Children and others with severe disabilities have been facing extraordinary delays in getting Medicaid approval for repairs or replacements for worn out or broken wheelchairs or for new equipment. These delays can make it impossible for people to get to work and can cause prolonged pain, damage to health, and physical injury.

Medicaid funding of "durable medical equipment" (DME) requires prior approval by the state Department of Health (DOH). The DOH Regional Medicaid Office in New York City, which handled all of the funding requests for New York City and Long Island, was closed in November 2004, with little public notice. Operations were moved to Albany. However, DOH admits it did not prepare staff for this change. As a result, a large backlog of funding requests was amassed. The Albany office has also been rejecting a large volume of applications, and is also frequently requiring additional and often unnecessary or duplicative information

In February, the Assembly Committee chairs met with DOH representatives and were assured that DOH was working to resolve the problems. However, significant problems, and possible violations of DOH regulations, remain. For example:

1) It takes too long to process requests. State regulations require DOH to issue a determination within 21 days, although providers report many claims extend beyond 21 days. Also, the rules now allow DOH to stop the 21-day clock simply by asking the applicant for more information. Many applicants report claims are returned three to four times before being approved or denied.

2) Guidelines are not clear. Despite a state rule that DOH make determinations based upon objective criteria and written guidelines, providers/vendors report they are unsure about the information they must submit in requests and what items DOH will approve.

3) DOH reviewers may be unqualified to assess what treatment and equipment is necessary.

Some of the issues witnesses may want to address are:

• Timelines for disposition of prior approval applications for durable medical equipment. How many were sent back for more information, how many approved or denied? Number of final determinations issued which exceeded 21 days? Compare experiences before the NYC Regional Office closure with experiences since then.

• Steps DOH has taken to improve this process, especially in regard to staffing and DME guidelines.

• Data on fair hearings requested, in process and resolved as a result of this process. More specifically, why they are requested, how long applicants wait for a hearing, how they are resolved, how many are still pending. Compare experiences before the NYC Regional Office closure with experiences since then.

• Pros and cons of closing of the NYC Regional Office.

• Clarity/suitability of state guidelines for prior approval requests for durable medical equipment. Are current guidelines clear and fair?

• Experiences with DOH staff reviewing funding requests, and steps taken to improve staffing level and training.

• Recommendations to improve this process.

Persons wishing to attend or present testimony at this hearing should complete and return the reply form as soon as possible, but no later than November 7, 2005. It is important the form be fully completed and returned so persons may be notified in the event of postponement or cancellation of the hearing.

Oral testimony will be limited to ten minutes in length. All testimony is under oath. In preparing the order of witnesses, the Committees will attempt to accommodate individual requests to speak at particular times in view of special circumstances. This request should be made on the attached reply form or communicated to Committee staff as soon as possible. Ten copies of any prepared statement should be submitted at the hearing registration table.

Testimony will be limited to individuals and organizations who did not testify at the previous hearing in New York City, except for individuals invited or requested to testify by the committees.

In order to meet the needs of those who may have a disability, the New York State Assembly, in accordance with its policy of non-discrimination on the basis of disability, as well as the Americans with Disabilities Act (ADA), has made its facilities and services available to all individuals with disabilities. For individuals with disabilities, accommodations will be provided, upon reasonable request, to afford such individuals access and admission to Assembly facilities and activities.

Questions about this hearing may be directed to Kathleen Fazio of the Assembly Oversight, Analysis and Investigation Committee staff at 518-455-3039 or faziok@assembly.state.ny.us.

DELAYS IN FUNDING OF DURABLE MEDICAL EQUIPMENT FOR PEOPLE WITH SEVERE DISABLITIES
REPLY FORM - PLEASE RESPOND BY MONDAY, NOVEMBER 7, 2005

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