DAR File No. 31505

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-70

Medical Supplies, Durable Medical Equipment, and Prosthetic Devices

NOTICE OF PROPOSED RULE

DAR File No.: 31505
Filed: 05/30/2008, 02:51
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to repeal and reenact Rule R414-70 to clarify mandatory and optional services for medical supplies, durable medical equipment, and prosthetic devices.

Summary of the rule or change:

The reenacted rule clarifies eligibility requirements for mandatory and optional services. It also refers Medicaid clients to the Medical Supplies Manual and List where the criteria to receive optional services are found. The previous rule listed in general terms some of the services and criteria provided as well as a list of some noncovered items. The reenacted rule also specifies criteria for nursing facility residents. Finally, the Department may provide, at its discretion, services not described in the Medical Supplies Manual and List based on criteria set forth in the rule.

State statutory or constitutional authorization for this rule:

Sections 26-1-5 and 26-18-3

Anticipated cost or savings to:

the state budget:

No significant impact to the state budget is expected. The rule clarifies ongoing Medicaid policy for medical supplies, durable medical equipment, and prosthetic devices. The majority of Medicaid recipients will receive the same services under this rule. On balance it is expected to be budget neutral.

local governments:

There is no budget impact because local governments do not fund or provide medical supplies, durable medical equipment, and prosthetic devices to Medicaid clients.

small businesses and persons other than businesses:

No significant impact to business is expected. The rule clarifies ongoing Medicaid policy for medical supplies, durable medical equipment, and prosthetic devices. The majority of Medicaid recipients will receive the same services under this rule. Providers and recipients should find it easier to determine what is available.

Compliance costs for affected persons:

There are no compliance costs because this change only clarifies ongoing Medicaid policy for medical supplies, durable medical equipment, and prosthetic devices.

Comments by the department head on the fiscal impact the rule may have on businesses:

Medical supplies, durable medical equipment and prosthetics are an optional service in Medicaid. This rule should make it easier for providers and recipients to know what services are authorized and may have a small positive fiscal impact on business. The current level of authorized funding in this category should not change as a result of this rule. A. Richard Melton, Acting Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

Direct questions regarding this rule to:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

07/15/2008

This rule may become effective on:

07/22/2008

Authorized by:

Richard Melton, Deputy Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-70. Medical Supplies, Durable Medical Equipment, and Prosthetic Devices.

[R414-70-1. Introduction and Authority.

(1) Medically necessary medical supplies, including disposable medical supplies, durable medical equipment, and prosthetic devices are available to recipients who are living at home.

(2) This rule is authorized by Sections 26-18-3 and 26-1-5, Utah Code Annotated.

(3) The authority for this program is found in 42 CFR 440.120(c), 440.130(d), 441.15(a)(3), and 440.70(b)(3).

(4) Durable Medical Equipment (DME) and medical supplies are mandatory services. Prosthetic devices are optional services as referenced in 42 CFR 440.225.

 

R414-70-2. Definitions.

(1) Medical supplies means items for medical use that are disposable or semi-disposable and are non-reusable.

(2) "Durable medical equipment" (DME) is equipment that:

(a) can withstand repeated use;

(b) is primarily and customarily used to serve a medical purpose;

(c) generally is not useful to a person in the absence of an illness or injury; and

(d) is appropriate for use in the home.

(3) "Prosthetic device" means replacement, corrective, or supportive devices such as braces, orthoses or prosthetic limbs, but not wheelchairs and standers, prescribed by physician or other licensed practitioner of the healing arts within the scope of his practice as defined by state law to:

(a) artificially replace a missing portion of the body:

(b) prevent or correct physical deformities or malfunction; or support a weak or deformed portion of the body, see 42 CFR 440.120.

(4) "Standard wheelchair" is a wheelchair that generally satisfies the needs of an average-sized patient, is fabricated to withstand normal usage and body weight, and has brakes and armrests. A standard wheelchair includes any stock frame and stock components or attachments assembled to fit the patient needs which can be reused and reconfigured for another patient.

(5) "Customized wheelchair" is a wheelchair that is uniquely constructed or substantially modified, such as with a customized frame, for a specific recipient. A stock wheelchair with additional stock components, attachments, or specially configured options or accessories is not a customized wheelchair.

 

R414-70-3. Recipient Eligibility Requirements.

Disposable medical supplies, DME, and prosthetic devices are available to categorically and medically needy eligible individuals.

 

R414-70-4. Program Access Requirements.

(1) Supplies, DME, and prosthetics are covered benefits for recipients who reside at home through medical suppliers and specialty prosthetic vendors. Recipients residing in long term care facilities will receive supplies , DME and prosthetics as decribed in Section R414-70-9.

(2) All supplies, DME, and prosthetics require a physician's order, must be documented in the plan of care, and must be medically necessary. A physician must review and verify the continuing need for the items at least annually and more frequently as needed for prior authorization.

(3) Supplies, DME, and prosthetics are for use by a recipients who reside at home and for use in the home. They may be used in conjunction with home health agency nursing if necessary.

 

R414-70-5. Disposable Medical Supplies.

(1) Supplies are limited to the quantity determined by Medicaid to be medically necessary for average medical use for one month. Additional supplies may be provided if the recipient demonstrates medical necessity to the Department.

(2) Disposable supplies include:

(a) surgical stockings, limited to replacement once every six months;

(b) ostomy supplies;

(c) first aid supplies, limited to those supplies used for post surgical need, decubitus treatment, and long term dressings.

(d) urinary Catheters;

(e) syringes;

(f) diapers and briefs, limited to coverage for disabled children and adults only and are not covered for adult incontinence not associated with a disability nor for normal infant use and hygiene;

(g) sterile water, limited to recipients in the technology dependent waiver only; and

(h) miscellaneous disposable supplies, such as diabetic supplies, lancets, and blood pressure cuffs.

(3) Oxygen and related respiratory equipment are covered.

(a) Oxygen is a benefit for a recipient who resides at home or in a long term care facility. For recipients residing in a long term care facility, all oxygen equipment is the responsibility of the facility, except for oxygen concentrators.

(b) The Department may require an oxygen system to be replaced by a concentrator if it is more economical or more appropriate for the recipient's needs. Portable gaseous or liquid oxygen and oxygen systems are provided based on medical need which can not be provided by a concentrator.

 

R414-70-6. Durable Medical Equipment.

(1) Medically necessary durable medical equipment, such as manual and power wheelchairs, commodes, bathing aids, oxygen concentrators, hospital beds, ventilators, CPAP machines, BiPAP machines, and ambulatory aids, such as canes and crutches, are benefits for recipients residing at home. All special adaptations and design of DME is limited to utilization in the home.

(2) Medicaid covers repairs to DME.

(3) The Department will pay for a particular DME item once every five years from the original purchase date. Additional replacement DME may be provided if the recipient demonstrates medical necessity to the Department.

(4) The Department may purchase or rent DME at its option.

(5) Wheelchairs which are suitable for use in the home are a benefit.

(a) Medicaid will pay for one wheelchair for a recipient.

(b) If Medicaid has supplied a wheelchair, Medicaid will not repair or service an alternate, patient-owned wheelchair.

(c) A standard wheelchair with attachments, components or accessories; a customized, manual wheelchair; or a motorized wheelchair may be provided if the recipient demonstrates medical necessity to the Department and the wheel chair is designed for use in the home. Special attachments, accessories and modifications for use outside the home are not covered.

(d) The recipient or primary care giver must be capable of routine wheelchair care and management.

(e) Wheelchair repairs

(i) Medicaid covers repairs for only one wheelchair. The provider must obtain authorization from the Department before making any repairs.

(ii) Repairs do not include routine maintenance, such as changing tires, inspecting the chair, changing batteries, grease, and oil.

(iii) Repairs to a rental chair are not a benefit.

(iv) Re-upholstery is a benefit if the warranty has expired, the original upholstery is beyond repair, not the result of abuse and neglect, and is medically necessary.

(f) A recipient who requires a wheelchair for employment, vocational development, or educational purposes must seek this benefit through the appropriate funded state agency. Medicaid coverage is limited to use in the home and not for employment, educational, or recreational needs.

 

R414-70-7. Prosthetic Devices and Appliances.

(1) Medicaid covers prosthetic devices that include hearing aids, special orthopedic appliances, prosthetic limbs, prosthetic eyes, braces, and orthoses. Medicaid does not cover prosthetic devices that include special shoes, cochlear implants, augmentative speech devices, and wigs or hair replacement after chemotherapy.

(2) Repairs and parts for artificial limbs are a benefit if medically necessary.

(3) Attachments and modifications to artificial limbs are a benefit.

(4) Duplicative appliances such as an artificial leg plus a wheelchair are not a benefit unless there is documentation that it is medically necessary to have both devices.

(5) The Department will pay for a particular item once every five years from the original purchase date. A replacement prosthetic device may be provided more often.

 

R414-70-8. Medical Supplies, DME and Prosthetics in Long Term Care Facilities.

All medical supplies, DME, and prosthetics for recipients in a long term care facility are provided by the facility under the per diem, except:

(1) oxygen concentrators;

(2) customized or power wheelchairs;

(3) repairs to customized or power wheelchairs;

(4) medically necessary braces and prosthetic devices;

(5) specialized wound care and decubitus supplies and equipment, including special mattresses and overlays;

(6) oxygen. Oxygen is limited to the gas product itself. All oxygen equipment or systems to deliver or administer the oxygen is covered under the per diem.

 

R414-70-9. Non Covered Items.

The following are not benefits:

(1) Items used primarily for hygiene, education, exercise, convenience, cosmetic purposes, social interaction, or comfort of the recipient.

(2) Modifications of DME or supplies for reasons of convenience, cosmetics, or comfort.

(3) DME for use outside the home, including wheelchair, wheelchair attachments, accessories and modifications for use outside the home.

(4) Equipment permanently attached or mounted to a building or a vehicle such as ramps, lifts, and bathroom rails.

(5) Routine maintenance such as cleaning, greasing and oiling of purchased equipment.

(6) Repairs to DME or prosthetic devices if:

(a) the recipient does not own the device or use the device in his home;

(b) the repair or part is for equipment which is not a benefit;

(c) the repair is covered by a warranty; or

(d) the damage is the result of abuse or neglect.

(7) First aid supplies not referenced in Section 5(2)(c).

(8) Non-medical supplies, devices, or products that are not primarily and customarily used to serve a medical purpose or generally are not useful to an individual in the absence of an

illness or injury

(9) Lifts in furniture to aid a patient to a standing position;

(10) Specialized or non-standard tires or wheels on wheelchairs are not a benefit unless medically necessary for use in the patient's home.

(11) Cervical pillows;

(12) Shoes not attached to a brace;

(13) Shoe repair;

(14) Non-prescription braces and supports;

(15) Reflux boards;

(16) Items purchased by the patient through mail order;

(17) A second oxygen system;

(18) Glucose monitors;

(19) Cochlear implants;

(20) Augmentative speech devices; and

(21) Wigs or hair replacement following chemotherapy.

 

R414-70-10. Reimbursement.

Medical supplies, DME and prosthetic devices are reimbursed using the established fee schedule as established in the Utah Medicaid State Plan and incorporated by reference in R414-1-5.]

R414-70-1. Introduction and Authority.

(1) This rule governs the provision of medical supplies, durable medical equipment (DME), and prosthetic device services.

(2) This rule is authorized by Sections 26-18-3 and 26-1-5.

(3) As required by Section 26-18-2.3, the Department provides these services in an efficient, economical manner, safeguarding against unnecessary, unreasonable, or inappropriate use of these services.

 

R414-70-2. Definitions.

As used in this rule:

(1) "Durable medical equipment"or "DME" means equipment that:

(a) can withstand repeated use;

(b) is primarily and customarily used to serve a medical purpose;

(c) generally is not useful to a person in the absence of an illness or injury; and

(d) is suitable for use in the home.

(2) "Entitled to nursing facility services" means an individual who:

(a) is in a nursing facility and whose nursing facility stay is covered by Medicaid; or

(b) is receiving services in a waiver program for individuals who require nursing facility level of care.

(3) "Individual eligible for optional services" means an individual who is not entitled to nursing facility services.

(4) "Individual entitled to mandatory services" means an individual who is entitled to nursing facility services.

(5) "Medical supplies" means items for medical use that are suitable for use in the home and that are disposable or semi-disposable and are non-reusable.

(6) "Medical Supplies Manual and List" means services described in the Utah Medicaid Provider Manual, Section 2, Medical Supplies, with its referenced Attachment, Medical Supplies List, as incorporated at R414-1-5(2).

(7) "Prosthetic device" means replacement, corrective, or supportive devices that are suitable for use in the home, such as braces, orthoses, or prosthetic limbs prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice as defined by state law to:

(a) artificially replace a missing portion of the body;

(b) prevent or correct physical deformities or malfunction; or

(c) support a weak or deformed portion of the body.

 

R414-70-3. Services.

(1) Medical supplies, DME, and prosthetic devices are optional services.

(2) Medical supplies, DME, and prosthetic devices are limited to services described in the Medical Supplies Manual and List.

(3) The Medical Supplies Manual and List specifies the reasonable and appropriate amount, duration, and scope of the service sufficient to reasonably achieve its purpose.

(4) Medical supplies, DME, and prosthetic devices may be provided to an individual only as part of a written plan that is reviewed at least annually by a physician.

 

R414-70-4. Services for Individuals Eligible for Optional Services.

(1) An individual eligible for optional services may receive medical supplies, DME, and prosthetic devices as described in the Medical Supplies Manual and List.

(2) An individual eligible for optional services must meet the criteria established in the Medical Supplies Manual and List and obtain prior approval if required.

 

R414-70-5. Services for Individuals Eligible for Mandatory Services.

(1) An individual entitled to mandatory services may receive medical supplies, DME, and prosthetic devices as described in the Medical Supplies Manual and List.

(2) An individual eligible for mandatory services must meet the criteria established in the Medical Supplies Manual and List and obtain prior approval if required.

(3) An individual entitled to mandatory services may request an agency review to seek medical supplies and DME not listed in the Medical Supplies Manual and List.

 

R414-70-6. Services for Individuals Residing in Long Term Care Facilities.

(1) The Department provides medical supplies, DME, and prosthetic devices to individuals residing in a nursing care facility or an ICF/MR as part of the per diem payment.

(2) An individual residing in a nursing care facility or ICF/MR may receive additional medical supplies, DME, and prosthetic devices only as specifically indicated on the Medical Supplies Manual and List.

(3) An individual residing in a nursing care facility or an ICF/MR may request an agency review to seek medical supplies and DME not listed in the Medical Supplies Manual and List.

 

R414-70-7. Less Costly Alternative.

The Department may provide at its discretion services not described in the Medical Supplies Manual and List as provided in R414-1-6(2)(dd).

 

R414-70-8. Reimbursement.

Medical supplies, DME, and prosthetic devices are reimbursed using the fee schedule in the Utah Medicaid State Plan and incorporated by reference in R414-1-5.

 

KEY: Medicaid, medical supplies, durable medical equipment, prosthetics

Date of Enactment or Last Substantive Amendment: [October 10, 2007]2008

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-2.3, 26-18-3