| 18 | | - | (a) Customized wheelchairs shall be covered under the Medicaid program only when a standard wheelchair does not meet an individual's needs as determined by the Department of Social Services. Wheelchair repairs and parts replacements may be subject to review and approval by the department. Refurbished wheelchairs, parts and components shall be utilized whenever practicable for purchases made as part of (1) the Department of Rehabilitation Services program established pursuant to section 17b-661, and (2) the Birth-to-Three program established pursuant to sections 17a-248 to 17a-248h, inclusive. The Department of Social Services may designate categories of durable medical equipment in addition to customized wheelchairs for which reused equipment, parts and components shall be utilized whenever practicable. |
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| 30 | + | (1) "Complex needs patient" means an individual with significant physical or functional impairment resulting from a medical condition or disease including, but not limited to: (A) Spinal cord injury, (B) traumatic brain injury, (C) cerebral palsy, (D) muscular dystrophy, (E) spina bifida, (F) osteogenesis imperfecta, (G) arthrogryposis, (H) amyotrophic lateral sclerosis, (I) multiple sclerosis, (J) demyelinating disease, (K) myelopathy, (L) myopathy, (M) progressive muscular atrophy, (N) anterior horn cell disease, (O) post-polio syndrome, (P) cerebellar degeneration, (Q) dystonia, (R) Huntington's disease, (S) spinocerebellar disease, and (T) certain types of amputation, paralysis, or paresis. |
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| 31 | + | |
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| 32 | + | (2) "Complex rehabilitation technology" means products classified as durable medical equipment within the Medicare program as of January 1, 2013, that are individually configured for individuals to meet their specific and unique medical, physical, and functional needs and capacities for basic and instrumental activities of daily living. Complex rehabilitation technology includes, but is not limited to: (A) Complex rehabilitation manual and power wheelchairs and accessories, (B) adaptive seating and positioning items and accessories, and (C) other specialized equipment and accessories, such as standing frames and gait trainers. |
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| 33 | + | |
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| 34 | + | (3) "Employee" means a person whose taxes are withheld by a qualified complex rehabilitation technology supplier and reported to the Internal Revenue Service. |
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| 35 | + | |
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| 36 | + | (4) "Healthcare Common Procedure Coding System" or "HCPCS" means the billing codes used by Medicare and overseen by the federal Centers for Medicare and Medicaid Services that are based on the current procedural technology codes developed by the American Medical Association. |
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| 37 | + | |
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| 38 | + | (5) "Individually configured" means a device with a combination of sizes, features, adjustments or modifications that a qualified complex rehabilitation technology supplier is customized by the specific individual by measuring, fitting, programming, adjusting or adapting the device so that the device is consistent with the individual's medical condition, physical and functional needs and capacities, body size, period of need and intended use as determined by an assessment or evaluation by a licensed health care professional. |
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| 39 | + | |
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| 40 | + | (6) "Licensed health care professional" means a health care professional licensed by the state Department of Public Health who has no financial relationship with a qualified complex rehabilitation technology supplier. Licensed health care professional includes, but is not limited to: (A) a physician, (B) a physical therapist, (C) an occupational therapist, or (D) other licensed health care professional who performs specialty evaluations within the professional's scope of practice. |
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| 41 | + | |
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| 42 | + | (7) "Medically necessary" has the same meaning as provided in section 17b-259b of the general statutes. |
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| 43 | + | |
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| 44 | + | (8) "Mixed HCPCS codes" means codes that refer to a mix of complex rehabilitation technology products and standard mobility and accessory products. |
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| 45 | + | |
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| 46 | + | (9) "Pure HCPCS codes" means codes that refer exclusively to complex rehabilitation technology products and services. |
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| 47 | + | |
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| 48 | + | (10) "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. |
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| 49 | + | |
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| 50 | + | (11) "Qualified complex rehabilitation technology supplier" means a company or entity that: |
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| 51 | + | |
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| 52 | + | (A) Is accredited by a recognized accrediting organization as a supplier of complex rehabilitation technology; |
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| 53 | + | |
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| 54 | + | (B) Is an enrolled Medicare supplier and meets the supplier and quality standards established for durable medical equipment, including those for a complex rehabilitation technology supplier under the Medicare program; |
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| 55 | + | |
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| 56 | + | (C) Has at least one employee who is a qualified complex rehabilitation technology professional for each service location to (i) analyze the needs and capacities of complex needs patients in consultation with a licensed health care professional, (ii) participate in the selection of appropriate covered complex rehabilitation technology for such needs and capacities, and (iii) provide technology-related training in the proper use of the complex rehabilitation technology; |
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| 57 | + | |
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| 58 | + | (D) Requires a qualified complex rehabilitation technology professional be physically present for the evaluation and determination of appropriate complex rehabilitation technology for complex needs patients; |
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| 59 | + | |
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| 60 | + | (E) Has the capability to provide service and repair by qualified technicians for all complex rehabilitation technology it sells; and |
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| 61 | + | |
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| 62 | + | (F) Provides written information regarding how to receive service and repair of complex rehabilitation technology to the complex needs patient at the time such technology is delivered. |
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| 63 | + | |
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| 64 | + | (b) To the extent permissible under federal law, the Commissioner of Social Services shall (1) establish specific reimbursement and billing procedures within the state Medicaid program for individually configured complex rehabilitation technology products and services used by complex needs patients, and (2) ensure that Medicaid payments for such products and services ensures adequate access by complex needs patients and takes into account the significant resources, infrastructure, and staff needed to meet their needs. |
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| 65 | + | |
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| 66 | + | (c) When establishing reimbursement and billing procedures pursuant to subsection (b) of this section, the commissioner shall, not later than October 1, 2014: (1) Designate products and services included in mixed and pure HCPCS billing codes as complex rehabilitation technology, and as needed, create new billing codes or code modifiers for services and products covered for complex needs patients; (2) set minimum standards consistent with subdivision (11) of subsection (a) of this section in order for suppliers to be considered qualified complex rehabilitation technology suppliers eligible for Medicaid reimbursement; (3) allow complex rehabilitation technology to be billed to the state Medicaid program as a purchase and paid for in a lump sum payment; (4) establish a payment amount for medically necessary complex rehabilitation technology products and services of (A) not less than one hundred per cent of the current Medicare fee schedule amount, or (B) for such products or services individually considered for reimbursement or not covered by Medicare, an amount equal to the manufacturer's suggested retail price minus ten per cent; (5) incorporate into state Medicaid billing procedures Medicare HCPCS pricing code modifiers governing competitively bid complex rehabilitation technology that is added to noncompetitively bid base products; (6) exempt products or services billed under mixed or pure HCPCS codes from inclusion in any bidding, selective contracting, request for proposal, or similar initiative; (7) require complex needs patients receiving a complex rehabilitation manual wheelchair, power wheelchair, or seating component to be evaluated by a qualified health care professional and a qualified complex rehabilitation technology professional to qualify for reimbursement; and (8) make other changes as needed to protect access to complex rehabilitation technology for complex needs patients. |
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| 67 | + | |
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| 68 | + | (d) The commissioner shall, to the extent permissible under federal law, amend the Medicaid state plan to implement the provisions of this section. |
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| 69 | + | |
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| 70 | + | (e) The commissioner shall adopt regulations in accordance with the provisions of chapter 54 of the general statutes to implement the provisions of this section. |
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