CAMPS appreciates the recognition by DHCS regarding the impact on patient access and providers if they went forward with their original SPA rate methodology using the Medicare non-rural DME rates. Their suggested change will help alleviate the negative impact. It is important to note that there are already patient access issues as documented by a California Children's Services (CCS) study released this year and a California Hospital Association study released last year. Patients are experiencing difficulties in finding DME providers resulting in delays in patient discharge from hospitals and higher costs to the Medi-Cal program. The parents of CCS patients reported waiting up to a year before getting necessary DME equipment. This is all occurring under current Medi-Cal reimbursement levels which should result in DHCS exempting DME from the 10% provider rate cut and the continued use of 80% of Medicare as the benchmark for Medi-Cal payment. CAMPS will continue to advocate for these additional reforms. If you are not part of CAMPS you need to engage now the fight is not over.

We also believe that the access study performed by DHCS does not represent a true picture of the availability of DME providers throughout California. The number of providers has declined by over 50% in the last two years. Though consolidation has played some part, the larger factor is declining Medi-Cal and Medicare reimbursement. In addition, simply counting enrolled providers ignores two important factors; (1) providers that have ceased operation may not have disenrolled , and (2) DME providers are typically not full service DME providers, i.e. they may only   provide basic medical equipment or custom rehab equipment.     In the case of highly specialized services like   oxygen and ventilator dependent   pediatric patients the numbers   of providers are   very small and getting smaller  and require intensive clinical services to keep patients out of the hospital systems.

We continue to advocate for further reforms of Medi-Cal DME reimbursement methodology be made, including eliminating the 10% provider rate cut, eliminating the 80% of Medicare for most items of DME to 100% of Medicare, and Medi-Cal recognition of the Medicare KU modifier in the appropriate payment of custom rehab equipment. The issue of retroactivity of the final rates is also something that must be eliminated.  The pending SPA is also not yet approved.

Update: Replacement Durable Medical Equipment (DME) and Medical Supplies for Recipients Impacted by Fires and Extreme Weather Conditions or Public Safety Power Shutoff

On October 28, 2019, in response to the Governor's recent proclamation of a statewide state of emergency due to the risk of wildfires, the Department of Health Care Services (DHCS) issued guidance for dispensing replacement medication(s) to recipients impacted by fires and extreme fire weather conditions or public safety power shutoff. This article provides additional guidance for dispensing DME and medical supplies.

Providers are instructed to incorporate the statement "Patient impacted by fires and extreme fire weather conditions or public safety power shutoff." within the Miscellaneous Information field on the Treatment Authorization Requests (TAR) for DME, medical supplies or situations requiring a TAR.

DME and medical supply providers must provide requested equipment or supplies immediately or, for items not in stock, as soon as possible, if the need to dispense DME or medical supplies is related to the recipient's displacement or subjection to fires and extreme fire weather conditions or public safety power shutoff. Providers must not have the recipient return after receiving TAR approval. The need for a TAR should not negatively affect the decision to provide DME or medical supplies immediately or as soon as possible, and the TAR can be submitted retroactively. It is imperative that the impacted recipient receive the DME or medical supply in a timely manner to facilitate compliance and assist the recipient to perform activities of daily living.

TARs for new or replacement DME or medical supplies will be automatically approved if the TAR indicates that the recipient is impacted by fire or by power shutoffs, and the provider will be paid for the claim for the DME or medical supply. The negative impact of the fire or power shutoff, alone, will meet the criteria of medical necessity.

Providers are encouraged to monitor the Medi-Cal website for future updates. Questions regarding this notice may be directed to the Telephone Service Center (TSC) at 1-800-541-5555, Monday through Friday, except holidays.

We previously informed you that as part of this year's state budget there were some optional services restored for Medi-Cal recipients. That restoration included creams and washes and we have pasted below the notice posted on the Medi-Cal website. We will get additional information on coverage and process in the next few weeks.  

Effective for dates of service on or after January 1, 2020, incontinence creams and washes require authorization and are no longer restricted to recipients under 21 years of age. Products on the List of Contracted Incontinence Creams and Washes are reimbursable with an approved Treatment Authorization Request (TAR) or Service Authorization Request (SAR) for recipients 5 years of age or older, effective for dates of service on and after January 1, 2020.