H08-07– Information

January 30, 2008

TO: / Home and Community Services (HCS) Division Regional Administrators
Area Agency on Aging (AAA) Directors
Division of Developmental Disabilities (DDD) Regional Administrators
FROM: / Bill Moss, Director, Home and Community Services Division
Linda Rolfe, Director, Division of Developmental Disabilities
SUBJECT: /
Approved Durable Medical Equipment (DME) Through Medicare and Medicaid
Purpose: / The purpose of this management bulletin is to address questions regarding approved DME for COPES and MPC clients.
Background: / This MB was originally issued in September of 2000. It is being reissued as a reminder to staff and supersedes the previous MB 00-49. The information in this MB will eventually be incorporated into the Long-term Care Manual as chapters continue to be revised.
What’s new, changed, or
Clarified / This MB addresses the following frequently asked questions pertaining to DME:
  1. Is a DME vendor required to provide an approved service/piece of equipment at the Medicare and Medicaid reimbursement rate? Yes, according to the HRSA Core Provider Agreement, the vendor must accept HRSA’s allowable rate as payment in full. The vendor cannot accept additional funds from the client, personal assistants, family, or other organizations for services covered. The vendor can refuse to serve the client due to the rate. The same holds true for Medicare. If Medicare approves equipment, but the vendor does not accept the rate, Medicaid cannot supplement or purchase the equipment. If the vendor accepts the rate on assignment from Medicare, they must accept the rate as payment in full.
  1. Can COPES specialized medical equipment and supplies service supplement the rate paid by Medicare or Medicaid for an approved item? No, this would be viewed as duplication of service and potentially fraudulent. If the vendor is unwilling to accept the payment from Medicare or Medicaid, ADSA would not purchase the equipment using the COPES program.
  1. Can ADSA’s state-funded Assistive Technology (AT) program supplement the rate paid by Medicare or Medicaid for an approved item? No, in order for the Assistive Technology program to cover an item, Medicare/Medicaid must deny the service or the service must not be covered by any other funding source. Denial of service must be in writing in the client’s file or documented in the SER notes for audit purposes. The AT program can supplement COPES for environmental modifications and/or specialized medical equipment and services if the COPES budget has insufficient money available. The AT program can also supplement other private funding sources.
  1. Can a discharge allowance be authorized to purchase or supplement payment for an approved item? These funds can only be used to purchase DME items that are denied or not covered by Medicaid or Medicare.
  1. If Medicaid denies equipment, can the client appeal the decision? Yes, the client may ask for a fair hearing with HRSA regarding the decision. If the client loses the fair hearing, case managers may access COPES waivered services to assist the client in obtaining needed equipment if the client is eligible. The contact person for HRSA DME program is:
Dianne Baum, Program Manager

360-725-1590
  1. What should I do if I suspect a provider is committing Medicaid fraud or if I have questions concerning provider fraud? The Medicaid Fraud Control Unit of the Attorney General’s Office investigates Medicaid fraud cases including billing for services not provided, over-prescribing medications, unnecessary services performed or billed, and billing clients beyond Medicaid reimbursement rates. If you suspect Medicaid fraud or have any questions, please contact:
Office of the Attorney General
Medicaid Fraud Control Unit
2425 Bristol Court SW
P.O. Box 40116
Olympia, WA98504
(360) 586-8888
(360) 586-8877 Fax
ACTION: /
  • Distribute this information to staff.
  • Case Managers should also report to Patty McDonald any cases where clients have received approval for equipment/services, but no vendor is available in the state to provide the service. (see contact info. below).

Related
REFERENCES:
ATTACHMENT(S):
CONTACT(S): / Patty McDonald, Program Manager
(360) 725-2559

For questions about the COPES program contact:
Chris Imhoff
(360) 725-2272

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