Conn. Agencies Regs. § 17-134d-83 - Policy and procedures governing oxygen therapy on behalf of Title XIX medicaid recipients

(a) Scope

Section 17-134d-83 through Section 17-134d-85 of the regulations of Connecticut State Agencies governs the billing and payment for Oxygen Therapy provided to persons determined eligible for such goods and services under the provisions of Connecticut's Medical Assistance Program in accordance with Chapter 302 of the General Statutes of Connecticut.

(b) Definitions

For the purpose of Regulation Section 17-134d-83 through Section 17-134d-85, the following definitions apply:

"Ambulatory" means an individual who is independently mobile or wheelchair mobile and is able to participate in the active daily living available to them in their living environment.

"Chronic Disease Hospital" means a long-term hospital having facilities, medical staff and all necessary personnel for the diagnosis, care and treatment of a wide range of chronic diseases as licensed by the Department of Health Services.

"Department" means State of Connecticut Department of Income Maintenance.

"Home" means the recipient's place of residence which includes a boarding home or Home for the Aged. Home does not include a hospital or long-term care facility.

"Hospital" means an establishment for the lodging, care and treatment of persons suffering from disease or other abnormal physical or mental conditions licensed by the Department of Health Services and includes inpatient psychiatric services in general hospitals.

"Long-Term Care Facilities" (LTC) are institutions licensed and certified under State law which have a provider agreement with the Department of Income Maintenance to provide a variety of medical, personal care, rehabilitative, and social services for recipients of Medical Assistance who are afflicted with acute, chronic or convalescent diseases or injuries or who because of their mental or physical condition require health-related care and services above the level of room and board which can be provided only through an institutional setting. These facilities include nursing facilities licensed as chronic and convalescent nursing homes, rest homes with nursing supervision and intermediate care facilities for the mentally retarded (ICFs/MR).

"Medical Equipment, Devices and Supplies" (MEDS) means Durable Medical Equipment, Medical Surgical Supplies, Orthotic and Prosthetic Devices and Oxygen Therapy.

"Oxygen Concentrator" means an electrically operated device that draws room air, separates the oxygen from the other gases in the air, and delivers the oxygen at high concentrations to the patient.

"Oxygen Therapy" means oxygen, equipment, supplies and services related to the delivery of oxygen.

"Oxygen Therapy Supplies" means all supplies needed for an oxygen system to function; such as cannula or mask, tubing, regulator with flow gauge and container.

"Portable Oxygen System" means oxygen in a portable unit which weighs less than 12 lbs. allowing the user greater ambulatory capability.

"Prescription" - The Certification of Medical Necessity form (Medicare Form HCFA-484) shall be the prescription form used for all oxygen therapy orders. This fully completed form signed by the prescribing physician will be the only acceptable initial certification form for oxygen services.

"Prior Authorization" (P.A.) means approval for a service from the Department of Income Maintenance before the provider actually provides the service. In order to receive approval from the Department a provider must comply with all prior authorization requirements found in Section 17-134d-84(b) and (c). P.A. does not guarantee payment unless all other eligibility requirements are met. Payment may not be made, however, if P.A. is required and not obtained.

"Provider" means the vendor/supplier of oxygen therapy who is enrolled with the Department as a MEDS supplier or supplier of oxygen therapy.

"Pro Re Nata" (P.R.N.) means as the situation demands.

"Psychiatric Hospital" means a facility that is engaged in providing, by or under the supervision of a physician, psychiatric services for the diagnosis and treatment of mentally ill persons and which has been accredited by the Joint Commission on Accreditation of Hospitals.

"Usual and Customary Charge to the General Public" means a charge which will be made for the particular service by the provider to the patient group accounting for the largest number of non-Medicaid services. In determining such charge, all charges made to third party payors and special discounts offered to an individual such as a senior citizen will be excluded.

(c) Provider Participation

In order to participate in the Medicaid program and receive payment directly from the Department all MEDS providers must:

(1) meet and maintain all applicable licensing and certification requirements of Federal and State statutes and regulations; and

(2) meet and maintain all Departmental enrollment requirements; and

(3) have a valid provider agreement on file which is signed by the provider and the Department upon application for enrollment into the Medicaid program and periodically thereafter as required by the Department and which is in effect for the period as stated in the agreement. The provider agreement specifies conditions and terms (Federal and State statutes, regulations and standards) which govern the program and to which the provider is mandated to adhere in order to participate in the program.

(d) Eligibility

Payment for oxygen therapy is available for all Medicaid eligible recipients who have a documented medical need, when it is prescribed by a physician subject to the conditions and limitations which apply to these services.

(e) Services Covered

(1) Except for the limitations and exclusions for oxygen therapy listed below, the Department will pay in accordance with Regulation Sections 17-134d-83 through Section 17-134d-85 for oxygen therapy in accordance with sections 1861 (s) (6) and 1862 (a) (1) (A) of the Social Security Act, 42 C.F.R. 410.38 and Medicare Carrier's Manual Chapter II, Coverage and Limitations, Section 2100.5 including Section 60-4 in the Coverage Issues Appendix of the Medicare Coverage Issue Manual, and as these may be amended from time to time.

(2) Payment for oxygen products and services via oxygen concentrators in LTC facilities shall be included in the per diem reimbursement rate established by the Commissioner of Income Maintenance. (LTC facilities must purchase oxygen concentrators in sufficient numbers to meet the needs of their residents and may have up to one reserve unit for each nursing station. These requirements supplement the emergency system required in the Public Health Code, as applicable.)

(f) Service Limitations

Services covered are limited to those listed in the Department's fee schedule.

(g) Oxygen Therapy Services Not Covered

The Department will not pay for:

(1) Anything of an unproven, experimental or research nature or for services in excess of those deemed medically necessary by the Department to treat the recipient's condition or for services not directly related to the recipient's diagnosis, symptoms or medical history.

(2) Oxygen therapy supplied to hospital inpatients including Chronic Disease and Psychiatric Hospitals are routine services and are included in the hospital daily rate.

(3) The P.R.N. use of oxygen therapy.

(4) Oxygen concentrators in long-term care facilities.

(A) The purchase of oxygen concentrators are included in the LTC facilities' per diem rate and thereby are available to nursing facility residents.

(B) LTC facilities with built in wall oxygen systems are exempt from the requirements pertaining to purchase of oxygen concentrators. Concentrators may not be used for P.R.N. oxygen therapy in a facility with this type of oxygen system.

(5) Information furnished to the recipient over the telephone by the provider or prescribing physician.

(6) Demurrage, delivery, or set up charges.

Notes

Conn. Agencies Regs. § 17-134d-83

Effective May 27, 1992