Current through Register Vol. 48, No. 38, September 20, 2024
a) Payment for the
provision of medical equipment, supplies, prosthetic devices and orthotic
devices shall be made only to participating providers who are licensed or
exempt from licensure under any licensure Act, including but not limited to the
Home Medical Equipment and Services Provider License Act [ 225 ILCS 51
].
b) Payment for medical
equipment, supplies, prosthetic devices and orthotic devices shall be made:
1) when:
A)
they are essential to enable a client to remain at home or to function in the
community;
B) the client's
physician has recommended in writing to the Department or in a patient care
plan that the supplies or equipment be provided and that they are medically
necessary; and
C) the Department
has approved payment based on consideration of:
i) the client's medical condition;
ii) the benefits the item is expected to
effect;
iii) the client's ability
to adjust to and to use the item recommended; and
iv) in the case of a communication device,
whether the device will increase the client's potential for full participation
in health care by assisting in cause and effect awareness, or training physical
movements or improving the client's understanding and comprehension of his or
her health needs and responsibilities; or
2) when the Individual Program Plan (IPP) of
an individual with developmental disabilities residing in an ICF/MR or a long
term care facility identifies the equipment, supplies, prosthetic devices and
orthotic devices that are necessary for his or her participation in active
treatment as described in
42 CFR
483.440, Condition of Participation: Active
Treatment Service.
c)
Payment shall be made for the repair of prosthetic devices, orthotic devices
and medical equipment owned by recipients if the item is out of warranty and
the sum of the individual repair parts and the labor does not exceed 75 percent
of the cost of a new unit. Labor charges are to be included in the repair
price. A guarantee of at least 180 days must be provided. Charges shall not
include tax, delivery, rebate, packaging or freight. The Department may agree
to assume repair costs of a rented or loaned communication system if such an
agreement is required by the manufacturer's or vendor's rental or loan terms.
The Department may deny payment for repairs if evidence indicates that damage
has resulted from abuse of the equipment.
d) Payment shall be made for loaner items
issued pending repair or replacement of prosthetic devices, orthotic devices
and medical equipment owned by recipients if it is the usual practice of the
supplier to provide and charge for such items.
e) Covered services are:
1) Non-durable medical supplies for an
individual's life maintenance care and treatment;
2) Durable medical equipment essential to
expedite a hospital discharge and to enable the person to be cared for at
home;
3) Prosthetic and orthotic
devices, including communication devices, that are essential to enhance
functional mobility or medically necessary communication, or are essential for
employment;
4) Respiratory
equipment and supplies necessary as a life saving measure or for prevention of
a medical emergency, institutionalization, or to facilitate
deinstitutionalization; and
5)
Repair of durable medical equipment, prosthetic devices and orthotic
devices.
f) Payment
shall be made for covered services on a prior approval basis, except as
provided under Section
140.477.
g) Effective July 1, 2017, to be eligible for
reimbursement by the Department, certain medical equipment and supplies will be
subject to a face-to-face encounter. The Department will, at a minimum, require
a face-to-face encounter for equipment and supplies for which Medicare requires
a face-to-face encounter. A list of medical equipment and supplies subject to a
face-to-face encounter will be published on the Department's website. The
face-to-face encounter must meet the following conditions:
1) The face-to-face patient encounter that is
related to the primary reason the patient requires medical equipment, supplies
or appliances must have occurred no more than 6 months prior to start of
services.
2) The face-to-face
encounter must be performed by the certifying physician, a nurse practitioner
or clinical nurse specialist who is working in collaboration with the physician
in accordance with State law, a physician assistant under the supervision of
the physician, or, for patients admitted to home health immediately after an
acute or post-acute stay, the physician who cared for the patient in an acute
or post-acute facility.
A) If the certifying
physician does not perform the face-to-face encounter personally, the
non-physician practitioner or the physician who cared for the patient in an
acute or post-acute facility performing the face-to-face encounter must
communicate the clinical findings of that face-to-face patient encounter to the
certifying physician. The clinical findings must be incorporated into a written
or electronic document in the patient's medical record.
B) The certifying physician must document
that the face-to-face encounter is related to the primary reason the patient
requires medical equipment, supplies or appliances and occurred within the
timeframes described in subsection (g)(1). The documentation must indicate the
practitioner who conducted the encounter and the date of the
encounter.
3) The
face-to-face patient encounter may occur through telehealth, in compliance with
Section
140.403.
h) Starting June 1, 2019, payment
for the provision of medical equipment, supplies, prosthetic devices and
orthotic devices will only be made to enrolled providers that are accredited by
a healthcare accrediting body approved by the federal Centers for Medicare and
Medicaid Services and recognized by the Department. Accrediting bodies approved
by the federal Centers for Medicare and Medicaid Services and recognized by the
Department may be found on the DMEPOS Accreditation website at
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/DMEPOSAccreditation.html.
