405 IAC 5-19-1 Medical supplies

Sec. 1. (a) Medical and surgical supplies (medical supplies) are: (1) disposable items that are not reusable and must be replaced on a frequent basis; (2) used primarily and customarily to serve a medical purpose; (3) generally not useful to a person in the absence of a disability, illness, or injury; and (4) covered only for the treatment of a medical condition. Reimbursement is available for medical supplies subject to the restrictions listed in this section. (b) Medical supplies include, but are not limited to, the following: (1) Antiseptics and solutions. (2) Bandages and dressing supplies. (3) Gauze pads. (4) Catheters. (5) Incontinence supplies. (6) Irrigation supplies. (7) Diabetic supplies, including blood glucose monitors. (8) Ostomy supplies. (9) Respiratory and tracheotomy supplies. (c) Covered medical supplies do not include the following: (1) Drug products, either legend or nonlegend. (2) Sanitary napkins. (3) Cosmetics. (4) Dentifrice items. (5) Tissue. (6) Nonostomy deodorizing products, soap, disposable wipes, shampoo, or other items generally used for personal hygiene. (d) Providers shall bill for medical supplies in accordance with the instructions set forth in the Indiana health coverage programs manual, bulletins, or banner pages. (e) Incontinence supplies, including underpads, incontinent briefs and liners, diapers, and disposable diapers, are covered only: (1) in cases documented as medically necessary at a rate determined by the office; and (2) for members three (3) years of age or older. (f) All medical supplies must be ordered in writing by a physician or dentist. (g) Medical supplies that are included in facility reimbursement, or that are otherwise included as part of reimbursement for a medical or surgical procedure, are not separately reimbursable to any party. All covered medical supplies, whether for routine or nonroutine use, are included in the per diem for nursing facilities, even if the facility does not include the cost of medical supplies in their facility cost reports. (h) Reimbursement is not available for medical supplies dispensed in quantities greater than a one (1) month supply for each calendar month, except when: (1) packaged by the manufacturer only in larger quantities; or (2) the member is a Medicare member and Medicare allows reimbursement for a larger quantity. (i) Medical supplies shall be for a specific medical purpose, not incidental or general purpose usage. (j) Reimbursement for medical supplies is equal to the lower of the following: (1) The provider's submitted charges, not to exceed the provider's usual and customary charges. (2) The Medicaid allowable fee schedule amount as determined under this section. (k) The Medicaid allowable fee schedule amount is the Medicaid fee schedule amount in effect on June 30, 2011. If this amount is not available, the Medicaid allowable shall be the amount determined as follows: (1) The Indiana Medicare fee schedule amount adjusted by a multiplier of eight-tenths (0.8), if available. If this amount is not available, then subdivision (2). (2) The average acquisition cost of the item adjusted by a multiplier of one and two-tenths (1.2), if available. If this amount is not available, then subdivision (3). (3) The manufacturer's suggested retail price adjusted by a multiplier of seventy-five hundredths (0.75). If this amount is not available, then subdivision (4). (4) The invoice cost of the item adjusted by a multiplier of one and two-tenths (1.2). (l) The office may review the statewide fee schedule and adjust it as necessary, subject to subsection (k)(1) through (k)(4). Any adjustments shall be made effective no earlier than permitted under IC 12-15-13-6. (m) Providers must include their usual and customary charge for each medical supply item when submitting claims for reimbursement. Providers shall not use the Medicaid calculated allowable fee schedule amount for their billed charge unless it is less than or equal to the amount charged by the provider to the general public.