BILL NUMBER: S1616

SPONSOR: RIVERA
 
TITLE OF BILL:

An act to amend the social services law, in relation to providing parity
to durable medical equipment providers by requiring Medicaid managed
care organizations to reimburse such providers at no less than one
hundred percent of the medical assistance durable medical equipment and
complex rehabilitation technology fee schedule for the same service or
item

 
PURPOSE:

This bill provides parity to durable medical equipment providers by
requiring Medicaid-managed care organizations to reimburse such provid-
ers.

 
SUMMARY OF PROVISIONS:

Section 1 amends subdivision 4 of section 364-j of the Social Services
Law, as it relates to the coverage of durable medical equipment and
              

related supplies, to require managed care providers to pay, directly or
indirectly, for durable medical equipment, prosthetics, orthotics, and
other related supplies at no less than one hundred percent of the Medi-
caid durable medical equipment and complex rehabilitation technology fee
schedule.

Section two of the bill relates to the effective date.

 
JUSTIFICATION:

Durable Medical Equipment (DME) is equipment that is considered
medically necessary as prescribed by a physician for use in a patient's
home. DME includes equipment such as wheelchairs, powered mobility
devices, hospital beds, oxygen systems, ventilators, respiratory care
supplies, orthotics, and prosthetics. For Medicaid consumers with a
disability, DME can improve safety while decreasing the need for care-
giver assistance. It can substantially improve overall quality of life
by increasing a consumer's independence with functional mobility and
activities of daily living (ADLs). Medicaid members who use DME services
may regain independence in the hopes of returning to their prior level
of function and home environment rather than needing costly institu-
tional care.

In recent years, Medicaid managed care organizations (MCO) have reduced
reimbursement on DME products to unsustainable levels. Many MCOs reim-
burse DME providers less than half of the Medicaid fee-for-service fee
schedule for identical devices and supplies paid in the fee-for-service
system. This reimbursement reduction is compounded by the fact that the
majority of their members are enrolled in a Medicaid Managed Care Plan,
which comprises approximately 75 percent of their revenue.

This MCO rate reduction has caused numerous access issues throughout the
state. Medicaid consumers and their physicians face challenges in find-
ing a DME supplier. Over 20 percent of providers have closed in recent
years, and twelve counties do not have a DME location. Without
reimbursement parity, additional DME providers will not survive and

consumers will no longer be able to access medically necessary services
and supplies.

The requirement of parity has been enacted in other areas of the Medi-
caid program, including behavioral health. In addition, other States
have implemented payment parity legislation and have established rate
floors, including Virginia, Kentucky, and North Carolina.

 
LEGISLATIVE HISTORY:

2021-2022: S5118-A Rivera/A5368-A McDonald

2023-2024: S3468 Rivera/A3408 McDonald

 
FISCAL IMPLICATIONS:

No fiscal.

 
EFFECTIVE DATE:
This act shall take effect on the ninetieth day after it shall have
become law.