

 “Reports show individual market erosion and increasing taxpayer liability” 

 “…Obamacare was failing its consumers.”

CMS even claims:

“CMS took immediate steps in 2017 to address market stability issues and to improve the performance of the Exchanges using the Federal platform in order to mitigate the deterioration of the individual health insurance market for consumers.

This is clearly inaccurate. Over the last few months the Center for Medicare Advocacy has continuously highlighted actions taken by the Administration that undermined the Affordable Care Act (ACA), depressed enrollment, and caused spikes in premiums.

To recap: in 2017, the Administration cut the enrollment period in half; slashed funding for enrollment assistance; refused to participate in enrollment events; shut down healthcare.gov during critical times; and refused to pay cost-sharing reductions to help consumers afford coverage. Recently, we have seen the Administration move to allow the sale of inadequate insurance plans such as Association Health Plans and Short-Term Limited-Duration Insurance. These certainly do not seem to be actions taken to “mitigate the deterioration of the individual health insurance market for consumers.”

Fortunately, the American people understand the need for quality health coverage and at least legislative attempts to repeal the ACA have been rejected. In some very good news, the New York Times reports this week, “As health insurers across the country begin filing their proposed rates for 2019, one thing is clear: The market created by the Affordable Care Act shows no signs of imminent collapse in spite of the continuing threats by [the Administration and others] to destroy it.”

If the Administration is truly interested in taking actions to “stabilize the market and provide all consumers…with more affordable health coverage options” as they claim, all attempts to sabotage the ACA must end.

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Free Webinar: Enhancing the Promise of Medicare – Oral Health, Audiology, Vision Benefits

July 18, 2018 @ 3 PM ET

​Presented By Center Attorneys David Lipschutz and Wey-Wey Kwok, and Diane Lifsey, Senior Policy Analyst for the National Committee to Preserve Social Security & Medicare

Register Now

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