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1 | | daily living including employment, prevent |
2 | | hospitalizations, prevent institutionalization, and |
3 | | prevent other costly secondary complications; and |
4 | | (4) provide adequate Medicaid payment for complex |
5 | | rehabilitation technology for the purpose of allowing |
6 | | continued access to medically necessary products and |
7 | | related services, including maintenance and repair. |
8 | | (b) The General Assembly directs the Department of |
9 | | Healthcare and Family Services to establish focused rules and |
10 | | policies within the State Medicaid program for complex |
11 | | rehabilitation technology and to make other required changes to |
12 | | protect access to these specialized products and services. |
13 | | Section 10. Definitions. As used in this Act: |
14 | | (a) "Complex needs patient" means an individual with a |
15 | | diagnosis or medical condition that results in significant |
16 | | physical impairment or functional limitation. "Complex needs |
17 | | patient" includes, but is not limited to, individuals with |
18 | | spinal cord injury, traumatic brain injury, cerebral palsy, |
19 | | muscular dystrophy, spina bifida, osteogenesis imperfecta, |
20 | | arthrogryposis, amyotrophic lateral sclerosis, multiple |
21 | | sclerosis, demyelinating disease, myelopathy, myopathy, |
22 | | progressive muscular atrophy, anterior horn cell disease, |
23 | | post-polio syndrome, cerebellar degeneration, dystonia, |
24 | | Huntington's disease, spinocerebellar disease, and certain |
25 | | types of amputation, paralysis, or paresis that result in |
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1 | | significant physical impairment or functional limitation. |
2 | | "Complex needs patient" does not negate the requirement that an |
3 | | individual meet medical necessity requirements under authority |
4 | | rules to qualify for receiving complex rehabilitation |
5 | | technology. |
6 | | (b) "Complex rehabilitation technology" means items |
7 | | classified within the Medicare program as of January 1, 2015 as |
8 | | durable medical equipment that are individually configured for |
9 | | individuals to meet their specific and unique medical, |
10 | | physical, and functional needs and capacities for basic |
11 | | activities of daily living and instrumental activities of daily |
12 | | living identified as medically necessary. "Complex |
13 | | rehabilitation technology" includes, but is not limited to, |
14 | | complex rehabilitation manual and power wheelchairs and |
15 | | options/accessories, adaptive seating and positioning items |
16 | | and options/accessories, and other specialized equipment such |
17 | | as standing frames and gait trainers and options/accessories. |
18 | | The related Healthcare Common Procedure Code System (HCPCS) |
19 | | billing codes include, but are not limited to, any of the |
20 | | following: |
21 | | (1) Pure Complex Rehabilitation Technology Codes: |
22 | | These HCPCS codes contain 100% complex rehabilitation |
23 | | technology products: E0637, E0638, E0641, E0642, E0986, |
24 | | E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, |
25 | | E1010, E1011, E1012, E1014, E1037, E1161, E1220, E1228, |
26 | | E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, |
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1 | | E1238, E1239, E2209, E2291, E2292, E2293, E2294, E2295, |
2 | | E2300, E2301, E2310, E2311, E2312, E2313, E2321, E2322, |
3 | | E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, |
4 | | E2331, E2351, E2373, E2374, E2376, E2377, E2609, E2610, |
5 | | E2617, E8000, E8001, E8002, K0005, K0835, K0836, K0837, |
6 | | K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, |
7 | | K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, |
8 | | K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, |
9 | | K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, |
10 | | K0885, K0886, K0890, K0891, and K0898. |
11 | | (2) Mixed Complex Rehabilitation Technology Codes: |
12 | | These HCPCS codes contain a mix of complex rehabilitation |
13 | | technology products and standard mobility and accessory |
14 | | products: E0950, E0951, E0952, E0955, E0956, E0957, E0958, |
15 | | E0960, E0967, E0978, E0990, E1015, E1016, E1028, E1029, |
16 | | E1030, E2205, E2208, E2231, E2368, E2369, E2370, E2605, |
17 | | E2606, E2607, E2608, E2613, E2614, E2615, E2616, E2620, |
18 | | E2621, E2624, E2625, K0004, K0006, K0007, K0008, K0009, |
19 | | K0040, K0108, and K0669. |
20 | | (3) Future codes created to expand on or replace those |
21 | | listed in paragraphs (1) and (2). |
22 | | (c) "Individually configured" means a device has a |
23 | | combination of sizes, features, adjustments, or modifications |
24 | | that a qualified complex rehabilitation technology supplier |
25 | | can customize to the specific individual by measuring, fitting, |
26 | | programming, adjusting, or adapting the device as appropriate |
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1 | | so that the device is consistent with an assessment or |
2 | | evaluation of the individual by a qualified health care |
3 | | professional and consistent with the individual's medical |
4 | | condition, physical and functional needs and capacities, body |
5 | | size, period of need, and intended use. |
6 | | (d) "Qualified complex rehabilitation technology |
7 | | professional" means an individual who is certified as an |
8 | | Assistive Technology Professional by the Rehabilitation |
9 | | Engineering and Assistive Technology Society of North America. |
10 | | (e) "Qualified complex rehabilitation technology supplier" |
11 | | means a company or entity that: |
12 | | (1) is accredited by a recognized accrediting |
13 | | organization as a supplier of complex rehabilitation |
14 | | technology; |
15 | | (2) is an enrolled Medicare supplier and meets the |
16 | | supplier and quality standards established for durable |
17 | | medical equipment suppliers, including those for complex |
18 | | rehabilitation technology, under the Medicare program; |
19 | | (3) employs as a W-2 employee at least one qualified |
20 | | complex rehabilitation technology professional for each |
21 | | location to: |
22 | | (A) analyze the needs and capacities of the complex |
23 | | needs patient in consultation with qualified health |
24 | | care professionals; |
25 | | (B) participate in the selection of appropriate |
26 | | complex rehabilitation technology for such needs and |
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1 | | capacities; and |
2 | | (C) provide technology-related training in the |
3 | | proper use of the complex rehabilitation technology; |
4 | | (4) requires a qualified complex rehabilitation |
5 | | technology professional be physically present for the |
6 | | evaluation and determination of appropriate complex |
7 | | rehabilitation technology; |
8 | | (5) has the capability to provide service and repair by |
9 | | qualified technicians for all complex rehabilitation |
10 | | technology it sells; |
11 | | (6) maintains an adequate inventory of commonly used |
12 | | repair parts; and |
13 | | (7) provides written information at the time of |
14 | | delivery of complex rehab technology regarding how the |
15 | | complex needs patient may receive service and repair. |
16 | | (f) "Qualified health care professional" means a health |
17 | | care professional licensed by the State who has no financial |
18 | | relationship with the qualified complex rehabilitation |
19 | | technology supplier and includes, but is not limited to: (1) a |
20 | | licensed physician, (2) a licensed physical therapist, (3) a |
21 | | licensed occupational therapist, or (4) any other licensed |
22 | | health care professional who performs specialty evaluations |
23 | | within the professional's scope of practice. |
24 | | Section 15. Creation of focused regulations and policies |
25 | | for complex rehabilitation technology. |
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1 | | (a) The Department of Healthcare and Family Services shall |
2 | | establish focused rules and policies for individually |
3 | | configured complex rehabilitation technology products and |
4 | | services. These focused rules and policies shall take into |
5 | | consideration the customized nature of complex rehabilitation |
6 | | technology and the broad range of services necessary to meet |
7 | | the unique medical and functional needs of people with complex |
8 | | medical needs by: |
9 | | (1) designating current HCPCS billing codes listed in |
10 | | paragraphs (1) and (2) of subsection (b) of Section 10 as |
11 | | complex rehabilitation technology, and as needed, creating |
12 | | new billing codes or modifiers for services and products |
13 | | covered for complex needs patients; |
14 | | (2) establishing specific supplier standards for |
15 | | companies or entities that provide complex rehabilitation |
16 | | technology and restricting the provision of complex |
17 | | rehabilitation technology to only qualified complex |
18 | | rehabilitation technology suppliers that meet such |
19 | | standards as defined in subsection (e) of Section 10; |
20 | | (3) requiring complex needs patients receiving a |
21 | | complex rehabilitation manual wheelchair, power |
22 | | wheelchair, or seating component to be evaluated by: |
23 | | (A) a qualified health care professional as |
24 | | defined in subsection (f) of Section 10 (such |
25 | | evaluation shall not be subject to any therapy cap); |
26 | | and |
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1 | | (B) a qualified complex rehabilitation technology |
2 | | professional as defined in subsection (d) Section 10; |
3 | | (4) amending the Medicaid wheelchair repair policy to: |
4 | | (A) not require a prior approval for wheelchair |
5 | | repair items that are typically replaced on an annual |
6 | | basis due to normal wear from daily use. For items so |
7 | | identified, such as tires, batteries, and upholstery, |
8 | | a prior approval shall not be required unless the |
9 | | quantity requested exceeds what would be typically |
10 | | required in a calendar year. The Department shall work |
11 | | with CRT suppliers and Medicaid beneficiary groups to |
12 | | determine appropriate annual quantity thresholds; |
13 | | (B) if repairs can not be completed within 3 |
14 | | business days, and if the Medicaid beneficiary does not |
15 | | have a backup wheelchair, require that suppliers |
16 | | provide a functioning loaner wheelchair as soon as one |
17 | | is available. The Department shall provide an |
18 | | appropriate rental payment for these instances; |
19 | | (C) inform Medicaid beneficiaries as to the agency |
20 | | or entity to which concerns or disputes with any part |
21 | | of this policy should be reported; and |
22 | | (D) incorporate by reference the provisions of the |
23 | | Assistive Technology Warranty Act; |
24 | | (5) maintaining payment policies and rates for complex |
25 | | rehabilitation technology to ensure payment amounts are |
26 | | adequate to provide complex needs patients with access to |
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1 | | such items. The policies and rates shall take into account |
2 | | the significant resources, infrastructure, and staff |
3 | | needed to appropriately provide complex rehabilitation |
4 | | technology to meet the unique needs of complex needs |
5 | | patients and shall: |
6 | | (A) provide that the HCPCS billing codes listed in |
7 | | paragraphs (1) and (2) of subsection (b) of Section 10 |
8 | | will maintain an allowed payment amount not less than |
9 | | 100% of the Medicare fee schedule amount being used by |
10 | | the Department on January 1, 2016 less 6%. If the |
11 | | medically necessary item is not covered by Medicare, or |
12 | | is individually considered for payment, then the State |
13 | | shall maintain an allowed payment amount equal to the |
14 | | item's Manufacturer's Suggested Retail Price minus |
15 | | 10%; |
16 | | (B) preserve the option for complex rehabilitation |
17 | | technology to be billed and paid for as a purchase |
18 | | allowing for lump sum payments for devices with a |
19 | | length of need of one year or greater; and |
20 | | (C) provide that State Medicaid billing procedures |
21 | | will incorporate Medicare HCPCS code modifiers |
22 | | governing competitively bid complex rehabilitation |
23 | | technology that is added to noncompetitively bid |
24 | | wheelchair bases; |
25 | | (6) exempting the HCPCS billing codes listed in |
26 | | paragraphs (1) and (2) of subsection (b) of Section 10 from |