Current through September 24, 2024
The Division of Medicaid covers the following medical
supplies when they are medically necessary and considered standard care for the
treatment of a beneficiary's medical condition and dispensed in quantities that
meet a beneficiary's medical needs without excessive utilization, including,
but not limited to: [Refer to Miss. Admin. Code Part 207 for coverage of
medical supplies in a long-term care facility.]
A. Alcohol preps, swabs, wipes and bottle are
covered for quantity or number of pints appropriate for the plan of care for
all beneficiaries for injection site cleanings, for self-administration, or
care giver administration of intramuscular or subcutaneous injections ordered
by a practitioner.
B. Apnea monitor
supplies for beneficiaries who have an apnea monitor.
1. Electrodes,
2. Lead wires, and
3. Battery pack.
C. Diabetic supplies for all beneficiaries
who meet the criteria for:
1. Blood glucose
monitors (BGM):
a) Test strips,
b) Lancets,
c) Insulin syringes,
d) Control solutions,
e) Replacement battery,
f) Spring lancet device,
g) Autoclix lancets (spring), and
h) Urine test or reagent strips.
2. Continuous glucose monitoring
(CGM):
a) CGM supply allowance covers
supplies as a bundle which includes disposable sensors and transmitter.
Supplies billed separately will not be covered.
b) DME receiver to display glucose data,
1) A DME receiver is covered if used alone or
in conjunction with a non-DME device including, but not limited to: a watch,
smartphone, tablet, laptop computer.
2) Non-DME devices will not be
covered.
3) If a DME receiver is
never used, the supply allowance will not be covered.
c) Replacement batteries.
D. Dressing supplies
for all beneficiaries.
1. 4x4 non-sterile
gauze pads,
2. 4x4 sterile gauze
pads, including drain sponges,
3.
Tape,
4. Sterile normal saline
solution, 1000 ml, and
5. Gloves,
sterile and non-sterile.
E. Biofeedback/Electromyography (EMG)
supplies for all beneficiaries who meet criteria for biofeedback/EMG.
1. Lead wires, and
2. Electrodes.
F. Enteral Feeding supplies for all
beneficiaries who meet criteria for enteral feeding pump.
1. 4x4 non-sterile gauze,
2. 4x4 sterile gauze, including drain
sponges,
3. Tape,
4. Sterile solution, 1000ml,
5. Gloves, sterile and non-sterile,
6. Feeding bag(s),
7. Feeding syringe, and
8. Sterile water, 1000ml.
G. Elbow and heel protectors for
all beneficiaries when one (1) of the following criteria is met:
1. The beneficiary is bed/chair confined and
has a history of decubitus ulcers on a heel or elbow.
2. The patient is bed/chair confined and
currently has a decubitus ulcer on a heel or elbow.
3. The beneficiary exhibits signs of redness
or discomfort at bony prominences or other areas of potential
breakdown
H. Hydrogen
peroxide for all beneficiaries who have a tracheostomy and a wound.
I. Insulin pen needles or pre-filled insulin
syringe needles for all beneficiaries receiving a prefilled insulin injection
device through the pharmacy program. Needles are covered through the medical
supply program only if one (1) of the following criteria is met:
1. The patient has very poor eyesight and is
unable to read the markings on a standard insulin syringe.
2. The patient has a condition of the hands
that will not allow them to manipulate a vial and syringe to draw up their
insulin.
J. Insulin pump
supplies for all beneficiaries who meet criteria for insulin pump.
1. Cartridges,
2. Infusion sets with cannula,
3. Skin cleanser,
4. Skin prep,
5. Alcohol prep,
6. Adhesive remover,
7. Replacement batteries, and
8. Gloves, sterile.
K. Intravenous (IV) Pump, also referred to as
an Infusion Pump, and supplies for all beneficiaries who meet criteria for an
IV pump.
1. Cassette appropriate for pump
type, and
2. Replacement
batteries.
L. IV
Supplies for all beneficiaries who meet criteria for an IV pump or an IV pole.
1. Central line supplies,
2. Administration set,
3. Tubing and clamp,
4. Extension set,
5. IV start kit,
6. Butterfly needles, all sizes,
7. IV catheters, all sizes,
8. Non-coring needles,
9. 2x2 gauze, sterile,
10. Tape, all types,
11. Syringe, any size without
needles,
12. Syringe, any type with
needle,
13. INT,
14. Flush kit,
15. Iodine prep,
16. Alcohol preps,
17. Dial-a-flow,
18. Sterile normal saline for injection -
2ml, 2.5ml, 3ml, 5ml, 10ml, 20ml, 30ml, and 50ml supplied in bottles, ampules
or vials, and
19. Gloves,
sterile.
M. Nebulizer
supplies for all beneficiaries when criteria for nebulizer are met.
1. Administration set, disposable,
non-filtered,
2. Administration
set, non-disposable, non-filtered,
3. Administration set, filtered,
4. Aerosol mask, and
5. Tubing.
N. Neuromuscular Electrical Stimulator (NMES)
supplies for all beneficiaries who meet criteria for neuromuscular electrical
stimulator.
1. Electrodes, and
2. Lead wires.
O. Ostomy supplies for all beneficiaries who
have a surgically established opening, or stoma to divert urine, feces, or
illegal contents outside the body.
P. Oxygen and oxygen related supplies are
covered for all beneficiaries who meet criteria for oxygen therapy.
1. E cylinders, including delivery,
2. H or K Cylinders, including
delivery,
3. Tubing,
4. Face masks,
5. Nasal cannulas, and
6. Regulators.
Q. Pulse oximeter supplies, which include an
oxygen probe, are covered for all beneficiaries who meet criteria for pulse
oximeter monitoring.
R. A sling for
all beneficiaries who have an injury or diagnosis which requires support or
immobilization of an upper extremity to control pain, restrict motion, prevent
further deformity, or protect the limb following trauma or surgery. The request
for coverage must be supported by the beneficiary's diagnosis, the goals for
use of the sling, and the expected duration of use.
S. Suction pump supplies (respiratory or
gastric) for all beneficiaries who meet criteria for a suction pump.
1. Respiratory suction supplies include:
a) Catheter kit, sterile,
b) Suction catheter, 8-15 FR,
c) Yankauer type respiratory
suction,
d) Respiratory suction
tubing,
e) Canister, disposable,
and
f) Gloves, any type.
2. Gastric suction supplies
include:
a) Gastric suction catheter
kit,
b) Gastric suction catheter,
8-15 FR,
c) Gastric suction whistle
tip, with valve,
d) Gastric suction
tubing,
e) Canister,
disposable,
f) Gloves, any type,
and
g) Gastric suction
tube.
T.
Supplies for maintenance of drug infusion catheter, per week, for all
beneficiaries who meet criteria for an IV pump.
1. Catheter insertion devices,
2. Dressing for catheter site,
3. Flush solutions not directly related to
drug infusion,
4.
Cannulas,
5. Needles,
6. Infusion supplies, excluding the insulin
reservoir, and
7. Gloves,
sterile.
U. Supplies for
external drug infusion pump, per cassette or bag, for all beneficiaries who
meet criteria for an IV pump.
1.
Cassettes,
2. Bags,
3. Diluting solution,
4. Tubing,
5. Other administration supplies,
6. Port charges, not used for syringe-type
reservoir,
7. Gloves,
sterile.
V. Syringes and
needles are covered for self-administration of intramuscular and/or
subcutaneous injectable medication for all beneficiaries that are performing
the administration of injections in any non-institutional setting where the
beneficiary's normal life activities take place.
W. Transcutaneous Electrical Nerve Stimulator
(TENS) supplies for all beneficiaries who meet criteria for Transcutaneous
Electric Nerve Stimulator.
1. Electrodes,
and
2. Lead wires.
X. Tracheostomy supplies for all
beneficiaries who have a tracheostomy with documentation of the specific
respiratory condition.
1. Trach mask or
collar,
2. Trach or laryngectomy
tube,
3. Trach, inner
cannula,
4. Replacement tracheal
suction catheter, any type,
5.
Trach care kit, for new trach,
6.
Trach care kit, for established trach,
7. Suction catheter kit, sterile,
8. Sterile water, 1000 ml,
9. Sterile normal saline for instillation,
supplied in 2ml, 2.5ml, 3ml, 5ml, 10ml, 20ml, 30ml, and 50 ml bottle, ampule,
or vial.
10. Trach ties,
11. Trach cleaning brush,
12. Heat and Moisture Exchangers
(HME),
13. Trach shower
protector,
14.
Tracheostomy/laryngectomy, tube plug/stop,
15. Tracheostoma filter,
16. Gauze, and
17. Gloves, sterile.
Y. Urinary catheters
1. Urinary catheters are covered for all
beneficiaries when one (1) of the following criteria is met:
a) Beneficiary must have an acute condition
which requires intermittent catheterization for measuring residual, instilling
medication, or other medically necessary indication,
b) Beneficiary has an acute condition which
requires the short-term use of an indwelling catheter,
c) Beneficiary has a chronic condition which
incontinence is exacerbating pressure sores that will not heal,
d) Beneficiary has a condition that requires
accurate measurement of intake and output on a short-term basis, or
e) Beneficiary has urinary retention that
cannot be relieved by medication.
2. Supplies include:
a) Insertion tray,
b) Irrigation tray, with bulb or piston
syringe,
c) Irrigation syringe,
bulb or piston,
d) Sterile solution
for irrigation,
e) Female external
collection device,
f) Indwelling
catheter, foley, two-way,
g)
Indwelling catheter, three-way,
h)
Male external catheter, with or without adhesive,
i) Intermittent catheter, straight
tip,
j) Bedside drainage
bag,
k) Leg bag with or without
strap,
l) Gloves,
sterile.
3. The Division
of Medicaid requires the beneficiary and/or caregiver to be capable of
performing the catheterization procedure and report results and have been
instructed in the procedure and properly demonstrated the ability to perform
the procedure.
4. The Division of
Medicaid covers condom catheters for beneficiaries with paraplegia, neurogenic
bladder, or other medically necessary indications when requested with
appropriate documentation.
Z. The Division of Medicaid covers supplies
for manual and electric breast pumps.
AA. Incontinence Garments
1. The Division of Medicaid covers the
following disposable incontinence garments:
a)
Diapers,
b) Pull-ons, and
c) Underpads.
2. The Division of Medicaid covers up to six
(6) units of incontinence garments per day for beneficiaries aged three (3) and
above only when certified as medically necessary. Prior authorization is
required for quantities in excess of the limit.
a) One (1) unit is equal to one (1) diaper or
one (1) pull-on or one (1) underpad.
b) The six (6) units can consist of any
combination of diapers, pull-ons and/or underpads.
3. A beneficiary must have a diagnosis of
incontinence or must meet one (1) of the following criteria due to a documented
medical condition in order for the incontinence garments to be considered
medically necessary:
a) Inability to utilize
regular toilet facilities.
b)
Inability to physically turn self or reposition self.
c) Inability to transfer self from bed to
chair or wheelchair without assistance.
4. The physician must order all incontinence
garments and maintain documentation of the medical necessity and diagnosis of
incontinence in the beneficiary's medical record.
5. The durable medical equipment (DME)
provider must maintain in the beneficiary's record a current certificate of
medical necessity (CMN), signed by the ordering physician and must include:
a) An initial physician's order,
b) The beneficiary's diagnosis along with
associated diagnoses and code(s),
c) The anticipated frequency and duration of
need,
d) The requested quantity per
month,
e) A detailed description of
the item(s) including the type, size and corresponding Healthcare Common
Procedure Coding System (HCPCS) code for each,
f) The ordering physician's signature and
date of signature. Signature stamps, date stamps, or the signature of anyone
other than the ordering physician is not acceptable.
6. The DME provider must have a current
physician's order and CMN to initiate or continue the provision of incontinence
garments to a beneficiary.
a) The CMN must be
renewed every six (6) months.
b)
For those cases where there is documentation justifying the need for
incontinence garments for beneficiaries whose medical condition is chronic,
recertification is only required every twelve (12) months.
7. The DME provider must maintain
documentation of proof of delivery of incontinence garments including:
a) Beneficiary's name,
b) Date of delivery which must be the date
the beneficiary received the item; including the dates of service the delivered
quantity is expected to last,
c)
Delivery address,
d) Detailed
description of incontinence garments delivered,
e) Quantity delivered, and
f) The signature of the beneficiary,
caregiver, or family member who received the supplies.
1) During a national or statewide emergency,
a signature is not required.
2)
During a national or statewide emergency, the provider must document the
emergency and confirmation of delivery by an alternate means including, but not
limited to:
(a) Telephone,
(b) Text message, or
(c) Other electronic communication.
8. DME
providers:
a) Are allowed to deliver
incontinence garments in quantities expected to last no more than a one (1)
month's supply.
b) Are not allowed
to dispense items to a beneficiary who already has at least a one (1) month's
supply on hand.
c) Must make
contact, either orally or in writing, with each beneficiary and/or their legal
representative or guardian to confirm the current need before delivering
additional incontinence garments.
d) Must keep documentation of the monthly
contact on file.
9. DME
providers must supply size, waist, and weight appropriate incontinence garments
based on the beneficiary's current measurements.
10. The DME provider must submit a new CMN
form signed and dated by the ordering physician detailing changes and medical
necessity to the Division of Medicaid or designee if DME provider needs to
amend the initial order for incontinence garments being delivered due to a
change in the beneficiary's size or underlying medical condition.
11. DME providers must maintain documentation
of measurements and medical conditions in the beneficiary's record which
supports reimbursement for the specific size of incontinence
garments.
42 U.S.C. §
1395 m; Miss. Code Ann. §§
43-13-117,
43-13-121.
