1 ML Syringes Letter Of Medical Necessity Date________________________
Child’s Name _________________________
Child’s Medicaid ID # ___________________
Name of Caregiver _______________________
Quantity of 1 ml syringes ______________________
Reason child needs 1 ML syringes ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Treating physician’s signature _______________________________________
Date: ___________________________________________________________
*protip -In any hospital, the standard of care is syringes are for one time use. To avoid infection control, nurses are not cleaning and washing syringes. Parents across the country are forced to put clear nail polish over the numbers just to stretch syringes out for the month. For proper cleaning syringes would need to be boiled. This removes the writing. MMAs ignore the med chart completely. Despite they’re supposed to provide 31 syringes per size minimum, often, they send maybe 7. It’s customary for severely disabled children to require 5 meds with a 0.5 ml syringe among other sizes leaving family’s in a difficult position. Telling parents to pay out of pocket is skirting the laws. MMAs are fully aware of standard of care.
As mentioned earlier. Medical directors working for HMO(s) tend to be doctors with a general license to practice medicine so they KNOW infection risks of reusing syringes. Case managers are licensed RN(S) – from an ethical standpoint, the syringe shortage caregivers are faced with must be remedied. The reality in the home is Medicaid reimbursement rates are so little in the PDN sector, pushing the plungers in and out for 1 cleaning, nurses often quit. the more meds there are. MMA(s) cannot expect a child receiving multiple 4 meds requiring a 1 ml syringe to leave a room multiple times because it’s the only way to dispense meds. Diuretic spironolactone is known to cause birth defects and other health problems. For caregiver and staff safety, cleaning those syringes is a HAZARD. RNs working for the private sector make $55 an hour from a PDN agency whereas RNs working for PDN agencies work for $25-$28 an hour on a 1099 (No Benefits).
The result is nurses won’t show up to work because there is no incentive to. Despite patient abandonment laws, if nurses are forced to stay until relief shows up, when PDN agencies miss shifts, they quit the case often resulting in loss of employment because state regulatory agencies allowed the pay scale for nurses to get chopped in half Oct 2019. (long before covid).MD(s) writing for syringes should calculate how many meds are given in a day and write per SIZE of syringe required x’s 30. Each med chart is different, every med should get it’s own syringe for one time use.Please calculate and defer to the individual med chart before working with providers to ensure accuracy. Feel free to google peer review studies why syringes are for one time use in ‘standard of care’. Immunocompromised children definitely should not reuse syringes.
Medicaid is a federal program and any MMA participating in Medicaid must adhere to Federal legislation and ALL CMS guidelines. These studies can be added to your letters of medical necessity adding validity as per why the child qualifies for syringe. quantity asked for based on medchart.
DOJ civil rights division is in charge of ensuring inspector generals have state regulatory agencies comply with below federal laws, which includes proper quantities of DME.
The goal is to save taxpayer monies keeping the child out of the hospital.
These are but a few examples of how to fill out your letter of medical necessity.
Medicaid services
Mandatory services include:
Physicians Services
Laboratory/x-ray
In-patient, out-patient hospital and nursing facility
EPSDT
Family planning
FQHCs and rural health clinic services
Nursing facility services
Advanced Registered Nurse Practitioner Services
Home Health Care
The Federal laws cited:
42 CFR Subpart B – Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) of Individuals Under Age 21
§ 441.50 Basis and purpose.
§ 441.55 State plan requirements.
§ 441.56 Required activities.
§ 441.57 Discretionary services.
§ 441.58 Periodicity schedule.
§ 441.59 Treatment of requests for EPSDT screening services.
§ 441.60 Continuing care.
§ 441.61 Utilization of providers and coordination with related programs.
§ 441.62 Transportation and scheduling assistance.
-Americans with disabilities act sec 2, 5, and 7
-The Medicaid Act – sections 5&7
-CFR440.70
Laws used
42 CFR 441.15 Section 3
42 CFR Subpart B – Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) of Individuals Under Age 21
Defining the ‘T’ in “EPSDT”
In addition to screening, vision, dental and hearing services, the Medicaid Act defines the EPSDT benefit to include “necessary healthcare, diagnostic services, treatment, and other measures to correct or ameliorate defects, physical, mental illnesses and conditions.
If caregiver lives in the state of Florida, include below information.
For the state of Florida – -Smith Vs Benson (settled in the state of Florida).
In IJanuary 2010 , Smith vs Benson went to the supreme court for incontinence supplies.
This includes diapers, wipes, caths, chuckc. 40% zinc and nystatin ointment/powder heals bed sores with frequent turning q 2
q stands for every, the numbers stand for how many hours in a 24 hour period.
Supreme court ruled in favor of covering incontinence supplies
Smith VS Benson demonstrated the FEDERAL laws every state MMA must adhere to in order to run a medicaid or medicare plan in insert state.
https://casetext.com/case/smith-v-benson (Every caregiver) or administrator looking to ease the burden on discharge coordinators are invited to look over the laws and work them into hospital systems such as epic writing out templates for future letters of medical necessity.
Read carefully, in a fair hearing, a medical director (once an emergency room doctor) not a qualified G.I. will lie under oath and cite an amendment belonging to a case ‘Smith Vs Brown’. which has nothing to do with healthcare. Adjudicators in the state of Florida are clerks working for the dept of children and families. They are NOT trained in anatomy and physiology, from personal experience they cannot interpret basic legislation.
42 C.F.R. § 440.230
§ 440.230 Sufficiency of amount, duration, and scope
(a) The plan must specify the amount, duration, and scope of each service that it provides for –
(1) The categorically needy; and
(2) Each covered group of medically needy.
b) Each service must be sufficient in amount, duration, and scope to reasonably achieve its purpose.
(c) The Medicaid agency may not arbitrarily deny or reduce the amount, duration, or scope of a required service under §§ 440.210 and 440.220 to an otherwise eligible beneficiary solely because of the diagnosis, type of illness, or condition.
42 U.S.C. § 1396a
Section 1396a – State plans for medical assistance
A State plan for medical assistance must-
(1) provide that it shall be in effect in all political subdivisions of the State, and, if administered by them, be mandatory upon them;
State laws:
409.905 (Mandatory Medicaid coverage for disabled children below the age of 21)
Please review Florida state legislation 409.905 Mandatory Medicaid services legislation. Please review section 2 EPSDT and Section 4 of this legislation which is why Florida ruled in favor of Smith under Home Health Services. Scroll down to the section entitled ‘Home Health’.
https://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0400-0499/0409/Sections/0409.905.html
This includes all mandatory and optional services that the state CAN cover under medicaid, whether or not such services are covered for adults.
For example if the child needs personal care services to ameliorate a behavioral health problem, then ESPDT should cover the services to the extent the child needs them – even if the state places a quantitative limit on personal care services or does not cover them at all for adults.
See, AHCA Model Contract Attachment II, Exhibit II-‐A, at 5 regarding procedures managed care plans should follow and stating “authorization of any medically necessary service to enrollees under the age of twenty-‐one (21) years when the service is not listed in the service-‐specific Florida Medicaid Coverage and Limitations Handbook, Florida Medicaid Coverage Policy, or the associated Florida Medicaid fee schedule, or is not a covered service of the plan; or the amount, frequency, or duration of the service exceeds the limitations specified in the service-‐specific handbook or the corresponding fee schedule. The Managed Care Plan shall also include following language verbatim in its enrollee handbooks: [Insert Managed Care Plan name] must provide all medically necessary services for its members who are under age 21. This is the law. This is true even if [Insert Managed Care Plan name] does not cover a service or the service has a limit. As long as your child’s services are medically necessary, services have:
No dollar limits; or
No time limits, like hourly or daily limits.
https://ahca.myflorida.com/Medicaid/statewide_mc/mma_plans_mc.shtml (Here is the link) For the above information.