NYS Medicaid Incontinence Supply Management Program History T he 20132014 State budget adopted MRT recommendations including an incontinence supply initiative Social Services Law Section 365a 2gv ID: 672542
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August 2016
NYS Medicaid Incontinence Supply Management ProgramSlide2
NYS Medicaid Incontinence Supply Management Program
History
The 2013-2014 State budget adopted MRT recommendations, including an incontinence supply initiativeSocial Services Law Section § 365-a (2)(g)(v) authorizes the ProgramThis initiative seeks to improve the quality of incontinence products provided to all Medicaid members by establishing minimum quality standards for adult and youth size diapers and reducing costs for incontinence products while maintaining the existing provider (Durable Medical Equipment and Pharmacy) network
August 2016
2016Slide3
NYS Medicaid Incontinence Supply Management ProgramCurrent Coverage, Utilization, and Management
Incontinence supplies are covered by Medicaid for ages three (3) and above, and include medically necessary reusable and disposable diapers, liners, and
underpads
Providers of incontinence products are nearly all for-profit enterprises and are reimbursed for these products on a per unit basis. In FFS, each billing (HCPCS) code has an assigned per unit Maximum Reimbursable Amount (MRA) Providers are reimbursed up to, but not exceeding the MRA for each HCPCS codeAugust 2016Slide4
NYS Medicaid Incontinence Supply Management ProgramCurrent Coverage, Utilization, and Management
Individual
and chain providers currently purchase incontinence related products through a variety of sources, with each provider paying varying unit rates for the same or similar
productIn FFS, enrolled providers are reimbursed an established Maximum Reimbursable Amount (MRA) regardless of their actual acquisition cost by invoiceIn MMC and MLTC, providers are reimbursed in accordance with the plan’s contractAugust 2016Slide5
Table 1. Baseline Medicaid Utilization for Fee for Service and Managed Care Populations – 2013 Statistics
HCPCS
Code
Brief DescriptionAnnual Spending (in millions)
Unique
Members
Units
per year
A4554
Disposable
Underpads
22.1383,91586,530,471T4521Disposable Adult Small Diaper2.227,7375,035,360T4522Disposable Adult Medium Diaper10.2834,66821,614,415T4523Disposable Adult Large Diaper18.5445,32429,542,342T4524Disposable Adult Extra Large Diaper10.9526,46716,477,462T4529Disposable Pediatric Small/Medium Diaper.0321895,548T4530Disposable Pediatric Large Diaper.431,4561,300,799T4533Disposable Youth Diaper1.865,4425,191,114T4535Disposable liners/pads9.1555,13236,363,469T4537Reusable Underpad, Bed Size4.6529,099353,321T4539Reusable Diaper, any size4.8727,257575,855T4540Reusable Underpad, Chair size1.0812,016155,840T4543Disposable Bariatric Diaper (waist/hip >62”)1.041,615879,841
August 2016
A unit refers to an individual item (e.g.: 1 diaper = 1 unit)Slide6
NYS Medicaid Incontinence Supply Management Program
Minimum Quality Standards for Incontinence Products
Beginning September 1, 2016, adult and youth sized diapers dispensed to all Medicaid members must meet the following minimum product specifications established by the Department of Health:
No plastic (non-breathable) backed productsRewet rate of <2.0 gRate of Acquisition (ROA) of <60 secondsRetention capacity of >250 gPresence of breathable zones with a minimum value of >100 cubic feet per minute (cfm)
Presence of a closure system which allows for multiple fastening and unfastening occurrences
These minimum standards apply to all products dispensed (Managed Care or Fee for Service)
August 2016Slide7
NYS Medicaid Incontinence Supply Management Program
Quality Standards – FFS and Managed Care
The quality standards for incontinence products will apply to all FFS, MMC, and MLTC members. MMC and MLTC plans will be required to ensure they offer products provided to members that meet the established Medicaid FFS minimum standards
Plans can choose to continue with their own contracts as long as the products dispensed meet the established quality standardsAugust 2016Slide8
NYS Medicaid Incontinence Supply Management Program
Preferred Vendor Contract
The NYS Department of Health has awarded a contract to Twin Med, LLC to become the preferred vendor of incontinence products for Medicaid providers
Medicaid providers who purchase incontinence supplies from Twin Med will receive competitive pricing as defined by the contract and a defined formulary that meets the new minimum product specificationsAugust 2016Slide9
NYS Medicaid Incontinence Supply Management Program
Preferred Vendor Contract
Twin Med, LLC will ensure that the Providers will receive all deliveries within three (3) business days of the date the order was placed.
They will have adequate inventory to ensure all deliveries are received within three (3) business daysTwin Med will not require a minimum unit order quantity. No additional delivery fees will be charged to the Medicaid providers based on order sizeIt will not be mandatory for plans or Medicaid providers to purchase from the contracted preferred wholesale distributor
August 2016Slide10
NYS Medicaid Incontinence Supply Management Program
Verification of Minimum Quality Standards
If products are purchased from Twin Med under the Program:
An enrolled Medicaid provider does not have to verify incontinence product quality standards Documentation demonstrating that the products meet the minimum quality standards will be maintained by Twin Med, LLC and available on requestAugust 2016Slide11
NYS Medicaid Incontinence Supply Management Program
Verification of Minimum Quality Standards
If products are
NOT purchased from Twin Med under the Program:The Medicaid providers will be responsible for verification that products dispensed meet the Department’s minimum quality standardsVerification must be through an independent testing laboratory facility
The Provider is responsible for keeping all verification documentation onsite
Documentation must be maintained for at least 6 years from the date of the order and produced to the NYS Department of Health or the Office of the Medicaid Inspector General when requested
August 2016Slide12
NYS Medicaid Incontinence Supply Management Program
Provider Ordering and Customer Support
Providers
will be able to place orders with Twin Med 24 hours per day, seven (7) days per week either online, via fax, or through a dedicated toll free phone lineTwin Med’s customer service support will provide live call support that is available during normal business hours of 9am to 5pm ETTwin Med will make product options, sizing/fit and minimum quality standards ratings available to Medicaid providers
A
complaint resolution process will be in place to address unanswered or unresolved questions and concerns. Email responses to the enrolled provider will be returned within two (2) business
days
August 2016Slide13
NYS Medicaid Incontinence Supply Management Program
Twin Med Formulary and Pricing
Pricing and the incontinence formulary may be found at www.twinmedny.com or www.emedny.org
The Twin Med formulary will be updated periodically to reflect current products that are offeredCurrent pricing is in effect until 11/15/2020Products may be ordered by internet, telephone or FAXAll Medicaid providers will have access to Department negotiated pricingPricing is based in HCPCS product code and is applied to all products in the published formulary that
meet the
description
Maximum
Reimbursable
Amounts (MRA) will be
adjusted in the future
to reflect the cost savings based on contract pricing
August 2016Slide14
NYS Medicaid Incontinence Supply Management Program
Products Offered
Twin Med will offer a minimum of two (2) products within each of the HCPCS code groups. All products will be guaranteed against defect. Any products found to be defective will be replaced at no cost to the network
providerTwin Med will offer products in a full range of sizes representing all defined HCPCS code categoriesTwin Med will make the product samples available to providers upon their request, free of charge. Sample products are meant to be used as representative of sizing and are NOT meant to be given to the member
August 2016Slide15
NYS Medicaid Incontinence Supply Management ProgramPricing
(HCPCS codes in BOLD are subject to minimum quality standards)
HCPCS CODE
BRIEF DESCRIPTIONCONTRACTED PRICEA4554
Disposable
Underpads
$0.15
T4521
Disposable
Adult Small Diaper
$0.25
T4522Disposable Adult Medium Diaper$0.25T4523Disposable Adult Large Diaper$0.34T4524Disposable Adult Extra Large Diaper$0.41T4529Disposable Pediatric Small/Medium Diaper$0.16T4530Disposable Pediatric Large Diaper$0.28T4533Disposable Youth Diaper$0.32T4535Disposable liners/pads$0.15T4537Reusable Underpad, Bed Size$7.00T4539Reusable Diaper, any size$6.00T4540Reusable Underpad, Chair size$3.95T4543Disposable Bariatric Diaper (waist/hip >62”)$0.65August 2016Slide16
NYS Medicaid Incontinence Supply Management Program
Twin Med Formulary as of 8/1/2016
HCPCS
Products
T4521
First Quality Prevail Briefs, Small, (20”-31”) 96/CS
Covidien Quilted Briefs, Small, (20”-31”) 96/CS
T4522
First Quality Procare Brief, Medium, (34”-44”) 96/CS
Nu-Fit Briefs Medium, (34”-44”) 96/CS
First Quality Procare Underwear, Medium (34”-46”) 80/CS First Quality Procare Plus Underwear, Medium, (34”-46”) 100/CS Covidien Quilted Briefs, Medium, (34”-44”), 100/CS
Covidien Surecare Underwear, Medium, (34”-48”) 80/CS
T4523
First Quality Procare Briefs, Large, (45”-58”) 72/CS
First Quality Nu-Fit Briefs, Large, (45”-58”) 72/CS
First Quality Procare Underwear, Large, (46”-58”) 72/CS
First Quality Procare Plus Underwear, Large, (46”-58”)
Covidien Simplicity Quilted Briefs, Large, (45”-58”) 72/CS
Covidien Surecare Underwear, Large, (44”-54”) 72/CS
T4524
First Quality Procare Briefs, X-Large, (59”-64”) 60/CS
First Quality Nu-Fit Briefs, X-Large, (59”-64”) 60/CS
First Quality Procare Underwear, X-Large, (58”-68”) 56/CS
First Quality Procare Plus Underwear, X-Large, (58”-68”) 100/CS
Covidien Simplicity Quilted Brief, X-Large, (59”-64”) 60/CS
Covidien Surecare Underwear, X-Large, (48”-66”) 56/CS
T4533
First Quality Prevail Briefs, Youth, (15”-22”) 96/CS
First Quality Prevail Extra Underwear, Youth/Small, (20”-34”) 88/CS
T4543
First Quality Procare Briefs, 2-XL, (62”-73”) 48/CS
First Quality Prevail Extra Underwear, 2-XL (68”-80”) 48/CS
Covidien Surecare Underwear, 2-XL (60”-80”) 48/CSA4554ProCure Fluff Underpad, (23”-36”) 150/CS Covidien Tendersorb Fluff Underpad (23”-36”) 150/CS First Quality Procare Fluff Underpad, (23”-36”) 150/CST4529First Quality Cuties Baby Diapers – Newborn 169/CS First Quality Cuties Baby Diapers – Size 1 200/CS First Quality Cuties Baby Diapers – Size 2 168/CS First Quality Cuties Baby Diapers – Size 3 144/CS
T4530First Quality Cuties Baby Diapers – Size 4 124/CS First Quality Cuties Baby Diapers – Size 5 108/CS First Quality Cuties Baby Diapers – Size 6 92/CS First Quality Cuties Baby Diapers – Size 7 80/CS First Quality Cuties Boy Training Pants – Size 2 104/CS First Quality Cuties Boy Training Pants – Size 3 92/CS First Quality Cuties Boy Training Pants – Size 4 76/CS First Quality Cuties Girl Training Pants – Size 2 104/CS First Quality Cuties Girl Training Pants – Size 3 92/CS First Quality Cuties Girl Training Pants – Size 4 76/CST4535ProCure Premium Absorbent Liners 4” x 10” 200/CS ProCure Premium Absorbent Liners 7” x 17” 200/CS First Quality Prevail Moderate Pads 9.25” 180/CS First Quality Prevail Moderate Long Pads 11” 144/CS Covidien SureCare Bladder Control Pads 4” x 10” 132/CS Covidien SureCare Bladder Control Pads 4” x 14” 168/CST4537ProCure Reusable Bed Pad, Twill 30” x 36” 24/CS ProCure Reusable Bed Pad, Twill 34” x 36” 24/CS ProCure Reusable Bed Pad, Plaid 30” x 36” 24/CS ProCure Reusable Bed Pad, Plaid 34” x 36” 24/CST4539ProCure Products Reusable Diaper, Medium 60/CS ProCure Products Reusable Diaper, Large 60/CS ProCure Products Reusable Diaper, X-Large 60/CS ProCure Products Reusable Diaper, 2XLarge 60/CS ProCure Products Reusable Fitted Brief, Medium, 24/CS ProCure Products Reusable Fitted Brief, Large, 24/CS ProCure Products Reusable Fitted Brief, X-Large, 24/CS ProCure Products Reusable Fitted Brief, 2XLarge, 24/CST4540ProCure Products Reusable Chair Pad, Twill 60/CS ProCure Products Reusable Chair Pad, Plaid, 60/CSSlide17
NYS Medicaid Incontinence Supply Management Program Audit and Complaint Investigation
The Department will incorporate incontinence product minimum quality standards into its routine pre and post payment reviews and other routine audit processes
The Department will also investigate any complaints received from members or other parties concerning Medicaid providers dispensing products which do not meet the established minimum quality standards
August 2016Slide18
NYS Medicaid Incontinence Supply Management ProgramTwin Med Contact information
Telephone: 1-844-886-3369 (1-844-8TMEDNY)
FAX: 1-844-986-3369 (1-844-9TMEDNY)
Website: www.twinmedny.comSlide19
New York State Department of Health
Bureau of Medical Review
Office of Health Insurance Programs
Division of OHIP Operations and SystemsRiverview Center, 150 Broadway Menands, NY 12204Email: ohipmedpa@health.ny.govPhone: 1-800-342-3005