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GAMES/GRTC Winter Meeting Washington Update: Complex Rehab Technology February 4, 2014 Cara Bachenheimer Senior Vice President, Government Relations Invacare.

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Presentation on theme: "GAMES/GRTC Winter Meeting Washington Update: Complex Rehab Technology February 4, 2014 Cara Bachenheimer Senior Vice President, Government Relations Invacare."— Presentation transcript:

1 GAMES/GRTC Winter Meeting Washington Update: Complex Rehab Technology February 4, 2014 Cara Bachenheimer Senior Vice President, Government Relations Invacare Corporation

2 Health Care in DC this year Observations On CRT Medicare Separate Benefit Category Other Medicare Issues Medicaid Activities Educational Tools Questions and Discussion Todays Topics 2

3 SGR/Doc fix/Physician payment reform bill SFC: Sen. Baucus leaving, Sen. Wyden likely moving in Ways and Means mark up Dec 12, 2013 Now: Senate Finance Committee December 12, 2013 mark-up Sen. Charles Schumer (D-NY) submitted CRT bill (S. 948) to Physician Payment Reform bill amendment list Later withdrawn Why is this significant? Health Care in DC 3

4 Increase CRT awareness…..what is it? Establish needed coverage, coding, standards, and payment changes with payers Enhance/develop data on clinical evidence and outcomes Build on advocacy involvement of consumers and clinicians Increase available financial support and other resources for advocacy and research Keys To The Future of CRT 4

5 Policy makers at federal, state, and private levels are more aware of CRT All CRT stakeholders are more engaged and that is building Exemption from Medicare Competitive Bidding Noble mission..…improving the quality of life for people with disabilities DC terminology: White Hat issue! Weve had some wins! Positive CRT Factors 5

6 Power WC Competitive Bid exemption Power WC purchase option retention Classifying K0005 and E1161 as CRT Competitive Bid exclusions of K0005 and E1161 Washington State CRT recognition Variety of Medicaid resolutions Past CRT Wins 6

7 First time event held last year - the week of August 19 th to 23 rd, 2013 Campaign took CRT message to Congress when they were home for August Recess Good participation for first year from CRT stakeholders…generated 11 co- sponsors Will be expanded and held annually National CRT Week 7

8 CRT is critical to the health and independence of people with complex disabilities CRT is specialized and individually configured like Orthotics/Prosthetics (custom braces/artificial limbs) These products and services are different than standard DME and need segregation Broad DME policies and codes do not address needs of people with disabilities H.R. 942 and S. 948 must be passed to provide needed distinction and solutions Message To Congress 8

9 Medically necessary and individually configured Manual and power wheelchair systems NOT what is seen on TV! Specialized seating and positioning systems Other adaptive items (standers, gait trainers) Requires evaluation, configuring, fitting, adjustment, training, or programming Provided through an interdisciplinary clinical and technology team (physician, therapist, ATP) Designed to meet the individual's specific and unique medical, physical, and functional needs Describing CRT 9

10 Congress gave a partial exemption from Competitive Bidding in 2008 (but that only protected CRT power wheelchairs) Congress maintained purchase option for complex rehab power wheelchairs in 2010 Recognition needs to be expanded through the establishment of a Separate Benefit Category for CRT Congress Has Said CRT Is Different 10

11 The Ensuring Access to Quality Complex Rehabilitation Technology Act of 2013 Creates separate Medicare DMEPOS benefit category for CRT and improves safeguards and access House bill H.R. 942 introduced in March 2013 by Representatives Joe Crowley (D-NY) and Jim Sensenbrenner (R-WI) Senate bill S. 948 introduced in May 2013 by Senators Chuck Schumer (D-NY) and Thad Cochran (R-MS) SBC Federal Bills 11

12 Creates separate category for CRT within the Medicare DMEPOS benefit (similar to O&P) Recognizes specific HCPCS codes as CRT and allows creation of new CRT codes as needed Eliminates the in-the-home restriction for CRT and adds functional considerations Expands clinical evaluation for CRT mobility Increases supplier standards regarding credentialed staff and repair capabilities Fully exempts CRT from competitive bidding Bill text and other info at Key Provisions of Legislation 12

13 House Bill - H.R co-sponsors 28 Republicans; 57 Democrats Georgia: Rep. Hank Johnson (D) Rep. John Barrow (D) Rep John Lewis (D) Rep Tom Price (R) Senate Bill - S Democrats; 2 Republicans See list by state at Support So Far 13

14 NCART hired DC actuarial firm (Dobson & DaVanzo) to estimate the cost Congressional estimates are typically made based on a 10 year projection Cost of the bill is estimated at $5 Million a year ($56 Million over 10 years) Does not include the impact of savings from improved access to CRT Congressional Budget Office (CBO) does official scoring Cost of Legislation 14

15 1)Need additional Senate and House co- sponsors, especially key committee members 2)Key committee staff 3)Congressional Budget Office score 4)Ultimate goal: get bills attached to larger Medicare-related legislation and passed in both chambers Legislative Road Map 15

16 SBC Headquarters at Sign-up for Updates Contacting Congress Sponsor Scorecard Advocacy Tools Dedicated SBC Website - Supporting Organizations - CRT Facts & Figures - SBC Proposal (detailed) - Other helpful documents - Call To Action - Legislation Info Pack - Intro to CRT Video - Legislation Text 16

17 Key documents all in one PDF file for ing and printing -- Pictorial Cover -- Reps. Crowley and Sensenbrenner letter -- Summary of Bill -- Sens. Schumer and Cochran announcement -- SBC Position Paper -- Complex Rehab vs Standard Mobility pictorial -- List of supporting consumer/clinician groups Download at CRT Legislation Information Pack 17

18 Grassroots is critical! All CRT stakeholders need to take action: Step 1- Go to Step 2- your Members of Congress Step 3- Follow up until your Members sign on Step 4- Spread the word (using the one page Call To Action) and get other CRT supporters engaged in our efforts Call To Action! 18

19 CRT power wheelchairs (Group 3 and above) are legislatively exempt H.R would expand Medicare CRT definition CRT manual wheelchairs (E1161, K0005, K0009) were excluded from Round 2 by CMS based on stakeholder advocacy Exemption/exclusion includes accessories and options supplied for these bases Suppliers must use modifiers when billing to get traditional fee schedule amounts- MLN Matters Bulletin 8181 CRT Items & Comp Bidding 19

20 Round 2 rules need further written clarification - Technically, certain repairs can be done by either contract or non-contract suppliers Repair vs. Replacement – some replacements can only be done by contract supplier See CMS Fact Sheet (Google ICN March 2013) CB items must be billed on assignment basis and supplier gets paid Single Payment Amount Labor and non-CB items can be billed non-assigned Active discussions underway with CMS WC Repairs & Comp Bidding 20

21 Issued in CMS Final ESRD Payment Rule November 22, 2013 Items currently paid for on-purchase basis CMS claims they dont meet original intent of purchase items, that they are $100 or less If the accessory is furnished with complex rehab equipment (K0835-K0864), the accessory will also have first month purchase option 50 of the 78 codes are wheelchair related Legislative pressure on CMS to address CMS Reclassifies 78 codes to Capped Rental 21

22 Effective Dates Vary – Whether Item is in Round 1 and/or Round 2: April 1, 2014: for items furnished in all areas of the country, if the item is not included in either Round of national competitive bidding – E1161 Adult Tilt-in-Space chair! July 1, 2016: for items furnished in all areas of the country, if the item is included in a Round 2 bid area and not in a Round 1 Re-compete and for items included in Round 1 Re- compete but furnished in an area other than one of the 9 Round 1 Re-compete areas, and January 1, 2017: for items included in a Round 1 Re-compete and furnished in one of the 9 Round 1 Re-compete areas CMS Reclassifies 78 codes to Capped Rental 22

23 The 78 codes 23

24 The 78 codes 24

25 The 78 codes 25

26 The 78 codes 26

27 PMD Prior Authorization Demonstration 3 year demo, began September 2012 esMD, 10 business days to initial response, 20 for resubmissions 7 states (CA, FL, IL, MI, NY, NC, TX) DME Providers Support! PMD Electronic Clinical Template Legislative expansion/acceleration? CMS PMD PA Demo 27

28 eDoC: Electronic Determination of Coverage Workgroup Office of National Coordinator for Health Information Technology in and industry stakeholders Goal: tools to facilitate provider documentation and communication PMD User story – approved October 30, 2013 Next: Pilot Phase CMS eDoC Initiative 28

29 State CRT separate recognition NCART National Medicaid Survey Movement to managed care plans DME Reuse/Refurbish Programs Legal advocacy resources available Medicaid 29

30 Remember, at state level - its about separate recognition not a separate category Can be accomplished in a variety of ways Strategy and actions are dependent on STATE laws and regulations Dont proceed without a plan State Separate Recognition 30

31 Supplier Standards- -- Increase level of qualifications to provide CRT -- Require service and repair capabilities Coding & Coverage- -- Segregate CRT products from standard DME -- Recognize specialized nature of CRT -- Base eligibility on medical AND functional needs Payment- -- Recognize significant services and required supplier personnel and infrastructure -- Provide funding to cover product AND service costs Minimum Recognition Specs 31

32 1)Identify specific changes needed (supplier standards, coverage, coding, payment) 2)Get stakeholder input and support (suppliers, manufacturers, clinicians, consumers, others) 3)Identify state contacts and potential champions and have initial discussions 4)Determine pathways (regulatory, legislative) 5)Identify actions and needed resources 6)Develop plan and timetable State Steps 32

33 Washington legislation- House Bill 144 passed and effective January 1, 2014 Other States with active Work Groups - Current State Activity -- California -- Colorado -- Connecticut -- Illinois -- New York -- North Carolina -- Oregon -- Oklahoma -- Pennsylvania -- Virginia 33

34 Medicare SBC materials NCART State Position Paper NCART State Outline NCART Legislation Templates NCART strategic advice and assistance Available State Resources 34

35 Everyone needs to be a CRT Advocate Education Materials section at Tools For Telling The CRT Story Separate Benefit Category Information CRT Facts and Figures The CRT Company (narrative, workflow, finances) CRT Delivery Process Many other helpful documents CRT Educational Materials 35

36 Entitled …. Complex Rehab Technology - Essential for Health. Essential for Life. Presents CRT from the perspectives of -- Individuals who use and rely on it -- Physicians who prescribe it -- Advocates who protect access Invest 10 minutes and get a great overview of CRT -- a must see for any policy maker Can be viewed and downloaded at Intro To CRT Video 36

37 Table of Contents: 1- Introduction 2- Types of Standing Devices 3- The Evaluation and Documentation Process 4- Funding Requests and Decisions 5- The Appeals Process 6- Glossary of Terms 7- NCART Workgroup Contacts 8- Other Resources and Links 9- Standing Device Evaluation Worksheet See Educational Material section at NCART Standing Device Guide 37

38 Questions and Discussion Cara C. Bachenheimer Invacare web site: Policy & Funding 38


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