Dive Brief:

• CMS has updated its guidance on the handling of certain reimbursement claims related to people who are eligible for both Medicare and Medicaid benefits.

• The update is intended to accelerate access to some durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) by removing a bureaucratic step.

• The American Association for Homecare (AAHomecare) welcomed the change, stating that it will potentially make it easier for suppliers to get claims processed.

Dive Insight:

Differences in the DMEPOS items covered by Medicare and Medicaid can create problems for people who are eligible for both sets of benefits. Medicaid covers some DMEPOS items that are excluded from the list of devices reimbursed by Medicare.

As Medicare is the primary payer for DMEPOS items covered by both programs, some state Medicaid programs have held off on paying for items until they have a Medicare reimbursement denial. This can delay patient access to devices. When suppliers are unsure how Medicare and Medicaid will pay for a device, CMS thinks they may be reluctant to provide the required DMEPOS product.

CMS wants to eliminate this confusion and the access constraints it creates. The agency took a step toward that goal two years ago when it cleared states to use denied Medicare prior authorization requests as evidence the program will not cover the device, freeing them from the need to obtain a new claim denial for every item.

Now, CMS has taken another step by providing states with a second strategy for handling DMEPOS claims. CMS is advising states to create lists of DMEPOS items that Medicare does not cover. Armed with such a resource, state Medicaid programs can immediately process claims for items on the list, rather than wait for proof of Medicare denial before taking action.

CMS thinks a "thoughtfully implemented" take on this approach will enable state Medicaid programs to reduce their bureaucratic burdens while complying with their statutory requirement to be the payer of last resort. AAHomecare thinks the change will benefit DMEPOS suppliers, too.

"The new guidance has the potential to make it easier for suppliers to have claims processed for these services," the homecare trade group wrote in a statement.  

AAHomecare said it has worked with the CMS office covering people eligible for both Medicare and Medicaid over the past 18 months to try to streamline the process for determining which program should cover a particular product or service. Having made progress on that front, AAHomecare now plans to work with state and regional associations to ensure Medicaid programs adopt the policy.