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Home Health & Hospice Week

Medicaid:

CMS Urges States To Cover HME Before Discharge

Published on Mon Aug 04, 2003

HME keeps beneficiaries in their homes and out of institutions.

More Medicaid business could be coming your way if states heed the Centers for Medicare & Medicaid Services' request for wider home medical equipment coverage under Medicaid.

CMS urges states to find creative ways to keep more beneficiaries in their homes, and out of institutions, by furnishing HME as conveniently as possible, according to a July 14 letter from CMS to state Medicaid directors (SMDL # 03-006).

By covering HME before a patient is discharged from a skilled nursing facility or other institution, Medicaid programs can eliminate the delay in receiving and adapting equipment that "often causes hardships for the individual and/or caregiver(s)," CMS says

Furnishing HME before institutional discharge also cuts down on unnecessary hazards in the home and increases the chance of a better fit and adaptability, CMS says in the letter.

States whose Medicaid program rules don't allow for coverage before discharge can try a few other avenues to pay for HME:

  • Trial periods. States may come to you to request a "trial period" in which beneficiaries receive equipment prior to community placement.

  • Waivers. Home and community based services waivers can cover HME for up to 60 days before a planned discharge to community, CMS says. However, payment can't be made until the patient actually is discharged.

  • SNFs. States can cover ME tailored to a patient under the SNF benefit, then allow that "dedicated" equipment to follow the patient home when she is discharged. For example, Pennsylvania in 1996 created a program where SNFs can purchase ME for a specific patient outside of the SNF per diem rate. The title for the equipment can be transferred to the beneficiary if he goes back home, CMS says.

    CMS has created two HCPCS codes to facilitate such billing, it says: T1028 (assessment of home, physical, and family environment) and S5165 (home modifications, per service).

    "The directive is encouraging in that it gives greater recognition to the need for products and services in the home," says consultant Schuyler Hoss with Northwest Healthcare Management in Vancouver, WA. The endorsement also adds to the HME industry's credibility, Hoss judges.

    But encouragements to do anything that might increase state budgets at this time are very unlikely to be followed, expects Mike Hamilton of the Alabama Durable Medical Equipment Association. CMS "can urge all they want, but nothing will happen unless they include funding" since state budgets are so tight, Hamilton concludes.

    Even if states do agree to increase coverage, payment rates are likely to be unfavorable to suppliers, Hoss and Hamilton agree.

    Nonetheless, "smart dealers will use the directive as leverage in working with state Medicaid programs in trying to expand the range of covered services," Hoss predicts.

    It could be especially useful in trying to obtain coverage for more sophisticated items and services, such as those in respiratory and custom rehab, which states tend to restrict, he says.

    Editor's Note: The letter is at http://cms.hhs.gov/states/letters/smd71403.pdf.

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