Provider Operations Section

Exceptional Payment Programs

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Exceptional Payment Section

Exceptional Payment Section

Durable Medical Equipment (DME)

Ventilator Dependent Resident Program (VDRP)

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Durable Medical Equipment (DME)

What types of Durable Medical Equipment are

covered?

Specially Adaptive Equipment – Specially Adapted DME is

DME that is uniquely constructed or substantially adapted or

modified in accordance with the written orders of a physician

for the particular use of one resident, making the

contemporaneous use by another resident unsuitable.

Exceptional Equipment – Exceptional DME is defined as DME

that meets the minimum acquisition cost and is either

Specially Adapted DME or other such DME that is designated

as Exceptional DME by the Department annually in the

Pennsylvania Bulletin.

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Durable Medical Equipment (DME)

er Operations Section

Durable Medical Equipment (DME)

Specially Adapted Equipment

Power Wheelchair

Manual Wheelchair

Exceptional Equipment

Assistive Communication Devices

Bed and/or Mattresses (wound care)

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Durable Medical Equipment (DME)

Required Documentation

MA97 – Outpatient Services Authorization form

MA97LTC – DME request for nursing facility resident

Physician’s prescription

For specially adapted wheelchair, clinical assessment report from CARF or JACHO certified rehab facility

Required supporting documentation

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Durable Medical Equipment (DME)

Overview of Process

Documentation received from the facility

Request is reviewed. For wheelchairs and ACD’s each part is priced individually, using the MA Fee Schedule -

If no code is available we pay 80% of the MSRP

Nursing Facility notified of decision

Nursing Facility orders equipment for the recipient

Notice of Decisions are sent to the Nursing Facility with the Departments decision

If approved, the Nursing Facility bills the Department

The Department does a follow-up with the Nursing Facility to determine that the equipment was provided to the resident

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Durable Medical Equipment (DME)

Overview of Process (continued)

The Nursing Facility is required to notify the Department if at anytime the status of the resident needs change, they are discharged or they cease to breath

If the resident discharges from the Nursing Facility then the purchased DME goes with them

Currently, the Departments Field Operations teams do yearly reviews to verify the resident is still in the facility and the equipment is in good condition

The equipment is the property of the resident and will transfer with the resident. However, while residing in the facility if the resident can no longer use the equipment. The equipment will then become property of the nursing facility and the facility can then use the equipment for another MA resident as they see fit

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Durable Medical Equipment (DME)

Overview of Process (continued)

The Department will coordinate with the MCO on monitoring equipment purchased after January 1, 2018

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Durable Medical Equipment (DME)

Billing

Wheelchairs and ACD’s: each part of the chair/ACD are billed individually. Using the codes and prices shown on the Notice of Decision

Mattress or Bed Rentals are billed on a month to month basis

See handouts

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Durable Medical Equipment (DME)

Transition/Continuity of Care

Any wheelchairs or ACD’s approved prior to January 1, 2018, the Department will do the follow-up

Any Bed or Mattress rentals that where approved prior to January 1, 2018 but continue in the new year will be transferred over to the MCO for follow-up

Any request received prior to January 1, 2018 but have not been reviewed by the Department will be transitioned to the MCO for review

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Durable Medical Equipment (DME)

Current number of cases to transfer from the Department to the MCO’s for the Southwestern region.

Bed/Mattress Follow-up: Currently 3 cases

New requests: Unknown at this time

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Durable Medical Equipment (DME)

Our questions to the MCO’s regarding the Transition/Continuity of Care

What information will you want from us regarding cases the MCO’s will need to follow? (i.e. beds/mattress)

All cases that need to be followed up on and any new cases that will need to be reviewed will be delivered to the MCO through a file that will be created on DocuShare

The Department will need the name of the clinician that we can use as a contact person

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Ventilator Dependent Resident Program

Provides additional funding for the care of residents in

participating Nursing Facilities who are determined to be

unweanable and chronically ventilator dependent.

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Rental and rent-to-own

ventilators

Reimbursement for the

Department’s approved

list of respiratory

supplies and

frequencies

Tracheostomy Collars

CPAP

BI-PAP

Any moveable

equipment other than

the ventilator

Ventilator Dependent

Resident Program covers…

Ventilator Dependent Resident

Program does not cover…

Nursing Facility Participation Eligibility Requirements-

(The Department will continue to certify ventilator

facilities)

Certified and Enrolled Medicare Provider

Provider Type 03

Operate an existing or proposed ventilator unit that during

onsite inspection qualifies for the VDRP

Favorable standing with PA’s Department of Health

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Ventilator Dependent Resident Program

Resident Enrollment Eligibility Requirements

MA eligible residents

Residents 21 years of age or older who require full ventilator

support (mandatory ventilation) for a minimum of 8 hours a

day

Residents 20 years of age or younger who require ventilator

support to sustain life

Chronically Ventilator Dependent - unweanable

Clinically stable

Residents residing in an approved and enrolled VDRP

facility.

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Ventilator Dependent Resident Program

Application Requirements for a Ventilator Dependent Resident in an Approved Facility

MA97 – Outpatient Services Authorization Form

Physician’s statement

Respiratory Therapy flow sheets

Required supporting documentation MDS

H & P

Any additional Physician’s orders and progress notes

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Ventilator Dependent Resident Program

Overview of Process VDR’s application is received from an approved facility

Request is reviewed for eligibility requirements

Nursing Facility is notified of the decision & a prior authorization number is provided

If approved, Nursing Facility bills the Department on a monthly basis for ventilator rental and actual supplies used

Nursing Facility participates in Bi-Annual Invoice Reviews by submitting current invoices of actual costs from their DME Suppliers to the Department - periodic Ventilator Surveys are also conducted

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Ventilator Dependent Resident Program

Overview of Process (Continued)

The Nursing Facility is required to notify the Department if at anytime the resident requires less than 8 hours a day of mandatory ventilation, weans from the ventilator, transfers or ceases to breath

Currently, the Department’s Field Operations teams do annual reviews to verify that each resident is still in the facility and there are no changes to their ventilator status

The Nursing Facility currently completes an Annual Program Survey that provides current statistics to include: ventilator beds per unit and VDRP participants per unit. The Department will coordinate with the MCO for future reporting. (See Handout)

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Ventilator Dependent Resident Program

Billing:

Ventilator rental and approved supplies are billed on a monthly basis

See Handouts

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Ventilator Dependent Resident Program

Transition/Continuity of Care

All current VDR participants approved prior to January 1, 2018 and active in the Program, will be transferred to the MCO

All VDRP applications received by the Department prior to January 1, 2018 but not yet reviewed for program eligibility will be transferred to the MCO through a file that will be created on DocuShare

The Department will need the name of the clinician that we can use as a contact person

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Ventilator Dependent Resident Program

Current number of cases to transfer from the Department to the MCO’s for the Southwestern Region.

Currently 6 Nursing Facilities are enrolled in the Ventilator Dependent Resident Program:

Cambria Care Center: Currently, 8 participants

Forbes Center for Rehab: Currently, 13 participants

Mountainview Specialty Care: Currently, 2 participants

St. John Specialty Care: Currently, 1 participants

Transitions Healthcare Washington, PA: Currently, 5 participants

William Penn Care Center: Currently, 0 participants

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Ventilator Dependent Resident Program

Our questions to the MCO’s regarding the Transition/Continuity of Care

What information will you want from us regarding cases the MCO’s will need to follow?

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Ventilator Dependent Resident Program

Provider Programs Contact

Stacy Bowman - DME c-stbowman@pa.gov 717-772-4120

Courtney Hammond - DME c-chammond@pa.gov 717-772-1471

Jane Snyder - VDRP c-jansnyde@pa.gov 717-772-0934

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