Durable Medical Equipment Program

PURPOSE: This rule establishes the regulatory basis for the administration of the MO HealthNet durable medical equipment program, designation of professional persons who may dispense durable medical equipment, and the method of reimbursement for durable medical equipment. This rule provides for such methods and procedures relating to the utilization of, and the payment for, care and services available under the MO HealthNet program as may be necessary to safeguard against unnecessary utilization of such care and services and to assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area. Specific details of the conditions for provider participation, criteria, and methodology of provider reimbursement, participant eligibility and amount, duration, and scope of services covered are included in the durable medical equipment provider program manual and bulletins which are incorporated by reference in this rule and available at the website www.dss.mo.gov/mhd. PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Administration. The MO HealthNet Durable Medical Equipment (DME) program shall be administered by the Department of Social Services, MO HealthNet Division. The services and items covered and not covered, the program limitations, and the maximum allowable fees for all covered services shall be determined by the Department of Social Services, MO HealthNet Division and shall be included in the DME provider manual, which is incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at http://manuals.momed.com/collections/collection_dme/print.pdf, September 6, 2019. This rule does not incorporate any subsequent amendments or additions. (2) Persons Eligible. Any person who is eligible for MO HealthNet benefits as determined by the Family Support Division is eligible for DME when the DME is medically necessary. DME must be prescribed by the participant’s physician and reviewed by the physician annually. Covered services are limited as specified in the DME provider manual. (3) Reimbursement. Payment will be made for each unit of service or item provided in accordance with the fee schedule determined by the MO HealthNet Division. Reimbursement will not exceed the lesser of the maximum allowed amount determined by the MO HealthNet Division or the provider’s billed charge. Reimbursement for DME services is made on a fee-for-service basis. The MO HealthNet maximum allowable fee for a unit of service has been determined by the MO HealthNet Division to be a reasonable fee, consistent with efficiency, economy, and quality of care. Sales tax is not covered by MO HealthNet, nor can it be billed to the participant. Providers must accept the MO HealthNet payment as the full and complete payment and may not accept additional payment from the participant. Charges for shipping, freight, COD, handling, delivery, and pickup are included in the reimbursement for items covered under the DME program and are not billable to the MO HealthNet participant. (4) Definition for Durable Medical Equipment and appliances. DME is equipment and appliances that can withstand repeated use, can be reusable or removable, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of a disability, illness, or injury, and is appropriate for use in any setting in which normal life activities take place as defined in 42 CFR 440.70(c)(1). All requirements of the definition must be met in order for the equipment to be covered by MO HealthNet. 42 CFR 440.70 is published by the Federal Register, at https://www.ecfr.gov/. A copy of 42 CFR 440.70 as of January 3, 2020, is incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at https://dssruletracker.mo.gov/dssproposed-rules/welcome.action. This rule does not incorporate subsequent amendments or additions. (5) Provider Participation. (A) The following types of providers may be reimbursed by MO HealthNet for items covered under the DME program if they are enrolled MO HealthNet DME providers and enrolled with Medicare as a durable medical equipment prosthetic and orthotic supplier: rental and sales providers, prosthetic fabricators, rehabilitation centers, orthotic fabricators, physicians (includes M.D., D.O., podiatrists—may dispense orthotic devices and artificial larynx), advanced practice nurses in a collaborative practice arrangement, pharmacies, and hospitals. (B) MO HealthNet participants are required to obtain services from Missouri or bordering state providers. MO HealthNet will consider enrollment of an out-of-state (non-bordering) durable medical equipment provider only if— 1. Medicare covered services are provided to patients who have both MO HealthNet and Medicare; or 2. The item needed is not available or does not have a comparable substitute from Missouri or bordering state providers. (C) If the provider requests authorization for equipment or supplies for a MO HealthNet patient who is not also Medicare eligible or requests authorization for services that are available or have a comparable substitute in Missouri or a bordering state, the out-of-state (non-bordering) provider may be subject to sanctions and any amounts paid by the MO HealthNet Division will be recouped. (D) The enrolled MO HealthNet provider shall agree to— 1. Keep any records necessary to disclose the extent of services the provider furnishes to participants; and 2. On request, furnish to the MO HealthNet Division or State Medicaid Fraud Control Unit any information regarding payments claimed by the provider for furnishing services under the plan. (6) Covered Services. It is the provider’s responsibility to determine the coverage benefits for a MO HealthNet eligible participant based on his or her type of assistance as outlined in the DME manual. Reimbursement will be made to qualified participating DME providers only for DME items, prescribed by the participant’s physician to be medically necessary. Specific procedure codes that are covered under the DME program are listed in Section 19 of the DME provider manual, which is incorporated by reference and made a part of this rule. These items must be suitable for use in any setting in which normal life activities take place, as defined in 42 CFR 440.70(c)(1) when ordered in writing by the participant’s physician. Although an item is classified as DME, it may not be covered in every instance. Coverage is based on the fact that the item is reasonable and necessary for treatment of the illness or injury, or to improve the functioning of a malformed or permanently inoperative body part, and the equipment meets the definition of DME. Even though a DME item may serve some useful medical purpose, consideration must be given by the physician and the DME supplier to what extent, if any, it is reasonable for MO HealthNet to pay for the item as opposed to another realistically feasible alternative pattern of care. Consideration should be given by the physician and the DME supplier as to whether the item serves essentially the same purpose as equipment already available to the participant. If two (2) different items each meet the need of the participant, the less expensive item must be employed, all other conditions being equal. (7) Documentation. The DME provider and physician shall document how they determined the least expensive, feasible alternative for treatment of the disability, illness or injury, or to improve the functioning of a malformed or permanently inoperative body part and maintain documentation in compliance with 13 CSR 70-3.030. (8) Durable medical equipment for participants who are in a nursing facility or inpatient hospital. DME is not covered for those participants residing in a nursing home. DME is included in the nursing home per diem rate and not paid for separately with the exception of custom and power wheelchairs, prosthetic devices, and ventilators. DME that is used while the participant is in inpatient hospital care is not paid for separately under the DME program. These costs are recognized as part of the hospital’s inpatient per diem rate. (9) Face-to-face encounter and documentation requirements. (A) For certain items of DME, a face-to-face encounter is required, as indicated in 42 CFR 440.70(g)(1). A list of DME items subject to faceto-face encounter requirements may be found at https://www.cms.gov/Research-Statistics-Dataand-Systems/Monitoring-Programs/MedicareF FS - C o m p l i a n c e - P ro g ra m s / M e d i c a l - Review/FacetoFaceEncounterRequirementforCertainDurableMedicalEquipment.html, revised March 26, 2015. A copy of the list of DME items subject to face-to-face encounter requirements as of January 3, 2020, is incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at https://dssruletracker.mo.gov/dssproposed-rules/welcome.action. This rule does not incorporate subsequent amendments or additions. (B) No Medicaid payment for items of DME for which a face-to-face encounter is required shall be made unless there is documentation of a face-to-face encounter that meets the following criteria: 1. Related to the primary reason the beneficiary requires medical equipment; 2. Occurs no more than six (6) months prior to the written order; 3. Occurs prior to the date of service delivery; and 4. Conducted by a physician (M.D. or D.O.) or one (1) of the following non-physician practitioners (NPP): A. A nurse practitioner working in collaboration with a physician; B. A clinical nurse specialist working in collaboration with a physician; or C. A physician assistant, under the supervision of a physician. (C) The physician responsible for ordering the DME service must document the face-toface encounter which is related to the primary reason the participant requires the DME. If an allowed NPP performs the face-to-face encounter, the clinical findings of that faceto-face encounter must be communicated to the enrolled ordering physician and be incorporated into the ordering physician’s medical record for the participant. (D) The DME provider must ensure that it has received the face-to-face documentation for each item of DME and for each participant for whom it is required. The DME provider must maintain the documentation in the participant’s record or files at their own location. The documentation must include the following: 1. The clinical findings of the face-toface encounter substantiating the need for the DME; 2. The primary reason that the DME is required; 3. The name, signature, and credentials of the practitioner who conducted the face-toface encounter; and 4. The date of the face-to-face encounter; or 5. The documentation requirements in paragraph (D)1.-4. above may be met when incorporated into the pre-certification process, as approved by MHD. (E) If a Medicare face-to-face encounter document has already been provided for the same participant episode of care, it will also suffice as the MO HealthNet face-to-face documentation requirement. (10) Non-Covered Items. MO HealthNet does not cover items which primarily serve the following purposes: personal comfort, convenience, education, hygiene, safety, cosmetic, new equipment of unproven value, and equipment of questionable current usefulness or therapeutic value. Specific items which are generally not covered can be found in Section 13.32 of the DME manual. Examples of noncovered items are: air conditioners, computers (unless determined to be used for an augmentative communication device), electric bathtub lifts, elevators, furniture, toys, home modifications, refrigerators, seat lift chairs, stair lifts or glides, treadmill, water softening systems, wheelchair lifts, wheelchair ramps, whirlpool tubs, or pumps. (11) Medicare/Medicaid Crossovers. For participants having both Medicare and MO HealthNet eligibility, the MO HealthNet program pays the lesser of the amounts indicated by Medicare to be deductible and/or coinsurance due on the Medicare allowed amount or the difference between the amount paid by Medicare and the MO HealthNet allowed amount. (12) Records Retention. Sanctions may be imposed by the MO HealthNet Division against a provider for failing to make available, and disclosing to the MO HealthNet Division or its authorized agents, all records relating to services provided to MO HealthNet participants or records relating to MO HealthNet payments, whether or not the records are commingled with non-Title XIX (Medicaid) records in compliance with 13 CSR 70-3.030. These records must be retained for five (5) years from the date of service. Fiscal and medical records coincide with and fully document services billed to the MO HealthNet agency. Providers must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request. Failure to furnish, reveal, or retain adequate documentation for services billed to the MO HealthNet program, as specified above, is a violation of this regulation. AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016.* Original rule filed Nov. 1, 2002, effective April 30, 2003. Emergency amendment filed Aug. 11, 2005, effective Sept. 1, 2005, expired Feb. 27, 2006. Amended: Filed June 15, 2005, effective Dec. 30, 2005. Emergency amendment filed June 15, 2006, effective July 1, 2006, expired Dec. 28, 2006. Amended: Filed May 15, 2006, effective Nov. 30, 2006. Amended: Filed Jan. 9, 2009, effective July 30, 2009. Amended: Filed Sept. 26, 2013, effective March 30, 2014. Amended: Filed Jan. 16, 2020, effective Aug. 30, 2020. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.