CAP-MR/DD Specialized Equipment and Supplies

VsDivision of Medical Assistance

Durable Medical Equipment

CAP-MR/DD Waiver Supplies T1999

• Includes devices, controls, or appliances specified in the person’s Plan of Care.

• Enable person to increase ability to perform ADLs or to perceive, control or communicate with the environment

• Shall be directly attributable to the person’s ability to avoid being institutionalized.

• Excludes those items which are not of direct benefit to the person.

• Must meet applicable standards of manufacture, design and installation.

Waiver Supplies Include the following categories:

• Category 1: Adaptive Positioning Devices

• Category 2: Mobility Aids

• Category 3: Aids for Daily Living

Adaptive Positioning DevicesStandersTrays and Attachments (for Standers)Prone Boards and AttachmentsPositioning Chairs and SittersMulti-function PhysiosystemBolster Rolls and WedgesMotor Activity ShapesTherapeutic Balls, Visualizer BallsPhysio-roll, Therapy mats when used in

conjunction with adaptive positioning devices.

Mobility Aids

• Specialized Adaptive Tricycles

All other items previously listed under this category are included on either the Medicaid Durable Medical Equipment Fee Schedule or the Orthotic and Prosthetic Fee Schedule and vendors may directly bill for these items.

Aids for Daily Living• Adaptive Eating Utensils (cups, mugs, spoons, forks,

knives, universal gripping aid for utensils, adjustable universal utensil cuff, utensil holder, non-skid inner lip plate, sloping deep plates, scooper, plate guards, non- skid pads for plate/bowl, wheelchair cup holders)

• Adaptive Eating Equipment• Adaptive, assistive devices/aids including adaptive

switches and attachments• Adaptive toothbrushes• Universal holder accessories for dressing, grooming, and

hygiene

Aids for Daily Living (Continued)• Toilet trainer with anterior and lateral supports• Adaptive toileting chairs and bath chairs and

accessories not on the State DME list• Adaptive hygiene/dressing aids• Adaptive clothing• Non-disposable clothing protectors• Reusable incontinence garments with

disposable liners for individuals age two and above

• Dietary scales, food/fluid thickeners for dysphasia treatment

Continuation of Aids for Daily Living

• Supplements covered by Medicaid for Home Infusion Therapy listed as tube feedings (our folks may take by mouth)

• Assistive listening devices for individuals with hearing and vision loss (TDD, large visual display devices, Braille screen communicators RM systems, volume control large print telephones, teletouch systems)

• Medication dispensing boxes

If any item is on the DME, Home Health, Home Infusion, or Orthotic

and Prosthetic Fee Schedule:

That item will not be covered by the waiver………..

When a waiver recipient is in need of equipment or supplies, the case

manager should always:

• Review the DME (Durable Medical Equipment) fee schedule

• Review the Home Health Fee Schedule• Review the Home Infusion Therapy Fee

Schedule• Review the Orthotic and Prosthetic Fee

Schedule

Fee Lists and Schedules

• www.dhhs.state.nc.us/dma/fee/dme_rates. pdf

• OR….to access ALL Medicaid fee schedules, go to:

• www.dhhs.state.nc.us/dma/fee/fee.htm• www.dhhs.state.nc.us/dma/

Waiver Supplies and Equipment T1999

• Are billed through your Local Management Entity in accordance with LME policy

• Require PA from ValueOptions as a component of the Plan of Care

• Require documentation of medical necessity (physician, PA, NP., etc.)

• Must fall within one of the three categories to be considered a waiver funded item

Durable Medical Equipment

HOW do we GET Equipment?

• Requires an order!!! Doctor, Physician’s Assistant or a Nurse Practioner.

• The item MUST be medically necessary and not for the convenience of the caregiver.

• Family/patient chooses a DME or O & P provider who is enrolled with DMA (most are in North Carolina). Your doctor probably can recommend a provider if family doesn’t know where to go.

• The DME provider will work with patient’s care team to identify needs (team can be the Physician, Physical Therapist, OT, SLP, RT, Case Manager, etc.) The care team will determine specifics of equipment, dimensions, components, etc.

Paperwork???• Yes! But you, the case manager, don’t have to

do it!! Durable Medical Equipment requires a CMN/PA form….Certificate of Medical Necessity/Prior Authorization form. The CMA/PA must be completed on all items Medicaid pays for. The DME provider, or the provider of Orthodics/Prostetics will complete this form and send to EDS.

• Every piece of equipment must have this form on record to protect the provider in case of an audit ….. Medicaid auditors look for this.

Who completes CMN?

• The durable medical equipment provider completes a portion and the doctor, NP, or PA who ordered the equipment needs to complete and sign the form. If there is a slowdown in the process, it may be the equipment provider waiting to obtain the form back from the doctor, etc. You may need to assist them by placing a call to the doctor, etc.

Children’s Mobility

• In addition to the Certificate of Medical Necessity form, if the item you need is a child’s mobility device, you must also submit a CSHS PA form to Children’s Special Health Services. These forms are submitted by mail and are submitted by the provider.

• This will be changing soon so please keep an eye on the Medicaid bulletin. EDS will be replacing CSHS………….

Prior Authorization

• Not every item requires prior authorization. If it DOES, there will be an asterisk (*) beside that coded item on the fee schedule. And again, DME providers are a huge resource of information.

Equipment is Delivered

• Once your equipment is delivered to the individual, the team (family, Case Manager, PT, SLT, OT, RT, etc.) must review the item to ensure it is as ordered and meets the patient’s functional requirements.

• If there is a problem, contact the DME provider directly. If it cannot be resolved, contact Medicaid at 919-855-4310.

DME & Children’s Mobility Devices

• Currently, Children’s Special Health Services (CSHS) is the prior approval reviewer for determination of medical necessity for wheelchair requests/mobility systems for children under 21 who are Medicaid eligible.

• Pending DMA notification through the Medicaid Bulletin, EDS will be the prior approval agent for pediatric wheelchair/mobility systems.

DME

• Items which can be found on the DME fee list include but are not limited to:

customized/specialized wheelchairsaccessories and parts

repairs of specialized/customized wheelchairs

DME Continued

• Splints/orthotics including replacement materials and repairs

• Prosthetic/orthopedic shoes and devices Protective helmets that are medically necessary

• If the item is on a DMA fee schedule then the item will not be covered by the waiver and is obtained using an enrolled vendor of these items through regular Medicaid.

All Equipment and Supplies

• All specialized equipment and supplies obtained through the waiver or through the processes noted above must be included as a component of the Plan of Care for waiver recipients.

• For specific information related to the above, please refer to the Division of Medical Assistance, Durable Medical Equipment Clinical Coverage Policy #5A or Orthotic and Prosthetic Device Clinical Coverage Policy #5B at:

www.ncdhhs.gov/dma/dme/dmepdf .pdf

Contact Information

• Clinical Policy/Behavioral Health Section of Division of Medical Assistance:

• Patricia Kirk RN• Patricia.Kirk@ncmail.net• 919-855-4290• DMA Durable Medical Equipment Division• 919-855-4310

EPSDT• Don’t forget; items not covered through the

CAP-MR/DD waiver or are not on a state DME fee list may be covered as part of an EPSDT benefit.