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

GAMES/GRTC Winter Meeting

Washington Update: Complex Rehab Technology

February 4, 2014

Cara BachenheimerSenior Vice President, Government

Relations Invacare Corporation

* Health Care in DC this year

* Observations On CRT

* Medicare Separate Benefit Category

* Other Medicare Issues

* Medicaid Activities

* Educational Tools

* Questions and Discussion

Today’s Topics

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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Later withdrawn Why is this significant?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

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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

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* 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!* We’ve had some wins!

Positive CRT Factors

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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

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First time event held last year - the week of August 19th to 23rd , 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

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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

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* 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

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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

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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

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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 www.access2crt.org

Key Provisions of Legislation

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House Bill - H.R. 942 85 co-sponsors28 Republicans; 57 DemocratsGeorgia: Rep. Hank Johnson (D)

Rep. John Barrow (D)Rep John Lewis (D)Rep Tom Price (R)

Senate Bill - S. 948 5 Democrats; 2 Republicans

See list by state at www.access2crt.org

Support So Far

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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

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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

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SBC Headquarters at www.access2crt.org

“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

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Key documents all in one PDF file for emailing 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 www.access2crt.org

CRT Legislation Information Pack

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Grassroots is critical! All CRT stakeholders need to take

action:

Step 1- Go to www.access2crt.org

Step 2- Email 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!

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CRT power wheelchairs (Group 3 and above) are legislatively exempt

H.R. 1717 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

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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 905283 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

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Issued in CMS Final ESRD Payment Rule

November 22, 2013

Items currently paid for on-purchase basis

CMS claims they don’t 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

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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

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The 78 codes

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HCPCS Brief Description Included in NCB

Round 2

Included in NCB 1

Recompete

Item billable as “purchase” when provided with

Complex Rehab power wheelchair

A4639 Infrared heat system replacement pad. A7025 Replace chest compress vest E0117 Underarm spring assist crutch E0140 Walker with trunk support x x E0144 Enclosed walker with rear seat E0149 Heavy duty wheeled walker x x E0197 Air pressure pad for mattress x E0198 Water pressure pad for mattress E0300 Enclosed pediatric crib hospital grade E0457 Chest shell E0620 Capillary blood skin piercing device laser E0656 Segmental pneumatic trunk E0657 Segmental pneumatic chest E0740 Incontinence treatment system E0760 Osteogenesis ultrasound stimulator E0762 Trans elec jt stim dev system E0764 Functional neuromuscular stimulation E0849 Cervical pneumatic traction equipment E0855 Cervical traction equipment

The 78 codes

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HCPCS Brief Description Included in NCB

Round 2

Included in NCB 1

Recompete

Item billable as “purchase” when provided with

Complex Rehab power wheelchair

E0856 Cervical collar w air bladder E0955 Cushioned headrest x x E0984 Add power tiller E0985 Wheelchair seat lift mechanism x E0986 Manual wheelchair push-rim power

assist x

E1002 Power seat tilt X E1003 Power seat recline X E1004 Power seat recline mechanism X E1005 Power seat recline power X E1006 Power seat combo w/o shear X E1007 Power seat combo w/shear X E1008 Power seat combo power shear X E1010 Add power leg elevation X E1014 Reclining back add ped w/c E1020 Residual limb support system x x E1028 Wheelchair manual swingaway x x E1029 Wheelchair vent tray fixed E1030 Wheelchair vent tray gimbaled X E1161 Manual adult wheelchair w tilt in space

The 78 codes

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HCPCS Brief Description Included in NCB

Round 2

Included in NCB 1

Recompete

Item billable as “purchase” when provided with

Complex Rehab power wheelchair

E1232 Folding pediatric wheelchair tilt-in-space.

E1233 Rig pediatric wc tilt in space w/o seat. E1234 Fld pediatric wc tilt in space w/o seat. E1235 Rigid pediatric wheelchair adjustable. E1236 Folding pediatric wc adjustable. E1237 Rigid ped wc adjustable w/o seat. E1238 Fld ped wc adjstable w/o seat. E1700 Jaw motion rehab system. E2227 Gear reduction drive wheel. E2228 Mwc acc, wheelchair brake. x E2310 Electro connect btw control X E2311 Electro connect btw 2 system X E2312 Mini-prop remote joystick X E2313 PWC harness, expand control X E2321 Hand interface joystick X E2322 Mult mech switches E2325 Sip and puff interface X E2326 Breath tube kit X E2327 Head control interface mechanism X

The 78 codes

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HCPCS Brief Description Included in NCB

Round 2

Included in NCB 1

Recompete

Item billable as “purchase” when provided with

Complex Rehab power wheelchair

E2328 Head/extremity control interface. X E2329 Head control interface nonproportional X E2330 Head control proximity switch X E2351 Electronic SGD interface X E2368 Pwr wc drivewheel motor replace x x E2369 Pwr wc drivewheel gear box replace x x E2370 Pwr wc dr wh motor/gear comb x x E2373 Hand/chin ctrl spec joystick X E2374 Hand/chin ctrl std joystick X E2375 Non-expandable controller x E2376 Expandable controller, replace X E2377 Expandable controller, initial X E2378 Pw actuator replacement E2500 SGD digitized pre-rec <=8min. E2502 SGD prerec msg >8min <=20min. E2504 SGD prerec msg >20min <=40min. E2506 SGD prerec msg > 40 min. E2508 SGD spelling phys contact E2510 SGD w multi methods messg/access K0015 Detach non-adjus hght armrest x x K0070 Rear whl complete pneum tire x x K0607 Repl battery for AED K0730 Ctrl dose inh drug delivery system

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

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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

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State CRT separate recognition

NCART National Medicaid Survey

Movement to managed care plans

DME Reuse/Refurbish Programs

Legal advocacy resources available

Medicaid

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* Remember, at state level - it’s 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

* Don’t proceed without a plan

State Separate “Recognition”

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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

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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

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* 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

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* Medicare SBC materials

* NCART State Position Paper

* NCART State Outline

* NCART Legislation Templates

* NCART strategic advice and assistance

Available State Resources

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* Everyone needs to be a CRT Advocate

* Education Materials section at www.ncart.us* 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

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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 www.ncart.us

Intro To CRT Video

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Table of Contents:1- Introduction2- Types of Standing Devices3- The Evaluation and Documentation Process4- Funding Requests and Decisions5- The Appeals Process6- Glossary of Terms7- NCART Workgroup Contacts8- Other Resources and Links9- Standing Device Evaluation Worksheet

See Educational Material section at www.ncart.us

NCART Standing Device Guide

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Questions and Discussion

Cara C. [email protected]

440-329-6226

Invacare web site: Policy & Funding

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