Dual Eligible Beneficiaries may face special obstacles when they try to access services, such as durable
medical equipment, that is covered to varying degrees by both Medicare and Medicaid.
The Integrated Care Resource Center recently released a briefing titled “Facilitating Access to Medicaid Durable Medical Equipment for Dually Eligible Beneficiaries in the Fee-for-Service System.” As the title states, the brief explores the approaches of Connecticut, California, and Illinois in ensuring dual-eligible beneficiaries receive the medical equipment they need.
⇒ Beneficiaries who are dually eligible for Medicare and Medicaid often experience difficulties accessing
durable medical equipment such as wheelchairs, in a timely manner. Whether Medicare or
Medicaid covers a specific item may be unclear.
To address this issue, some states, such as Illinois, California, and Connecticut, have developed procedures for provisional prior authorization from Medicaid for such items. States may supplement these procedures by posting lists of DME items that Medicare consistently denies as non covered, and allow DME suppliers to bill Medicaid directly for these items without first billing Medicare. This can make it more likely that suppliers will provide DME to dually eligible beneficiaries in a timely way, with less confusion and uncertainty about who will pay and when.
Policies Implemented by the Three States:
Currently, fourteen states have implemented provisional prior authorization policies supported by lists of DME items that Medicare does not generally cover. The ICRC explored the policies of three states to better understand how PA improves access for dual-eligible individuals.
California, Connecticut, and Illinois have slightly different DME billing policies. California and Illinois both implemented a feature that further facilitates the provisional PA approach. Each maintains an online list of DME items that Medicare generally denies as non-covered under Part B, but that Medicaid may cover. When it is clear from the list that Medicare will not cover the item, DME suppliers can submit their claims directly to Medicaid without first submitting them for a Medicare denial. In contrast, Connecticut developed a system that allows for prior authorization of DME before a Medicare denial.
Illinois’ Approach to DME Delivery
Illinois Medicaid simplifies the adjudication and payment of DME claims for dually eligible beneficiaries by enabling providers to use:
- An online information system called Medical Electronic Data Interchange that lets providers
verify multiple elements of a beneficiary’s eligibility, including QMB status. - 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.
Online table for DME providers:
Illinois currently maintains a table on its website that indicates whether Medicare normally covers a specified DME item.
| HIPAA | Description | PA Required | Medicare Covered | Max Quantity | Max Days |
| A4213 | Syringe, Sterile, 20cc or Greater, Each | No | No | 15 | 30 |
| A6250 | Skin Sealants, Protectants, Moisturizers, Any Type | Yes | No | N/A | N/A |
| A7007 | Large Volume Nebulizer, Disposable Unfilled, Used w/AE | No | No | 2 | 30 |
| E1300 | Whirlpool, Over Tub Type, Portable | Yes | No | N/A | N/A |
California’s Approach to DME Delivery:
As in all states, the California Medicaid program (called Medi-Cal) requires that DME suppliers submit most
claims for dually eligible beneficiaries to the appropriate Medicare carrier or fiscal intermediary so they can
process the Medicare benefit first. However, providers are allowed to submit claims directly to Medi-Cal
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.
Online Table of HCPCS codes for DME Coverage:
| Codes | Description | When to bill Medi-cal directly |
| A9273, A9274, A9279, A9281, E0240 – E0245, E0273, E0625 | DME | Always |
| E0970, E079, E1065, E1091, K0740, K0872 – K0876, K0881 – K0883, K0887 – K0889, K0892 – K0898 | DME | On the UB-04, if the facility type code is other than 33 (Home Health – Outpatient) or 14, 24, 34, 44, 54, 64, 74, 75 or 89. On the CMS-1500, if the Place of Service Code is other than 12 (Home) or 99 (Other) |
Connecticut’s Approach to DME Delivery;
Connecticut began to operate its Medicaid program HUSKY Health through a self-insured, managed FFS
model in 2012. The Connecticut Department of Social Services has contracts with Administrative Service
Organizations for medical, behavioral, and dental health services as well as non-emergency
medical transportation. Community Health Network of Connecticut is the ASO that administers all
medical services, including DME.
Recent Federal Developments:
Two recent developments at the federal level may make it easier for states to provide prior authorization for Medicaid DME when Medicare may also cover the item:
1. Earlier Medicare authorization of some types of power wheelchairs. As of July 2017, a new Medicare prior authorization process is in effect nationwide for two types of power wheelchairs that may 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, 31 additional power mobility device codes will be subject to required prior authorization. These items are currently included in the Prior Authorization of Power Mobility Devices Demonstration, which is scheduled to end on August 31, 2018.
2. New incentive for states to develop lists of DME that Medicare will not cover. A new federal law,
effective January 1, 2018, limits federal matching payment for Medicaid DME that is jointly covered by Medicare to the amount Medicare would have paid, in the aggregate, for those items. This limitation does not apply to items of DME that Medicaid covers but Medicare does not.
