AT3: AT Reuse & Medicaid Guidance for AT Act Programs

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Introduction to Medicaid and AT Reuse

The Senate Labor Health, Human Services, Education and Related Activities Subcommittee of the Senate Appropriations Committee issued report language regarding Assistive Technology Act Programs Reutilization Programs:

The Committee is encouraged that several State Medicaid Programs have developed assistive technology and durable medical equipment reuse programs. These programs retrieve and refurbish devices that were purchased with Medicaid funds, but are no longer being used by Medicaid recipients or other sources. Refurbished equipment may be reassigned to Medicaid members as a priority or to other eligible individuals who are disabled or elderly. CMS should encourage State Medicaid programs to partner with State Assistive Technology Act Programs to develop and implement reutilization programs with a goal of containing Medicaid costs.

Durable Medical Equipment (DME) is a high cost component of Medicaid Health Services. In 1990, CMS reported DME expenditure levels at $4.1 billion. In 2009, CMS reported DME expenditure levels at $34.9 billion. Clearly, managing growth in DME expenditures and engaging in activities that continue to support the DME needs of Medicaid beneficiaries is important. Several Assistive Technology (AT) Programs have partnered with their state Medicaid program in an attempt to manage DME costs. Since the purpose of an AT Program’s device reutilization service is to support the reuse of AT and/or DME that is no longer needed or used by its original owner, it made sense to forge such collaborations. DME needs that may be temporary in nature are ideally suited to the type of a program. Through reuse recipients obtain equipment at significantly lower cost or no cost, and states see DME costs are better managed. Assistive Technology device reutilization programs, which encompass Durable Medical Equipment, are one of four core activities the 56 federally-funded Assistive Technology (AT) Act Programs provide. The 2004 reauthorization of the AT Act required a common set of activities to be provided by all AT Act programs. Required state-level activities include AT device demonstration programs, AT device short-term loan programs, state financing activities and AT device reutilization programs.

How the partnerships work

  • The AT Program tracks the Medicaid purchases of specific DME items and recovers the equipment that is no longer being used.
  • DME items no longer being used, purchased through other funding sources, are also retrieved.
  • The AT Program works with local DME providers and/or trained staff to refurbish the equipment, restoring it to nearly new condition.
  • Then this DME can be reassigned to another Medicaid member or any citizen in need.
  • Considerable health care savings have occurred in the states where this arrangement exists.

Benefits of Medicaid partnerships with AT Act Programs

Additional benefits of a Medicaid partnership with AT program reutilization activities include:

  1. . Reusing DME helps manage Medicaid costs while also meeting the needs of persons with disabilities and the increasing aging population.
  2. . Access to needed technology improves the health and safety of persons with disabling and health conditions.
  3. . Access to technology helps keep individuals in less restrictive, less expensive environments.
  4. . The AT Programs providing reutilization programs are effective, efficient programs that receive high marks from the individuals receiving the lightly used equipment.
  5. . Reuse of quality equipment reduces consumption of natural resources and reduces use of landfills.

Years of experience with different models and the pursuit of improved standards of practice through the Indicators of Quality for Assistive Technology Reuse (IQ-ATR) make the AT Act Programs exceptional partners for Medicaid for safe, effective and appropriate reuse programs. AT Act Reuse Programs in Partnerships with Medicaid Summaries

Models of AT Act Reuse Programs

KANSAS DURABLE MEDICAL EQUIPMENT REUSE PROGRAM RAM, 2003

Program Name: The Kansas Equipment Exchange (KEE) Program Director: Dr. Sara Sack, Kansas University, Assistive Technology for Kansans Kansas has operated a durable medical equipment (DME) reuse partnership between the AT Act program and Medicaid successfully for over a decade. The Kansas Equipment Exchange (KEE) conducts a statewide equipment recovery campaign and accepts donations of lightly used DME obtained through public and private sources. All DME requests for Medicaid beneficiaries are first evaluated for new equipment, in the case that Medicaid coverage requirements are not met, the requested DME may be accessed from the reuse program. DME needs that may be temporary in nature are met by equipment accessed through the KEE program. Since 2003, the KEE program has received more than $10 million of durable medical equipment from private donors, and has refurbished and reassigned more than $8 million of used equipment. More than $1 million of equipment purchased by Medicaid has been recovered through the program, refurbished and reassigned to Kansans.

OKLAHOMA DURABLE MEDICAL EQUIPMENT REUSE PROGRAM RAM, 2012

Program Name: Oklahoma Durable Medical Equipment Reuse Program (OKDMERP) Program Director: Linda Jaco, Oklahoma State University, Oklahoma ABLE Tech Oklahoma’s reuse program, Oklahoma Durable Equipment Reuse Program (OKDMERP) in partnership with the Oklahoma Health Care Authority (Oklahoma Medicaid), began operations in 2012. DME is appropriately matched, reassigned and delivered to an Oklahoma resident in need. Priority is given to SoonerCare members, but other Oklahoma residents are eligible. Since 2012, the OKDMERP has resulted in nearly $3.5 million in healthcare savings to agencies and individuals. Over the period, 5,237 DME devices were reassigned including 2,503 devices to SoonerCare (Oklahoma Medicaid) members resulting in $1,055,581 in Medicaid savings.

SOUTH DAKOTA DURABLE MEDICAL EQUIPMENT REUSE PROGRAM RAM, 2017 Program Name: Program Director: EDIT: Kansas has operated a durable medical equipment (DME) reuse partnership between the AT Act program and Medicaid successfully for over a decade. The Kansas Equipment Exchange (KEE) conducts a statewide equipment recovery campaign and accepts donations of lightly used DME obtained through public and private sources. All DME requests for Medicaid beneficiaries are first evaluated for new equipment, in the case that Medicaid coverage requirements are not met, the requested DME may be accessed from the reuse program. DME needs that may be temporary in nature are met by equipment accessed through the KEE program. Since 2003, the KEE program has received more than $10 million of durable medical equipment from private donors, and has refurbished and reassigned more than $8 million of used equipment. More than $1 million of equipment purchased by Medicaid has been recovered through the program, refurbished and reassigned to Kansans.

Beginning the Conversation

Research shows that access to durable medical equipment (DME) improves health and safety, minimizes doctor visits and returns to hospitals, reduces or delays assisted living and nursing home placements, and enables some people and/or caregivers to keep working. Access to DME is not always available and those who cannot obtain it fail to experience the needed outcomes and quality-of-life improvements that DME can provide. Individuals who lack access may be uninsured or uninsured, or they may have coverage but experience delays in obtaining devices. For all of these individuals, the reutilization of lightly used DME has great value.

Know:

  1. . Who at Mediciad
  2. . What you can offer
  3. . How
  4. . When
  5. . Where

Talking Points with Medicaid

  • Reuse serves the uninsured and the under-insured. It can provide an interim solution for people with coverage who experience delays, or a secondary device to minimize the burden of transporting bulky devices to school or workplace. Safe, appropriate and effective reuse matches the beneficiary to the needed device, not “a device”.
  • Customer satisfaction surveys of reuse programs confirm that people in need of a device who lack financial means for timely access are “highly satisfied” to have a lightly used, refurbished device. Of 37,740 persons reporting from 56 states and territories, 89.3% reported that they were “highly satisfied” with the reused device.
  • Overall, reuse benefits all citizens by reducing the consumption of natural resources (raw materials and fuel) and minimizes environmental impact by keeping usable devices out of landfills.
  • The financial benefits of DME reuse are measurable using return-on-investment (ROI) analysis. Traditionally, this has used only the value of donated equipment and the cost of program operations in the computation. In 2011, the Kansas program returned $3.49 for every dollar spent. Some research has explored the inclusion of the value of preventing additional use of healthcare services into the ROI analysis.

Initial Considerations for Developing a Quality AT Reuse Program with Medicaid

  • Reuse programs need clear and concise policies and procedures for assessing whether a particular item is appropriate for reuse.
  • It is important to determine the safety and cost effectiveness of reuse of a particular device.
  • Factors for consideration include the age of the device, the type of use, the environment of use and possible impact of the method by which the device has been transported.
  • The type of repair or refurbishing required to sanitize the device or to restore it to original manufacturer specifications could render reuse financially impractical.
  • One category of devices that poses a challenge for reuse is complex rehabilitation technology (CRT). In this category are wheelchairs that are fitted, programmed, adjusted or adapted for the needs of a specific individual. Identifying another individual who requires identical customization is very different from reassigning standard devices without modification. Reusing these devices without a professional evaluation of the precise needs of another individual is unsafe. If a program chooses to reutilize complex rehabilitation technology, policies and procedures should be in place to use appropriate allied health professionals to assure that the equipment is appropriately matched to the needs of the individual.

The Pass It On Center has published Indicators of Quality for Assistive Technology Reutilization (IQ-ATR) that provide a more comprehensive exploration of a range of best practices that, if followed consistently by reuse programs, can provide safeguards to beneficiaries, reuse programs and third-party providers like Medicaid.

Ensuring Quality AT Reuse with Medicaid

The Pass It On Center has published Indicators of Quality for Assistive Technology Reutilization (IQ-ATR) that provide a more comprehensive exploration of a range of best practices that, if followed consistently by reuse programs, can provide safeguards to beneficiaries, reuse programs and third-party providers like Medicaid. The IQ-ATR developed in 2009, revised in 2017, address all areas of Program Operations. They are cited below in appropriate sections to describe the expected practices.

  • PARTNERSHIPS: AGREEMENTS, ROLES, RESPONSIBILITIES

The contract between Medicaid and the AT reuse program will specify roles and responsibilities. These will be clearly defined.

  • EQUIPMENT TRACKING

The program should have written policies and procedures and an accurate and efficient method to track the inventory of available devices that includes:

  1. Unique identification of every donated device (by paper label or bar code)
  2. The ability to determine the availability of devices by type
  3. The assignment of an inventory valuation to each device (often based on a percentage of the manufacturer’s suggested retail price)
  4. The ability to identify devices subject to recall notices
  5. The ability to identify customers who have received devices subject to recalls, market withdrawals or safety alerts

(IQ-ATR 3.4 - Device Tracking, IQ-ATR 3.5 - Device Valuation and IQ-ATR 3.6 - Management of Device Recalls, Market Withdrawals and Safety Alerts) The inventory system should be capable of capturing detailed specifications for equipment (e.g., manufacturer, model number, serial number, seat height, seat depth, weight limit for a manual wheelchair). This data facilitates the identification of appropriate equipment for specific needs. The program may formulate policies related to priority holds or wait-listing for the Medicaid program or other participants. Appropriate disposal of devices that have no more useful life can present a challenge to the reuse center, especially if those devices are electronic and/or digital. The components of many electronic devices are potential hazards to the environment if not disposed properly. When a device has no more useful life, or if some portions remain after it is cannibalized for spare parts, disposal of the device or parts must be done in a manner consistent with environmental regulations. Reuse programs should identify certified recycling resources. (IQ-ATR 3.17 - End-of-life Recycling)

  • SANITIZATION

When devices are acquired by an assistive technology reutilization center, one of the first priorities is to make those devices safe for use by other individuals. Steps should be taken immediately to minimize the potential transmission of disease. The best way to protect all individuals who will come into contact with reutilized equipment is to institute sanitization practices that make the objects safe to handle and to use. The recommended practices are based on manufacturer recommendations, guidelines from the CDC and the practical experiences of reuse programs in implementing these recommendations. (IQ-ATR 3.10 - Sanitization of Donated Equipment)


REFURBISHING, REPAIRING AND STORING DONATED DEVICES The program has written, device-specific procedures that are applied consistently for evaluating the repair and refurbishing needs of donated equipment (IQ-ATR 3.9 - Evaluation of Used Devices). Once identified, the refurbishment/repair of equipment must be performed in a manner that is consistent with manufacturer instructions and original specifications (IQ-ATR 3.11 - Refurbishing Donated Equipment). Programs offer a limited warranty on refurbished devices, often a 30-day warranty with a commitment to repair or replace the device if necessary (IQ-ATR 3.14 - Limited Warranty for Refurbished Devices). Appropriate storage facilities are essential to separate sanitized from unsanitized equipment; to organize storage of different types of devices; and to provide proper heating, cooling and ventilation as needed (IQ-ATR 3.15 - Storage of Donated Equipment). TRANSPORTATION Procedures and training are essential for picking up donated equipment or delivering refurbished devices (IQ-ATR 3.16 - Transportation of Donated Equipment). USER SERVICES User Services address the intake of the consumer at point of application for services, and interactions and services from the time the consumer is assigned a piece of equipment. PATIENT INFORMATION PRIVACY COMPLIANCE (HIPAA) As noted above, program staff should be trained in the privacy provisions of HIPAA. INTAKE AND ELIGIBILITY PROCESS Customer or patient intake may result from referral by a physician, hospital or other professional resource, or it may be the result of self-referral. Each program specifies eligibility requirements. The application for services should gather sufficient detail to determine eligibility (IQ-ATR 4.1 - Customer Intake). PRESCRIPTION REQUIREMENTS AND MATCHING DEVICES TO CUSTOMER As noted earlier, the reuse program should adhere to all prescription requirements. Appropriate device reuse for some categories requires appropriate matching of devices to customers based on medical prescriptions and the services of professionals (e.g., occupational therapists or other AT professionals) (IQ-ATR 4.2 - Matching Device to Customer). The customer and direct support provider(s) are informed of all appropriate device options and are allowed to participate in the choice of device (IQ-ATR 4.3 - Customer Choice). The customer and his direct support provider(s) are given basic training on features, operation, maintenance, safety and troubleshooting for the device at the time the device is reassigned (IQ-ATR 4.4 - Customer Training on Device). The customer is given a trial period with the device (IQ-ATR 4.5 - Customer Trial on Device). If the customer is unable to pick up the equipment, it may be delivered by trained staff. Some programs have limited transportation alternatives (IQ-ATR 4.7 - Equipment Delivery to Customer, IQ-ATR 4.8 - Trained Delivery Staff). If a new user experiences difficulty, he or she should be able to call for and receive technical assistance (IQ-ATR 4.6 - Technical Assistance). Programs should establish a follow-up protocol to ensure that the needed devices are being used and that the customer has not encountered difficulty (IQ-ATR 4.9 - Customer Follow-up).