Ohio Admin. Code 5160-10-26 - DMEPOS: nutrition products

(A) Coverage.

(1) Enteral and parenteral nutrition.

(a) The default certificate of medical necessity (CMN) form is the ODM 01907, "Certificate of Medical Necessity: Enteral and Parenteral Nutrition" (rev. 7/2018 7/2024). The CMN must include includes the following information:

(i) Attestation to one of the following statements:

(a) The individual is able to ingest food but cannot derive sufficient energy and nutrients from ordinary food, even if the food is prepared in a liquefied, puréed, or blended form;

(b) The individual is unable to ingest food safely but can digest it; or

(c) The individual is unable to digest food in the alimentary canal and must obtain nutrition parenterally.

(ii) For an individual who has difficulty in maintaining weight, a current weight history; and

(iii) For an individual who requires needs a daily intake of more than two thousand calories, an explanation of the need.

(b) A new prescription is required needed for a change in the type or increase in the quantity of an item.

(c) Substitutions are permitted, so long as the substituted product is correctly formulated to meet the needs of the individual and the prescriber is notified before the supplier dispenses the product.

(d) Payment will not be made for quantities that exceed one month's supply.

(e) Suppliers must not may dispense supplies items more than up to one week before the scheduled dispensing date.

(f) Payment includes dispensing and either shipping or delivery.

(2) Provision of donor human milk.

(a) Payment can be made only to a medicaid-enrolled provider that is a member in good standing of the human milk banking association of North America.

(b) The provider must keep keeps on file the following documents:

(i) An explanation by a prescriber of the medical necessity of human milk for the recipient;

(ii) An attestation that the prescriber has given the recipient's parent or guardian information about human milk (e.g., nutrients, growth factors, shelf life, the effects of pasteurization, the possibility of disease transmission) and the donation process (e.g., donor screening, pasteurization, storage, transport), which may be in the form of educational material obtained from the provider; and

(iii) A consent form, signed and dated by the recipient's parent or guardian, indicating that the parent or guardian has been made aware of the benefits and risks of using banked donor human milk.

(c) No separate payment is made Payment to a provider for supplying donor human milk in a hospital setting is made in accordance with Chapter 5160-2 of the Administrative Code.

(d) Payment For donor human milk supplied in a non-hospital setting, payment includes processing, additives, and either shipping or delivery; no payment is made for the milk itself.

(B) Constraints and limitations. Separate payment will not be made for the following items as medical supplies:

(1) Ordinary prepared food;

(2) Commercial products that serve as ordinary food (e.g., shakes, smoothies, energy bars, vitamin or mineral supplements, baby food);

(3) Food products to be eaten as part of a diet related to diabetes, obesity, gastric bypass, or bariatric surgery;

(4) Food products for which a provider receives medicaid per diem payment; and

(5) Standard infant formula (not used to treat errors of metabolism) for which payment may be made through a program other than medicaid.

Notes

Ohio Admin. Code 5160-10-26

Effective: 7/1/2024
Five Year Review (FYR) Dates: 1/30/2024 and 07/01/2029
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 01/01/2006, 08/18/2008, 01/01/2010, 08/02/2011, 07/16/2018