Q&A: Medicaid Makeover, Batteries Not Included

As States Battle to Balance Their Budgets, Will Mobility Be Sacrificed?

While new power chair codes and shifting documentation policies have put Medicare in the spotlight for much of 2005, mobility dealers and rehab technology suppliers know that shrinking state budgets have put Medicaid programs under fire. One notorious example: Missouri governor Matt Blunt caused turmoil earlier this year by suggesting that Medicaid stop paying for wheelchairs … or at least the batteries that power them.

Darren Jernigan, Permobil's director of government affairs, spent much of this year crossing the country to talk to those closest to Medicaid's most pressing issues. As 2005 comes to a close, we asked Jernigan for a year-end Medicaid report, and which states' programs should be carefully monitored in 2006.

Mobility Management: Which states have you recently visited to talk about Medicaid and mobility?
Darren Jernigan: Since 2004 we have been to and/or developed contacts in the following states: Alabama, Arkansas, Connecticut, Florida, Georgia, Illinois, Kentucky, Louisiana, Michigan, New Hampshire, North Carolina, Oklahoma, South Carolina and West Virginia. (At press time, Jernigan also had a Medicaid-themed trip planned to Albany, N.Y., in September.)

MM: When you're on these trips, whom do you talk to?
Jernigan: We usually get together with the director of policies of Medicaid in regard to DME. Once we have discussed issues such as HIPAA, codes, certification, best practices, etc., we then get an opportunity to speak directly to review nurses or consultants hired to do reviews.

What is surprising is that some of these individuals have never seen a power chair, much less sat in one and experienced what a tilt-and-recline seating option feels like for an end-user. State associations help out a great deal because all of this type of lobbying is a grass-roots effort.

MM: What are these people concerned about?
Jernigan: I think it is safe to say that the Medicaids are not concerned with the amount of money being spent, but more with if the beneficiary is getting the appropriate equipment. Why does a chair cost $25,000? (The reviewers say,) "Oh, I see," or "Oh, I didn't know that." It really is about educating reviewers on product, policies and practices. Fraud is a big issue, and every state is interested in certification and having qualified providers serving their beneficiaries. Some have even adopted a certification policy — Alabama, California, Georgia, Massachusetts and Tennessee.

Missouri Governor's Medicaid Actions Hit Mainstream Media

MM: What's the current Medicaid climate like?
Jernigan: There seems to be a lot of gloom and doom out there, and where some states are concerned, it is deservedly so. The answer is the same everywhere: "No money." Even with recent increases in revenues in Missouri, officials say that the state doesn't have the money to match additional funding. "The problem we have in this state is, when you don't have the money, it doesn't matter that if you spend $2, you get $5," State Sen. Kevin Engler (R-Farmington) said. "We have to balance the budget."

While states are not obligated to participate in the Medicaid program, if they do they must operate their programs in compliance with federal regulatory requirements. Missouri is considering pulling out of the program altogether. States like Missouri and Tennessee are starting to implement their own policies inconsistent with Title XIX of the Social Security Act, where Medicaid policy requirements for the states are dictated. And courts are backing them up in some regards. In Tennessee, the court has ruled that the state can determine what is medically necessary, not the doctor. States are starting to bypass CMS (the Centers for Medicare & Medicaid Services), acting on the grounds of state sovereignty and taking their chances with conservative courts. Tennessee has now pulled 323,000 folks off the (Medicaid beneficiary) rolls.

In fact, it is getting harder to fight back. The concept that Medicaid is an entitlement is hanging on by a thread. For instance, in a typical case, the U.S. Court of Appeals for the 9th Circuit, in San Francisco, said in August of this year that Medicaid recipients could not enforce the provision of the Medicaid law that promises them "equal access" to care and services. In establishing this guarantee, the court said, "Congress did not unambiguously create an individually enforceable right."

MM: Tell us the "hot spots" — i.e., the states that you're really concerned about — for 2006 and why mobility/rehab suppliers should be watching them.
Jernigan: Name a state, and I will show you a hot spot (Alaska, you're not included). Obviously, keep an eye on Missouri as they head to federal court. Tennessee may become a model on how to balance budgets. There are a few states that do well — Virginia, hats off to you. California has a small problem in that the state will pre-authorize and then the contracted organization administering MediCal will deny the item in question. Florida has 13 Medicaid regions in which some have stopped paying for batteries and tie-downs. Missouri has stopped paying for batteries and chargers, for crying out loud.

So keep up the good fight. Challenge everything you can get your hands on, and do not give up. States are so all over the board. Thirty-three states actually have definitions for medical necessity, as the federal government has failed to provide one for us. Each state has a manual on what its policies are and what they cover. Learn it, use their own words against them, and get those DME items reimbursed!

Missouri Governor's Medicaid Actions Hit Mainstream Media

Elected last November, Missouri Gov. Matt Blunt quickly alarmed Medicaid constituents when he moved to drastically cut funds to the state health-care program, pare beneficiaries from Medicaid rolls and stop funding "optional" equipment such as wheelchairs and prosthetics.

While rehab organizations moved to educate the governor — for instance, United Seating & Mobility, headquartered in Earth City, Mo., sent a series of consumer case studies to Blunt — Missouri's mainstream media also took note. One such commentary, by Columbia Daily Tribune columnist Tony Messenger, was titled "Governor's Plan to Avoid Disabled Turns to Nightmare."

The column is structured as a would-be bedtime story that Blunt — 34 years old and a new father — reads to his young son. The children's fable, Messenger writes, is called "The Tale of the Wheelchair People," and is "a chilling story of a period in our country's history when we let disabled people have jobs, gave them access to decent health care and even, gasp, allowed them access to public meetings."

The fable starts out with the "prince from southwest Missouri" ascending his new throne, only to find the state in financial straits. So he turned to "an easy target: The Wheelchair People." Those people, the tale says, "had been allowed to gain strength because previous governors were weak and would not send them away. Instead, they plied them with gifts, even paying for their wheelchairs and offering them employment … Before we knew it, there were laws protecting them and forcing the good and decent barons of business to have to build ramps for all the wheelchairs the state had purchased."

The prince planned, the story says, to "cut their funding so that the sidewalks of Missouri would once again be safe for good, hard-working people."

Contacted at his Tribune office, Messenger called reader response to this Aug. 2 column "amazing. More than I've received on almost any column I've written. Really hit a nerve." In fact, Messenger says he plans a follow-up column featuring "a local veterinarian who uses a wheelchair, about what her life and economic contribution to society would be like without some state help along the way of her life path."

To read Messenger's full column about "The Wheelchair People," go to http://archive.columbiatribune.com/2005/aug/20050802feat003.asp.

This article originally appeared in the October 2005 issue of Mobility Management.

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