Quarterly Newsletter Supplement: Notification of Changes for Medicaid DME Services

Optima Health has received notice from the Virginia Department of Medical Assistance Services (DMAS) of its intention to implement a rate floor for durable medical equipment (DME), orthotics, prosthetics and supplies as a result of General Assembly action item #313 MMMM (“Action Item”).

Notification of Changes for Medicaid DME Services

Sentara Health Plans/Optima Health is notifying you that our provider agreements are amended (pursuant to the Change of Law provision and/or the terms of the Medicaid Addendum) to comply with DMAS' instructions and the Action Item by adding the following new provision, effective on July 1, 2021:

Effective 7/1/2021, as it pertains to services rendered to Virginia Medicaid members, any reimbursement rates for DME services that are below the DME floor rate shall be amended to the DME floor rate. "DME floor rate" is defined as ninety (90) percent of the Fee-For-Service Medicaid fee schedule rate for all DME services. In cases where there is no rate available, the reimbursement methodology set forth in 12VAC30-80-30.A(6) will be used to determine and define DME Floor Rate.

In the event SHP and DME providers enter into a mutually agreed upon a Value Based Purchasing ("VBP") or Alternative Payment Methodology ("APM") (including, but not limited to, risk-based payment arrangements and per-member per-month payment arrangements), the VBP or APM payment must not fall below ninety (90) percent of the Fee-For-Service rate per item. Except for the reimbursement methodology in cases where there is no rate available, this change does not apply to any items or services for which the contracted rate is equal to or above the DME Floor Rate. Also, this change does not apply to items and services not addressed by the DME Floor Rate.

Questions?

If you have any questions about this announcement, please contact your network educator or contract manager at 877-865-9075.