SB0420sam001 99TH GENERAL ASSEMBLY

Sen. Heather A. Steans

Filed: 4/14/2016

09900SB0420sam001 LRB099 03252 KTG 47152 a

AMENDMENT TO SENATE BILL 420

AMENDMENT NO. ______. Amend Senate Bill 420 by replacing everything after the enacting clause with the following:

"Section 1. Short title. This Act may be cited as the Complex Needs Patient Act.

Section 5. Purpose.

(a) It is the intent of the General Assembly to:

(1) protect access for complex needs patients to important medically necessary complex rehabilitation technology (CRT) and supporting services;

(2) establish and improve safeguards relating to the evaluation, delivery, and repair of medically necessary complex rehabilitation technology;

(3) provide supports for complex needs patients to stay in the home or community setting, engage in basic activities of daily living and instrumental activities of daily living including employment, prevent hospitalizations, prevent institutionalization, and prevent other costly secondary complications; and

(4) provide adequate Medicaid payment for complex rehabilitation technology for the purpose of allowing continued access to medically necessary products and related services, including maintenance and repair.

(b) The General Assembly directs the Department of Healthcare and Family Services to establish focused rules and policies within the State Medicaid program for complex rehabilitation technology and to make other required changes to protect access to these specialized products and services.

Section 10. Definitions. As used in this Act:

(a) "Complex needs patient" means an individual with a diagnosis or medical condition that results in significant physical impairment or functional limitation. "Complex needs patient" includes, but is not limited to, individuals with spinal cord injury, traumatic brain injury, cerebral palsy, muscular dystrophy, spina bifida, osteogenesis imperfecta, arthrogryposis, amyotrophic lateral sclerosis, multiple sclerosis, demyelinating disease, myelopathy, myopathy, progressive muscular atrophy, anterior horn cell disease, post-polio syndrome, cerebellar degeneration, dystonia, Huntington's disease, spinocerebellar disease, and certain types of amputation, paralysis, or paresis that result in significant physical impairment or functional limitation. "Complex needs patient" does not negate the requirement that an individual meet medical necessity requirements under authority rules to qualify for receiving complex rehabilitation technology.

(b) "Complex rehabilitation technology" means items classified within the Medicare program as of January 1, 2015 as durable medical equipment that are individually configured for individuals to meet their specific and unique medical, physical, and functional needs and capacities for basic activities of daily living and instrumental activities of daily living identified as medically necessary. "Complex rehabilitation technology" includes, but is not limited to, complex rehabilitation manual and power wheelchairs and options/accessories, adaptive seating and positioning items and options/accessories, and other specialized equipment such as standing frames and gait trainers and options/accessories. The related Healthcare Common Procedure Code System (HCPCS) billing codes include, but are not limited to, any of the following:

(1) Pure Complex Rehabilitation Technology Codes: These HCPCS codes contain 100% complex rehabilitation technology products: E0637, E0638, E0641, E0642, E0986, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1011, E1012, E1014, E1037, E1161, E1220, E1228, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1239, E2209, E2291, E2292, E2293, E2294, E2295, E2300, E2301, E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2351, E2373, E2374, E2376, E2377, E2609, E2610, E2617, E8000, E8001, E8002, K0005, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, and K0898.

(2) Mixed Complex Rehabilitation Technology Codes: These HCPCS codes contain a mix of complex rehabilitation technology products and standard mobility and accessory products: E0950, E0951, E0952, E0955, E0956, E0957, E0958, E0960, E0967, E0978, E0990, E1015, E1016, E1028, E1029, E1030, E2205, E2208, E2231, E2368, E2369, E2370, E2605, E2606, E2607, E2608, E2613, E2614, E2615, E2616, E2620, E2621, E2624, E2625, K0004, K0006, K0007, K0008, K0009, K0040, K0108, and K0669.

(3) Future codes created to expand on or replace those listed in paragraphs (1) and (2).

(c) "Individually configured" means a device has a combination of sizes, features, adjustments, or modifications that a qualified complex rehabilitation technology supplier can customize to the specific individual by measuring, fitting, programming, adjusting, or adapting the device as appropriate so that the device is consistent with an assessment or evaluation of the individual by a qualified health care professional and consistent with the individual's medical condition, physical and functional needs and capacities, body size, period of need, and intended use.

(d) "Qualified complex rehabilitation technology professional" means an individual who is certified as an Assistive Technology Professional by the Rehabilitation Engineering and Assistive Technology Society of North America.

(e) "Qualified complex rehabilitation technology supplier" means a company or entity that:

(1) is accredited by a recognized accrediting organization as a supplier of complex rehabilitation technology;

(2) is an enrolled Medicare supplier and meets the supplier and quality standards established for durable medical equipment suppliers, including those for complex rehabilitation technology, under the Medicare program;

(3) employs as a W-2 employee at least one qualified complex rehabilitation technology professional for each location to:

(A) analyze the needs and capacities of the complex needs patient in consultation with qualified health care professionals;

(B) participate in the selection of appropriate complex rehabilitation technology for such needs and capacities; and

(C) provide technology-related training in the proper use of the complex rehabilitation technology;

(4) requires a qualified complex rehabilitation technology professional be physically present for the evaluation and determination of appropriate complex rehabilitation technology;

(5) has the capability to provide service and repair by qualified technicians for all complex rehabilitation technology it sells;

(6) maintains an adequate inventory of commonly used repair parts; and

(7) provides written information at the time of delivery of complex rehab technology regarding how the complex needs patient may receive service and repair.

(f) "Qualified health care professional" means a health care professional licensed by the State who has no financial relationship with the qualified complex rehabilitation technology supplier and includes, but is not limited to: (1) a licensed physician, (2) a licensed physical therapist, (3) a licensed occupational therapist, or (4) any other licensed health care professional who performs specialty evaluations within the professional's scope of practice.

Section 15. Creation of focused regulations and policies for complex rehabilitation technology.

(a) The Department of Healthcare and Family Services shall establish focused rules and policies for individually configured complex rehabilitation technology products and services. These focused rules and policies shall take into consideration the customized nature of complex rehabilitation technology and the broad range of services necessary to meet the unique medical and functional needs of people with complex medical needs by:

(1) designating current HCPCS billing codes listed in paragraphs (1) and (2) of subsection (b) of Section 10 as complex rehabilitation technology, and as needed, creating new billing codes or modifiers for services and products covered for complex needs patients;

(2) establishing specific supplier standards for companies or entities that provide complex rehabilitation technology and restricting the provision of complex rehabilitation technology to only qualified complex rehabilitation technology suppliers that meet such standards as defined in subsection (e) of Section 10;

(3) requiring complex needs patients receiving a complex rehabilitation manual wheelchair, power wheelchair, or seating component to be evaluated by:

(A) a qualified health care professional as defined in subsection (f) of Section 10 (such evaluation shall not be subject to any therapy cap); and

(B) a qualified complex rehabilitation technology professional as defined in subsection (d) Section 10;

(4) amending the Medicaid wheelchair repair policy to:

(A) not require a prior approval for wheelchair repair items that are typically replaced on an annual basis due to normal wear from daily use. For items so identified, such as tires, batteries, and upholstery, a prior approval shall not be required unless the quantity requested exceeds what would be typically required in a calendar year. The Department shall work with CRT suppliers and Medicaid beneficiary groups to determine appropriate annual quantity thresholds;

(B) if repairs can not be completed within 3 business days, and if the Medicaid beneficiary does not have a backup wheelchair, require that suppliers provide a functioning loaner wheelchair as soon as one is available. The Department shall provide an appropriate rental payment for these instances;

(C) inform Medicaid beneficiaries as to the agency or entity to which concerns or disputes with any part of this policy should be reported; and

(D) incorporate by reference the provisions of the Assistive Technology Warranty Act;

(5) maintaining payment policies and rates for complex rehabilitation technology to ensure payment amounts are adequate to provide complex needs patients with access to such items. The policies and rates shall take into account the significant resources, infrastructure, and staff needed to appropriately provide complex rehabilitation technology to meet the unique needs of complex needs patients and shall:

(A) provide that the HCPCS billing codes listed in paragraphs (1) and (2) of subsection (b) of Section 10 will maintain an allowed payment amount not less than 100% of the Medicare fee schedule amount being used by the Department on January 1, 2016 less 6%. If the medically necessary item is not covered by Medicare, or is individually considered for payment, then the State shall maintain an allowed payment amount equal to the item's Manufacturer's Suggested Retail Price minus 10%;

(B) preserve the option for complex rehabilitation technology to be billed and paid for as a purchase allowing for lump sum payments for devices with a length of need of one year or greater; and

(C) provide that State Medicaid billing procedures will incorporate Medicare HCPCS code modifiers governing competitively bid complex rehabilitation technology that is added to noncompetitively bid wheelchair bases;

(6) exempting the HCPCS billing codes listed in paragraphs (1) and (2) of subsection (b) of Section 10 from inclusion in any bidding, selective contracting, or similar initiative;

(7) requiring that Managed Care Medicaid plans adopt the rules and policies outlined in this Act and contract with any willing, qualified complex rehabilitation technology supplier; and

(8) making other changes as needed to protect access to complex rehabilitation technology for complex needs patients.

Section 99. Effective date. This Act takes effect July 1, 2016.".