Proposed Rule: Access to DME for Dually Eligible People

On June 30, 2016 the Centers for Medicare & Medicaid Services (CMS) published a proposed rule about the difficulties of dually eligible people (individuals eligible for both Medicare and Medicaid) to obtain Durable Medical Equipment (DME). The proposed rule seeks information about the problem, as well as potential solutions. The proposed rule is primarily focused on End Stage Renal Disease (ESRD). The DME request for information is separate from the ESRD-specific content.

The Center for Medicare Advocacy (the Center) will respond to the request for information regarding access to DME for dually eligible people. We encourage other beneficiary advocates to do so as well, and to contact us if we can help. CMS seeks specific examples of problems, as well as specific solutions. The Center’s response will include a discussion of:

  • The misalignment of coverage and payment procedures in Medicare and Medicaid that lead to denials and delays of important equipment for this vulnerable population. Generally Medicare provides approval or denial only after delivery of the DME. Without the delivery of the DME to trigger a Medicare coverage decision, suppliers are usually unable to bill Medicaid, because State Medicaid agencies generally require that a bill be submitted first to Medicare. Only after Medicare has rejected the claim or paid its share will Medicaid process a payment. Thus, suppliers do not have assurance that the DME will be covered by Medicare, yet they do not have the ability to bill Medicaid until they have a Medicare decision. This often results in suppliers refusing delivery of DME because they worry they will not be paid by either program.
  • The mismatch between Medicaid and Medicare suppliers, and beneficiary access difficulties; problems with repairs for equipment; delays; and how the competitive bidding process may be affecting availability of suppliers.
  • The challenges created by the intersection of the two programs. We often hear about problems that begin during the transition from having only Medicaid to also having Medicare coverage.
  • Some promising practices that have worked well to align the two programs. These include a Medicaid prior authorization system in Connecticut that provides suppliers with Medicaid prior authorization – and dually eligible beneficiaries with better access to DME. With assurance that the DME will be covered by Medicaid if Medicare is denied, suppliers are more willing to deliver the necessary DME.

For more information see 81 FR 42801 (June 30, 2016)

Request for information (Section IX. Access to Care Issues for DME, page 42864-5.):

Comments are due August 23, 2016.

July 6, 2016 – K. Kertesz