Slide 1: Durable Medical Equipment (DME) Plan Presentations
March 8, 2022, Implementation Council Meeting
Slide 2: Plan Data Presentations - Background
The IC, working in collaboration with MassHealth and Plans in September, developed outlines for plan information data sharing on the following topics:
•	Personal Care Attendant (PCA) - authorizations for PCA hours
•	Massage Therapy - authorizations
•	DME - new purchase requests and repairs requests for:
   Power Beds, Power Wheelchairs, Electric Lifts, Ceiling Lifts, Other DME
•	Acupuncture - requests 
•	Nonmedical Transportation – authorizations

For each of these services, the IC asked plans to explain their utilization management process, define approvals, modifications, and denials for each presentation, break up data by One Care Rating Category, and to show data over time (for years 2018 – 2022).
Slide 3: Plan Data Presentation Timeline
•	September 2021: The IC, in collaboration with plans and MassHealth, started conversation on how plans can best share data on authorizations, modifications and denials for PCA hours, Acupuncture, and DME.
•	October 2021: Plans shared data on Personal Care Attendant (PCA) authorizations for PCA hours.
•	November 2021: Plans shared claims data for acupuncture.
o	Plans also pulled data on claims for DME but decided in conversation with the IC that it was not the best way to show DME usage.
•	February 2022: Plans shared information on the full UM process including the definition of medically necessary, the determination of need process, and the role of the care team in the UM process.
•	March 2022: Plans will continue the process of sharing data on DME as part of the IC’s ongoing efforts to develop action steps to strengthen the One Care model. 
Slide 4: March IC Meeting DME Data Presentation
Today’s presentations:
•	CCA and Tufts will provide data on DME approvals, modifications, and denials
•	CCA, Tufts, and United will share draft examples of the letter that goes to One Care members when DME requests are modified, denied or approved
Slide 5: Plan Presentations
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Slide 6: Lessons Learned
These are lessons learned from the DME presentations, however, they apply to all services.
•	It is not clear if plans are always providing members the “most generous” benefit available to them. 
•	Data for One Care services is not collected in the same way across the plans and is not regularly made available to the public. 
•	The relationship between the utilization management (UM) team, the care team, the care coordinator and the approval of services remains confusing. 
•	It is not clear how the plans are applying independent living philosophy to care plan creation and UM decisions.
Slide 7: Round Robin
The purpose of the Round Robin is to identify areas to inform action steps to better meet the need of One Care members.
•	Focusing on these presentations, what stood out to you the most as a point of action or a point needing further discussion? 
•	For example: 
o	Are there certain items in the letters that you found helpful to the consumer?
o	What information presented on approvals, modifications, or denials did you find most helpful?
Slide 8: Recommendations to MassHealth
Starting with DME, the IC is asking MassHealth to:
•	Require plans to demonstrate that approvals are based on member care plan health, wellness, and independence goals rather than on strict medical necessity and determination of need guidelines. 
•	Require plans to collect and share data in a uniform manner. 
o	Each plan collects data in a different way. It is important to ensure that data is collected in a uniform manner and is shared on a regular basis with the IC. 
•	Require increased transparency, for example on approvals, modifications, and denials.
o	Each plan should collect information on why requests are modified or denied and how decisions are made and share this information publicly in a format to be designed.
Slide 9: Proposed Standardized Letter Example
[Name], you and your care team requested an E&J Land Rover wheelchair including ultrahigh beam lights, tilt and recline system and solar battery run motors on September 1, 2021. After 3 denials and modifications due to failure of provision of appropriate administrative information, we have made a final decision on your requests using HCBS codes and evaluating your request to understand how it aligns with your care plan created with your care team.  We made the final decision about your request on November 1, 2021.
Final Decision: you and your care team requested an E&J Land Rover wheelchair including ultrahigh beam lights, tilt and recline system and solar battery run motors.
Approvals: the E&J Land Rover wheelchair you requested including the tilt and recline system because, as your care plan indicates you are a "heavy wheelchair user" and need the wheelchair in all climates (rain, snow etc.) and terrains (muddy trails) to maintain your independence in the community. The tilt and recline system has been approved because it meets our standard HCBS code requirements for a person with your level disability.
Modifications: your request for high beam lights has been modified to standard wheelchair lights, because it does not meet HCBS code standards and in consultation with your care team, have come to the decision that standard wheelchair lights will meet your needs, and
Denials: your request for solar battery run motors has been denied. Solar battery run motors are in the experimental stage of development and do not meet minimum safety standards.