NYS Medicaid Incontinence Supply Management Program Overview
The NYS Medicaid Incontinence Supply Management Program, initiated in August 2016, aims to improve the quality of incontinence products provided to all Medicaid members by establishing minimum quality standards, reducing costs, and maintaining existing provider networks. The program covers a range of incontinence supplies for Medicaid members aged three and above. Providers are reimbursed based on established Maximum Reimbursable Amounts (MRAs) regardless of the actual acquisition cost.
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NYS Medicaid Incontinence Supply Management Program August 2016
August 2016 2 NYS Medicaid Incontinence Supply Management Program History 2016 The 2013-2014 State budget adopted MRT recommendations, including an incontinence supply initiative Social Services Law Section 365-a (2)(g)(v) authorizes the Program This 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 3 NYS Medicaid Incontinence Supply Management Program Current 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 code
August 2016 4 NYS Medicaid Incontinence Supply Management Program Current 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 product In FFS, enrolled providers are reimbursed an established Maximum Reimbursable Amount (MRA) regardless of their actual acquisition cost by invoice In MMC and MLTC, providers are reimbursed in accordance with the plan s contract
August 2016 5 Table 1. Baseline Medicaid Utilization for Fee for Service and Managed Care Populations 2013 Statistics HCPCS Code Brief Description Annual Spending (in millions) Unique Members Units per year A4554 Disposable Underpads 22.13 83,915 86,530,471 T4521 Disposable Adult Small Diaper 2.22 7,737 5,035,360 T4522 Disposable Adult Medium Diaper 10.28 34,668 21,614,415 T4523 Disposable Adult Large Diaper 18.54 45,324 29,542,342 T4524 Disposable Adult Extra Large Diaper 10.95 26,467 16,477,462 T4529 Disposable Pediatric Small/Medium Diaper .03 218 95,548 T4530 Disposable Pediatric Large Diaper .43 1,456 1,300,799 T4533 Disposable Youth Diaper 1.86 5,442 5,191,114 T4535 Disposable liners/pads 9.15 55,132 36,363,469 T4537 Reusable Underpad, Bed Size 4.65 29,099 353,321 T4539 Reusable Diaper, any size 4.87 27,257 575,855 T4540 Reusable Underpad, Chair size 1.08 12,016 155,840 T4543 Disposable Bariatric Diaper (waist/hip >62 ) 1.04 1,615 879,841 A unit refers to an individual item (e.g.: 1 diaper = 1 unit)
August 2016 6 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 products Rewet rate of <2.0 g Rate of Acquisition (ROA) of <60 seconds Retention capacity of >250 g Presence 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 2016 7 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 standards
August 2016 8 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 specifications
August 2016 9 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 days Twin Med will not require a minimum unit order quantity. No additional delivery fees will be charged to the Medicaid providers based on order size It will not be mandatory for plans or Medicaid providers to purchase from the contracted preferred wholesale distributor
August 2016 10 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 request
August 2016 11 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 standards Verification 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 2016 12 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 line Twin Med s customer service support will provide live call support that is available during normal business hours of 9am to 5pm ET Twin 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 2016 13 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 offered Current pricing is in effect until 11/15/2020 Products may be ordered by internet, telephone or FAX All Medicaid providers will have access to Department negotiated pricing Pricing 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 2016 14 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 provider Twin Med will offer products in a full range of sizes representing all defined HCPCS code categories Twin 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 2016 15 NYS Medicaid Incontinence Supply Management Program Pricing (HCPCS codes in BOLD are subject to minimum quality standards) HCPCS CODE BRIEF DESCRIPTION CONTRACTED PRICE A4554 T4521 T4522 T4523 Disposable Underpads $0.15 Disposable Adult Small Diaper $0.25 Disposable Adult Medium Diaper $0.25 Disposable Adult Large Diaper $0.34 Disposable Adult Extra Large Diaper $0.41 T4524 T4529 Disposable Pediatric Small/Medium Diaper $0.16 T4530 T4533 Disposable Pediatric Large Diaper $0.28 Disposable Youth Diaper $0.32 T4535 Disposable liners/pads $0.15 T4537 Reusable Underpad, Bed Size $7.00 T4539 Reusable Diaper, any size $6.00 T4540 T4543 Reusable Underpad, Chair size $3.95 $0.65 Disposable Bariatric Diaper (waist/hip >62 )
16 NYS Medicaid Incontinence Supply Management Program Twin Med Formulary as of 8/1/2016 HCPCS T4521 Products T4530 First 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/CS ProCure 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/CS ProCure 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/CS ProCure 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/CS ProCure Products Reusable Chair Pad, Twill 60/CS ProCure Products Reusable Chair Pad, Plaid, 60/CS First Quality Prevail Briefs, Small, (20 -31 ) 96/CS Covidien Quilted Briefs, Small, (20 -31 ) 96/CS 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 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 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 First Quality Prevail Briefs, Youth, (15 -22 ) 96/CS First Quality Prevail Extra Underwear, Youth/Small, (20 -34 ) 88/CS 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/CS ProCure Fluff Underpad, (23 -36 ) 150/CS Covidien Tendersorb Fluff Underpad (23 -36 ) 150/CS First Quality Procare Fluff Underpad, (23 -36 ) 150/CS First 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 T4522 T4523 T4535 T4524 T4537 T4533 T4539 T4543 A4554 T4529 T4540
August 2016 17 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
18 NYS Medicaid Incontinence Supply Management Program Twin Med Contact information Telephone: 1-844-886-3369 (1-844-8TMEDNY) FAX: 1-844-986-3369 (1-844-9TMEDNY) Website: www.twinmedny.com
New York State Department of Health Bureau of Medical Review Office of Health Insurance Programs Division of OHIP Operations and Systems Riverview Center, 150 Broadway Menands, NY 12204 Email: ohipmedpa@health.ny.gov Phone: 1-800-342-3005
