Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 2
Subtitle 09 - MEDICAL CARE PROGRAMS
Chapter 10.09.12 - Disposable Medical Supplies and Durable Medical Equipment
Section 10.09.12.07 - Payment Procedures
Current through Register Vol. 51, No. 19, September 20, 2024
A. Payment procedures shall be as set forth in COMAR 10.09.36.04.
B. The provider's billed charges to the Program may not exceed the provider's customary charge. If the item is free to individuals not covered by Medicaid:
C. The provider shall give the Program the full advantage of any and all manufacturer's warranty offered on the item.
D. Effective July 1, 2022, the Department shall pay providers 85 percent of the lowest rural, non-rural, or competitive bidding area (CBA) Medicare rate established January 1 of each year for prosthetic devices. For prosthetic devices for which Medicare has not established a rate, the Department shall pay providers the manufacturer's suggested retail price of the item, less 26.5 percent. The payment shall include all fitting, dispensing, and follow-up care.
E. Charges for osteogenesis stimulators shall include all follow-up care, batteries, repairs, and replacement parts within the limitations of Regulation .05E and F, at the following times:
F. With the exception of items free to individuals not covered by Medicaid, the Department shall reimburse providers for the purchase of covered services at the lesser of the provider's customary charge or:
F-1. Enteral Nutritional Product and Enteral and Parenteral Supply Reimbursement Rates Effective February 1, 2021.
HCPCS |
HCPCS Unit |
Per Unit Rate |
B4149 |
100 cal |
$1.77 |
B4150 |
100 cal |
$0.69 |
B4152 |
100 cal |
$0.57 |
B4153 |
100 cal |
$2.03 |
B4154 |
100 cal |
$1.20 |
B4155 |
100 cal |
$1.19 |
HCPCS |
HCPCS Unit |
Per Unit Rate |
B4034 |
1 item |
$5.19 |
B4035 |
1 item |
$9.90 |
B4036 |
1 item |
$6.80 |
B4081 |
1 item |
$18.37 |
B4082 |
1 item |
$13.66 |
B4083 |
1 item |
$2.10 |
B4087 |
1 item |
$30.32 |
B4088 |
1 item |
$107.11 |
B4220 |
1 item |
$7.65 |
B4222 |
1 item |
$9.44 |
B4224 |
1 item |
$22.69 |
B9002 |
1 item |
$1,041.91 |
B9004 |
1 item |
$2,411.31 |
B9006 |
1 item |
$2,411.31 |
HCPCS |
HCPCS Unit |
Per Unit Rate |
B4102 |
500 ml |
$3.56 |
B4103 |
500 ml |
$3.33 |
B4158 |
100 cal |
$0.69 |
B4159 |
100 cal |
$0.69 |
B4160 |
100 cal |
$0.85 |
B4161 |
100 cal |
$2.03 |
B4162 |
100 cal |
$3.31 |
HCPCS |
HCPCS Unit |
Per Unit Rate |
B9998 |
1 item |
$249.90 |
B9999 |
1 item |
$249.90 |
G. The Department shall reimburse providers for the monthly rental of covered services as follows:
H. The Department reserves the right to prorate the monthly rental amount for daily rentals.
I. The Department shall pay for repairs to purchased durable medical equipment according to the following:
J. The determination to purchase or rent medical equipment shall be based on the prescriber's best faith estimate of length of time the equipment will be needed by the recipient. When the equipment is ordered for:
K. Medical equipment that is determined by the Department to require frequent and substantial servicing in order to avoid risk to the recipient's health shall be reimbursed at the rental rate in accordance with §G of this regulation until either the equipment is no longer medically necessary or the recipient is no longer eligible for Medical Assistance fee-for-service benefits.
L. Every 90 days during the rental term the provider shall obtain recertification from the prescriber and keep in the provider's records a recertification of continuous medical need that the equipment is still medically necessary.
M. The Department shall review purchase prices and rental charges for items for which Medicare has not established a rate at least every 3 years.
N. If services are provided under a contract pursuant to Regulation .04F of this chapter, the Department shall reimburse the contracted vendor or vendors at rates and under conditions in accordance with the contract or contracts.
O. Once an item has been purchased in full, then title to the equipment shall remain with the Department, and the equipment, after use by the recipient, shall be recovered by the Department or its designee. The Department may arrange for the provision of recycled equipment under an exclusive contract with a vendor or vendors that have been awarded in accordance with State regulations and policies governing contracts and procurement. The Department also may determine the geographical scope and the types of equipment, or both, to be included under the contract. The vendor or vendors shall be reimbursed at a rate and under terms established in the contract.
P. For equipment that is not covered under a contract awarded under §O of this regulation, the provider that originally furnished the equipment to the recipient shall recover the equipment after it is no longer required by the recipient. After recovery of the equipment, the provider shall determine the viability of recycling the item and, upon its reissue, bill the Program 75 percent of the Program's original payment.
Q. To the extent that the Department chooses to use an exclusive contract to provide recycled equipment under §O of this regulation, the Department shall reimburse providers for evaluation of a recipient for equipment that is subsequently provided through the Department's recycling program at 11.5 percent of the reimbursement rate established under §§A-H of this regulation.
R. The Department will authorize payment on Medicare claims if:
S. Supplemental payments on Medicare claims are made subject to the following provisions:
T. The provider may not bill the Department for:
U. The methodology in §§F and G of this regulation shall be used to establish a list of approved items with the corresponding procedure code, maximum allowable reimbursement amount, useful life expectancy, and maximum number allowed. This list shall be made available to the providers for ease of administration of the Program. When the approved list of items contains a price for a procedure code, the Department shall reimburse providers the lesser of the price listed in the approved list or the provider's customary charge unless the service is free to individuals not covered by Medicaid.
V. The provider shall ensure that the equipment is in good working condition both throughout the rental of the equipment and at the end of the rental term.
W. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.
X. Durable medical equipment and disposable medical supply rates may be increased at the Program's discretion, when the Program determines in its sole discretion that the Medicare rate creates a barrier to accessing medical equipment and supplies.
Y. Refills.
Z. The disposable medical supplies or durable medical equipment provider shall identify the individual who ordered the disposable medical supplies and durable medical equipment by recording the individual practitioner's National Provider Identifier (NPI) number on the claim.