60.06-2
Medical Supplies and DME
Requirements
Medical Supplies and DME must meet all of the following
requirements:
A. Comply with the
criteria in Section 60, including the definitions in Section
60.01;
B. Be prescribed by a Qualified
Provider;
C. Be provided to a
member who is not in a hospital, unless necessary for transition to home, in
which case the provider must comply with the criteria for emergency rental in
this Section;
D. Have
scientifically valid clinical evidence of their efficacy and not be considered
investigational or experimental by the Department;
E. Be approved and defined by the Food and
Drug Administration;
F. Be
cost-effective;
G. Have a warranty
that includes parts and labor;
H.
Be provided by a MaineCare authorized provider of Medical Supplies and DME who
has a location where members can procure repairs and servicing of items with
warranties and guarantees or meet one of the exceptions outlined in this
Section; and
I. A member's need for
medical supplies, equipment, and appliances must be reviewed by a physician or
other Qualified Provider annually.
J.
Durable Medical Equipment
Only. The prescribing provider must maintain documentation that includes
a statement verifying the date of the face-to-face encounter for that specific
piece of DME and the name of the Qualified Provider who performed the
face-to-face encounter.
60.06
-3
Reasonable and Necessary for Treatment
All DME and supplies must be certified as reasonable and
necessary by the prescribing provider. In making such a determination, the
following criteria shall be met:
A.
The equipment is medically necessary;
B. The equipment serves a different purpose
than equipment already available to the member; and the equipment is not an
upgrade for currently functioning equipment that meets members' basic needs and
already supplied to the member;
C.
The equipment is not more costly than a medically appropriate and realistically
feasible alternative plan of care;
D. The cost of the item is not
disproportionate to the therapeutic benefits which could ordinarily be derived
from use of the equipment;
E. The
item is not Home/Environmental modifications, which do not meet the definition
of Medical Supplies or DME and are not covered under this Section;
and
F. Providers must retain
documentation, if applicable, indicating the equipment can freely pass through
all entryways without the need for modification or, if applicable, retain
documentation indicating that necessary modifications or structural changes
have occurred prior to the request for authorization.
60.06 -4
Rental and/or Purchase
The Department shall rent and/or purchase items
consistent with Medicare practices. If Medicare makes an item available for
both purchase and rental, the Department or its authorized entity shall decide
between rental and purchase of the item on a case by case basis based on
medical necessity.
A.
Rental
1. All rental equipment
except for emergency equipment must receive PA. Please refer to the PA section
regarding emergency equipment. The request for continued PA of services must
indicate the emergency dates of services.
2. The Department decides when to purchase
rented equipment if a member requires its use for an extended period of time.
If the Department decides to purchase the rented equipment, the total rental
paid to date will be applied to the MaineCare allowed purchase price as listed
in the fee schedule or as otherwise set by the Department.
3. Unless otherwise authorized under this
section, rental rates include the cost of servicing, repairs or other
maintenance and include replacement parts for defective equipment and
disposable items. The Department is not responsible for the cost of repairs
(including labor or replacement parts) for rented items or equipment.
4. All rented equipment must be clean and in
proper working condition when delivered.
B.
Outright Purchase of New DME
1. The Department may purchase outright any
DME if the member will use it for an extended period of time. Once an item is
purchased, it becomes the property of the member.
2. The Department reserves the right to
purchase the necessary equipment at the lowest price available and to
preferentially choose equipment that includes a warranty.
3. All purchased equipment must be new and
unused, clean, in proper working condition, free from defects, and meet all
implied and expressed warranties.
C.
Outright Purchase of Used
Equipment
Used equipment will be reimbursed on a prorated basis
using the remaining useful life of the equipment based on Generally Accepted
Accounting Principles (GAAP) applied to the MaineCare rate of reimbursement. To
qualify for payment, a DME provider must complete a PA form(see Section 60.06).
The equipment being reconditioned must not exceed the expense for new
equipment.
D.
Delivery, Installation, and Member Instructional Time
The maximum allowable fee for purchase or rental of
equipment includes the following:
1.
Cost of delivery to the inside of the member's residence and, when appropriate,
to the room in which the equipment will be used;
2. Assembly of parts, installation, and
set-up of the equipment or customized fitting;
3. Instruction to the member or caregivers in
the safe and proper use of the equipment or supplies, sufficient to ensure that
they have demonstrated they can provide necessary service and/or use of the
equipment or supplies. Instructions to ensure safe and proper use of the
equipment or supplies and any limitations on replacement.
60.06-7
Replacement of DME
Replacement will not be allowed in cases of malicious
damages, culpable neglect, or when the member or responsible party has sold,
given away, thrown out, or wrongfully disposed of the DME. DME that is
functioning properly will not be replaced, unless a change in the member's
condition requires a change of DME.
A.
Replacement of all DME is allowed for the following reasons:
1. Irreparable damage or wear that affects
the essential performance of the DME;
2. A change in the member's condition that
requires a change of DME. In such cases, the Department requires a current
prescribing provider's order documenting the need for the change; or
3. Repairing the DME (parts and labor) would
cost more than sixty (60) percent of the replacement cost of the DME.
B.
Additional Rules for
Hearing Aids1. Members age twenty-one
(21) years and older, in addition to the criteria above, are eligible to
receive one (1) hearing aid or one (1) replacement pair every five (5) years.
PA will be required and must meet the criteria specified in section
60.06-2.
2. Members under the age of twenty-one (21),
are eligible to receive a replacement hearing aid once per year as medically
necessary and as identified and referenced in the MaineCare Benefits
Manual, Section
94.
C.
Additional Rules for
Automatic Positive Airway Pressure (APAP) andContinuous Positive Airway
Pressure (CPAP) Devices [GREATORE THAN OR EQAL TO] five (5) years old
1. The DME supplier is required to perform an
assessment on the device before the Department will consider replacement or
repair;
2. If there is no obvious
external reason as to why the device is no longer functioning properly, the DME
supplier is required to submit a written attestation detailing this;
OR
3. If the reason the device is
not functioning is obvious, the DME supplier is required to submit
documentation, including repair cost information, to the Department. Repair
criteria can be viewed in section
60.06-2. Prior
Authorization for repair is required and must meet the criteria specified in
section 60.06-2.
D.
Additional Rules for
Bilevel Positive Airway Pressure (Bi-PAP) Devices [GREATORE THAN OR EQUAL
TO]five (5) years old
1. The DME
supplier is required to perform an assessment on the device before the
Department will consider replacement or repair;
2. If there is no obvious external reason as
to why the device is no longer functioning properly, the DME supplier is
required to send the device to the Manufacturer for assessment;
3. Once the assessment has been completed,
the DME supplier is required to submit documentation, including repair cost
information, to the Department. Repair criteria can be viewed in section
60.06-2. Prior
Authorization for repair is required and must meet the criteria specified in
section 60.06-2.
60.06-8
Requirements for Medical Supplies and DME for Members Residing in Their
Home
A. Covered Medical Supplies and
DME may be provided to members for use in any setting in which normal life
activities take place, other than a hospital or any setting in which payment is
or could be made under MaineCare for inpatient services that include room and
board. Special rules apply for Medical Supplies provided to members in Nursing
Facilities (NF) and intermediate care facility for individuals with
intellectual disabilities (ICF- IID).
B. Providers may not bill under this section
for routine Medical Supplies essential for the home health agency to carry out
the physician's plan of care for members receiving home health services (see
Section 40 of the
MaineCare Benefits Manual).
C. Post-surgical supplies will be covered as
long as medically necessary as certified by the prescribing provider. Providers
may not dispense more than a thirty-four (34) day supply at a time, with the
exception of items specified in section
60.0713.
D. Equipment or items that are used primarily
for purposes of safety or physical restraint are not covered, including
enclosed cribs and beds and barred enclosures. Physical restraints are defined
as any physical or mechanical device, material, or equipment, attached or
adjacent to the member's body that the member cannot remove easily and which
restricts freedom of movement or normal access to one's body.
E. Items used for positioning that meet the
definition of Medical Supplies or DME are not considered restraints and are
covered when medically necessary.
60.06-9
Medical Supplies and DME Not
Covered for Members in an NF or ICF-IID
The Department will not reimburse DME providers for
Medical Supplies and DME, including upgrades and add-ons, provided to MaineCare
members residing in a NF or ICF-IID that are considered part of that facility's
regular rate of reimbursement. Some supplies and equipment provided to members
in a NF or ICF-IID as part of the regular rate are listed below and are
included for reference only.
Facilities that serve a special group of individuals with
disabilities are expected to furnish that equipment which is normally used in
their care (e.g. children's wheelchairs) as a part of their reasonable
cost.
The following items may not be billed by either the
facility or supplier.
1. Alcohol,
swabs and rubbing
2. Analgesics,
non-prescription:
a) aspirin: plain buffered
and coated suppositories.
b)
Acetaminophen: tablets, liquids, and suppositories.
3. Antacids, non-prescription:
a) aluminium/magnesium hydroxyde (ex.
Maalox)
b) Aluminium/magnesium
hydroxyde with simethicone (ex. Mylanta, Maalox Plus)
c) Calcium carbonate tablets (ex.
Tums)
d) Calcium carbonate/
magnesium hydroxyde tablets (ex. Rolaids).
4. Alternating pressure pads, air mattresses,
"egg crate" mattresses, gel mattresses
5. Applicators
6. Bandages
7. Band-Aids
8. Basins
9. Beds, standard hospital type, not
therapy
10. Bed pans
11. Bed rails
12. Blood pressure equipment
13. Bottles, water
14. Canes
15. Calcium supplements, non-prescription
(ex. Tums, Oscal).
16.
Catheters
17. Catheter trays,
disposable
18. Chairs, standard and
geriatric
19. Commodes
20. Corner chair
21. Cotton
22. Cough syrup and expectorants, all
non-prescription brands
23.
Crutches
24. Cushions (e.g.,
comfort rings), excluding wheelchair cushions that require mounting
hardware
25 Dietary
supplements
26.
Disinfectants
27. Douche trays,
disposable
28. Dressings
29. Enema equipment
30. Enteral feeding, supplies, and
equipment.
31. Facility
deodorants
32. Gauze bandages,
sterile or non-sterile
33.
Glucometers
34. General service
supplies such as administration of oxygen and related medications, hand
feeding, incontinency care, tray service, and enemas
35. Gloves, sterile or non-sterile
36. Gowns
37. Ice bags
38. Incontinency supplies (full brief- all
sizes; bed pad; undergarment liners, disposable or reusable; under
pads)
39. Irrigation
trays
40. Laundry services,
personal (including supplies and equipment)
41. Laxatives, non-prescription: Stool
softeners (ex. Docusate sodium liquid or capsule). Bulk: (ex. Psyllium).
Stimulants: (ex. Bisacodyl tablets and suppositories; docusate casanthranol,
liquid and/or capsule). Enemas: (ex. Saline, phosphate types-except Fleets);
oil retention. Misc.: milk of magnesia; glycerin suppositories; lactulose and
analogs (when used as a laxative); mineral oil.
42. Lubricants, skin, bath oil
43. Mats - ICF- IID only
44. Ointments and creams, available over the
counter, including petroleum jelly and hydrocortisone 0.5%
45. Ophthalmic lubricants, tears and
ointments
46. Oxygen, for emergency
and prn use only, including portable oxygen and equipment
47. Parenteral supplies and
equipment
48. Pillows
49. Pitchers, water
50. Powders, medicated and baby
51. Prone boards
52. Restraints, poseys, thoracic chest
supports, wedge pillows, etc.
53.
Sand and water tables - ICF- IID only
54. Sensory stimulation materials- ICF- IID
only
55. Sheepskin pads, any size
or style
56. Shower
chairs
57. Soap, including
hypoallergenic
58. Special dietary
supplements
59. Specimen
containers
60. Sterile I.V. or
irrigation solution
61.
Stethoscopes
62. Supplies,
non-prescription, necessary for the treatment for decubitis
63. Suture sets
64. Swabs, medicated or unmedicated
65. Syringes and needles
66. Tapes
67. Testing materials to be used by staff of
facility, not to include materials normally included in psychometric testing -
ICF- IID only
68.
Thermometers
69. Towels,
washcloths
70. Tongue
depressors
71. Traction
equipment
72. Trapezes
73. Tub seats
74. Tubes, gavage, lavage, etc.
75. Under pads
76. Urinals
77. Urinary drainage equipment and supplies
(disposable)
78. Velcro strips -
ICF- IID only
79. Vestibular boards
- ICF- IID only
80. Vitamins,
non-prescription, all brands
81.
Walkers
82. Wheelchairs, standard,
including those with removable or adjustable trays, arm and leg rests including
elevators, pediatric, "hemi" chairs, reclining wheelchairs, lightweight
wheelchairs, high strength light-weight wheelchairs, ultra-light-weight
wheelchairs, heavy duty wheelchairs, extra heavy-duty wheelchairs and other
manual wheelchairs/base.
83. Wipes,
rectal medicated
84. Routine
personal hygiene and grooming items to include, but not be limited to items for
shaving, shampooing, bathing, nail clipping (unless specified as a covered
service when performed by a podiatrist as covered under the MaineCare
Benefits Manual), haircutting or the services of a barber when
requested and paid for by the member. Examples of items include but not limited
to: combs, lotions, mouthwash, toothbrushes, toothpaste, shampoo (regular,
medication and non-tears baby shampoo), sunscreen and tissues.
