Durable Medical
Equipment (DME)
and Supplies
Improving
health care access
and outcomes for the
people
we serve while demonstrating sound
stewardship of financial
resources
•
60% Children & Adolescents under age 20
•
32% Adults ages 21-64
•
10% People with Disabilities in all age groups
•
8% Elderly ages 65 or older
•
More than 1/3 of babies born in Colorado are born
to mothers who are on Medicaid
•
15% live in rural areas
•
85% live in areas with populations above 100,000
•
13 % of overall Medicaid clients live in Denver
County
•
Durable Medical Equipment: equipment that
can withstand repeated use and that
generally would be of no values to the client
in the absence of a disability, illness, or injury.
•
Covered Benefits: supplies and DME must be
medically necessary and prescribed by an
authorized prescriptive authority for use by
an eligible client
•
Eligible Providers
Providers must be enrolled as a Colorado Medical Assistance
Program provider in order to:
Treat Colorado Medical Assistance Program
Submit claims for payment to the Colorado Medical Assistance Program
•
Prescribing Providers
Supplies and DME must be prescribed by a:
Physician
Physician assistant Nurse practitioner
The prescription must be within the scope of the prescribing provider’s license
•
Supply/Equipment Providers
May be either enrolled as pharmacy or DME supply company
•
The following DME and Supplies are benefits
for clients regardless of age
Ambulation devices and accessories including but not limited to
canes, crutches or walkers
Bath and bedroom safety equipment
Bath and bedroom equipment and accessories including, but not
limited to, specialized beds and mattress overlays
Manual or power Wheelchairs and accessories
Diabetic monitoring equipment and related disposable supplies Elastic supports/stockings
Blood pressure, apnea, blood oxygen, Pacemaker and uterine
monitoring equipment and supplies
•
Continued…
Oxygen and oxygen equipment in the client’s home, a nursing facility
or other institution
Transcutaneous and/or neuromuscular electrical nerve
stimulators(TENS/NMES)
Trapeze, traction and fracture frames Lymphedema pumps and compressors Specialized use rehabilitation equipment Oral and enteral formulas and supplies Parenteral equipment and supplies
Facilitative Devices -tablet technologies using E1399 with AV modifer Alternative and Augmentative Communication Devices (AACD)
•
The following Prosthetic or Orthotic Devices
are benefits for clients regardless of age
Artificial limbs
Facial Prosthetics
Ankle-foot/knee-ankle-foot orthotics
Recumbent ankle positioning splints
Thoracic-lumbar-sacral orthoses
Lumbar-sacral orthoses
Rigid and semi-rigid braces
•
The following DME are benefits to only
clients under the age of 21
Hearing aids and accessories
Phonic ear
Therapy balls for use in physical or occupational therapy
treatment
Selective therapeutic toys
Computers and computer software when utilization to
meet medical rather than educational needs
Vision correction unrelated to eye surgery
•
Through EPSDT, each state’s Medicaid plan
must provide to any EPSDT recipient
any
medically necessary health care service
,
even if the service is not available under the
State's Medicaid plan to the rest of the
Medicaid population
It is a reasonable, appropriate, and effective
method for meeting the client’s medical
need;
The expected use is in accordance with
current medical standards or practices
(clinical guidelines exist);
It is cost effective; and
It provides for a safe environment or
situation for the client
•
EPSDT exceptions
Services not otherwise covered under Medicaid DME
benefit will be considered for coverage for clients
aged 20 and under – even if the code is closed in our
system
•
Waiver exceptions
Waivers may cover items outside of EPSDT – ie;
hippotherapy which is not a benefit under EPSDT but
can be paid by the CES HCBS
waiver dollars if
available.
•
Some supply items and most DME items
require prior authorization
For detailed list of prior authorization requirements, please refer to
the DME manual found on the Department’s website
PAR is not required for Medicare Crossover claims
PAR is required for clients who have other primary insurance
•
Approval of a PAR does not guarantee CO
Medicaid payment
Only assures that the approved service is a medical necessity
Prior Authorization Requests
(PARs) for Supplies and DME
From a primary care physician or DME Provider
Parents or family members are not able to submit their
own PAR
, but they may assist provider in language as they
often understand better the need/use
A PAR form MUST have a signed prescription from the
medical provider
A letter of medical necessity
must
accompany the completed
PAR form
A letter is not a prescription
Additional documentation as needed
WIKI information, clinical guidelines, flyer or marketing
materials
Letter approving, pending or denying request will be mailed
to the requesting party as well as the client
Medicaid DME Benefit YES Submit to Medicaid via DME provider N
O
Available under EPSDT N
O
Waiver covered services N
O
YES Submit to Medicaid via DME provider
YES
Request to be forwarded to the local waiver manager for final
approval from State Waiver Manager
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