Complex Rehab Technology. Federal Issues and Legislation. ROCH 2015 Marriott Marquis June 8, 2015

Transcription

1 Complex Rehab Technology Federal Issues and Legislation ROCH 2015 Marriott Marquis June 8,

2 CRT Overview 2

3 What Is CRT Medically necessary and individually configured: -- Specialized manual and power wheelchair systems (Not what is seen on TV!) (Only 9% of Medicare WCs) -- Adaptive seating and positioning systems -- Other specialized items (standing devices, 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 3

4 Manual WCs - Complex vs. Standard Complex Manual WCs - 5% of Medicare Intended for long-term use High Adjustability Provides Positioning Accommodates Orthopedic Needs Provides Pressure Management Standard Manual WCs - 95% of Medicare Intended for short-term use Minimal to Zero Adjustability Provides NO Positioning NO Accommodation of Orthopedic Needs Provides NO Pressure Management 4

5 Power WCs - Complex vs. Standard Complex Power WCs - 22% of Medicare NOT what s advertised on TV Intended for Progressive Diagnoses Advanced Electronics and Controls Provides Positioning Accommodates Orthopedic Needs Provides Pressure Management Offers Ventilator Accommodation Standard Power WCs - 78% of Medicare Intended for Ambulatory Limitations Basic Joystick Drive ONLY Provides NO Positioning NO Accommodation of Orthopedic Needs Provides NO Pressure Management NO Ventilator Accommodation 5

6 CRT SBC Legislation The Ensuring Access to Quality Complex Rehabilitation Technology Act of 2015 Creates Medicare DMEPOS separate benefit category (SBC) for CRT and improves safeguards and access House bill H.R reintroduced in March 2015 by Representatives Jim Sensenbrenner (R-WI) and Joe Crowley (D-NY) Senate bill S reintroduced in May 2015 by Senators Thad Cochran (R-MS) and Chuck Schumer (D-NY) 6

7 Legislation Details 1. Creates separate category for CRT within the Medicare DMEPOS benefit (like Orthotics & Prosthetics) 2. Designates specific HCPCS codes as CRT and allows creation of new CRT codes as needed 3. Eliminates the in-the-home restriction for CRT and adds functional considerations 4. Increases CRT supplier standards: enhanced ATP staff credential; required repair capabilities and notice 5. Expands clinical evaluation to all CRT mobility 6. Allows nursing home residents to access CRT if part of move to community residence 7. Clarifies exemption of CRT from competitive bidding 7

8 Why SBC Is Needed Access to CRT is threatened because its differences from DME are not recognized Changes are needed (coding, coverage, standards) to fully recognize the specialized nature of CRT and the medical and functional needs of the individuals who rely on it A Separate Benefit Category (SBC) will improve and protect access within Medicare and then flow to Medicaid and other payers 8

9 Message To Congress 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 overlook individual needs of people with disabilities H.R and S must be passed to provide needed distinction and improvements 9

10 Precedent Congress Has Recognized CRT Is Different Congress gave partial exemption from Competitive Bidding in 2008 (but that only protected one class of CRT) Congress exempted complex power wheelchairs from inclusion in capped rental legislation in 2010 Recognition needs to be expanded through establishment of Separate Category for CRT 10

11 Broad Support from National Consumer/Clinician Groups Over 50 national groups signed on: United Spinal Association, ALS Association, American Association of People with Disabilities, National Multiple Sclerosis Society, National Council on Independent Living, Paralyzed Veterans of America, Christopher and Dana Reeve Foundation, and many others Full list of groups in your folders 11

12 SBC Key Talking Points CRT is critical to people with high level disabilities to meet their medical needs and maximize function and independence Small population of people/products that need distinction (only 9% of Medicare wheelchairs) Bill will improve CRT access and elevate standards and safeguards to protect the Medicare program and beneficiaries Bill has strong bipartisan Congressional support and broad support from national consumer and medical professional groups 12

13 Co-Sponsors at House bill H.R has 97 Reps. signed on Republicans and 48 Democrats on House Ways & Means Committee on House Energy & Commerce Committee (168 members signed on in 2014) Senate bill S has 8 Sens. signed on -- 4 Democrats and 4 Republicans -- 3 on Senate Finance Committee (22 members signed on in 2014) See full list, by state in your folders 13

14 Is the bill the same as last year? Only minor changes.. Reinstate purchase option for certain CRT items (rather than only rent) - actually SAVES money - less expensive to purchase when need is over 12 months Excludes required PT/OT CRT Evaluation from therapy cap- this is a NEW safeguard that should not be limited 14

15 Cost of Legislation A Washington DC actuarial firm (Dobson & DaVanzo) was hired to estimate the cost Congressional estimates are typically made based on a 10 year projection The cost of the bill is estimated at approx. $5 Million a year ($56 Million over 10 years) Does not include the impact of savings from improved access to CRT We are awaiting Congressional Budget Office (CBO) to do official scoring 15

16 Competitive Bid Pricing Applied to CRT Effective 1/1/16 CMS intends to apply pricing from the Medicare Competitive Bidding program to accessories used on CRT wheelchairs Impacts 171 wheelchair accessory codes with payment reductions ranging from 20% to over 50% Since 2008 CRT wheelchairs and accessories have been exempted/excluded from Comp Bidding This goes against Congressional legislation and subsequent CMS policies Will result in MAJOR disruption in access to individually configured CRT manual and power wheelchairs 16

17 Comp Bid Pricing (cont d) This has widespread access issues--will extend beyond Medicare to Medicaid and private health insurance programs 101 Members of Congress have sent letter to CMS asking them to RESCIND this policy change and retain current payment levels If CMS does not voluntarily rescind, Congress will need to take legislative action to prevent major access disruptions 17

18 Medical Necessity Documentation Challenges 18

19 CRT From The Consumer s Perspective 19