405 IAC 5-19-3 - Reimbursement parameters for durable medical equipment
Authority: IC 12-15
Affected: IC 12-13-7-3; IC 12-15-13-6
Sec. 3.
(a) Medicaid
reimbursement is available for the rental or purchase of DME subject to the
restrictions listed in this rule.
(b) DME and associated repair costs,
including, but not limited to:
(1) ice
bags;
(2) bed rails;
(3) canes;
(4) walkers;
(5) crutches;
(6) standard wheelchairs;
(7) traction equipment; or
(8) oxygen and equipment and supplies for its
delivery; for the usual care and treatment of members in long-term care
facilities are reimbursed in the facility's per diem rate and may not be billed
to Medicaid by the facility, pharmacy, or other provider. Nonstandard or
custom/special equipment and associated repair costs require prior
authorization by the office and may be billed separately to Medicaid, when
authorized. Facilities cannot require members to purchase or rent such
equipment with their personal funds.
(c) Reimbursement of DME is equal to the
lower of the provider's submitted charges, not to exceed the provider's usual
and customary charges, or the Medicaid allowable amount. The Medicaid allowable
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, 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).
(d) The office may review the statewide fee
schedule and adjust it as necessary, subject to subsection (c)(1) through
(c)(4). Any adjustment shall be made effective no earlier than permitted under
IC 12-15-13-6.
(e) The total payment for the rental period
may not exceed the purchase price.
(f) Items identified by the office that
require frequent or substantial servicing will be paid on a rental basis only.
No purchase payment will be made.
(g) All DME must be ordered in writing by a
physician. The written order must be kept on file for audit purposes.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
Authority: IC 12-15
Affected: IC 12-13-7-3; IC 12-15-13-6
Sec. 3.
(a) Medicaid reimbursement is available for the rental or purchase of DME subject to the restrictions listed in this rule.
(b) DME and associated repair costs, including, but not limited to:
(1) ice bags;
(2) bed rails;
(3) canes;
(4) walkers;
(5) crutches;
(6) standard wheelchairs;
(7) traction equipment; or
(8) oxygen and equipment and supplies for its delivery; for the usual care and treatment of members in long-term care facilities are reimbursed in the facility's per diem rate and may not be billed to Medicaid by the facility, pharmacy, or other provider. Nonstandard or custom/special equipment and associated repair costs require prior authorization by the office and may be billed separately to Medicaid, when authorized. Facilities cannot require members to purchase or rent such equipment with their personal funds.
(c) Reimbursement of DME is equal to the lower of the provider's submitted charges, not to exceed the provider's usual and customary charges, or the Medicaid allowable amount. The Medicaid allowable 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, 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).
(d) The office may review the statewide fee schedule and adjust it as necessary, subject to subsection (c)(1) through (c)(4). Any adjustment shall be made effective no earlier than permitted under IC 12-15-13-6.
(e) The total payment for the rental period may not exceed the purchase price.
(f) Items identified by the office that require frequent or substantial servicing will be paid on a rental basis only. No purchase payment will be made.
(g) All DME must be ordered in writing by a physician. The written order must be kept on file for audit purposes.