Current through Register Vol. 35, No. 18, September 24, 2024
A.
Reimbursement for purchase or rental: Unless otherwise specified
in this section, the provider's billed charges must be the usual and customary
charge for the item or service. The term "usual and customary charge" refers to
the amount that the individual provider charges the general public in the
majority of cases for a specific item or service. Reimbursement for DME,
medical supplies and nutritional products is made at the lesser of:
(1) the provider's billed charges or the MAD
fee schedule; or
(2) when there is
no applicable MAD fee schedule, payment is limited to the provider's
acquisition invoice cost plus a percentage, as follows.
(a) DME, medical supplies and nutritional
products:
(i) items for which the provider's
actual acquisition cost, reflecting all discounts and rebates, is less than
$1,000, payment is limited to the provider's actual acquisition cost plus 20
percent;
(ii) items for which the
provider's actual acquisition cost, reflecting all discounts and rebates, is
$1,000 or greater, payment is limited to the provider's actual acquisition cost
plus 10 percent;
(b) for
a custom specialized wheelchair and its customized related accessories, payment
is limited to the provider's actual acquisition cost plus 15 percent.
B.
Rental
payments must be applied towards the purchase with the exception of
ventilators: Unless otherwise specified in this section, the provider's
billed charges must be the usual and customary charge for the item or service.
Reimbursement for rental of DME is made at the lesser of:
(1) the provider's billed charges;
or
(2) the MAD fee schedule, when
applicable; payment for the month of rental is limited to the provider's
acquisition invoice cost plus a percentage as follows:
(a) the provider must keep a running total of
rental payments for each piece of equipment;
(b) the provider must consider the item sold
and the item becomes the property of the MAP eligible recipient when 13 rental
payments have been made for the item;
(c) the provider must consider the item sold
and the item becomes the property of the MAP eligible recipient when the rental
payments total the lesser of the provider's usual and customary charge for the
purchase of the item or the MAD fee schedule for the purchase of the
item;
(d) or for an item for which
a fee schedule purchase price has not been established by MAD when the provider
has received rental payments equal to one of the following:
(i) items for which the provider's actual
acquisition cost, reflecting all discounts and rebates, is less than $1,000,
payment is limited to the provider's actual acquisition cost plus 20
percent;
(ii) items for which the
provider's actual acquisition cost, reflecting all discounts and rebates, is
$1,000 or greater, payment is limited to the provider's actual acquisition cost
plus 10 percent;
(3) MAD follows medicare regulations
regarding capped rental; for rental months one through three, the full fee
schedule rental fee is allowed; for rental months four through 13, the rental
fee schedule rental fee is reduced by 25 percent; no additional rental payments
are made following the 13th month or to the most
current schedule determined by medicare; the provider may only bill for routine
maintenance and for repairs, and oxygen contents to the extent as allowed by
medicare;
(4) oxygen is paid using
the medicare billing, capped rental period, and payment rules;
(5) the provider must retain a copy of his or
her acquisition invoice showing the provider's purchase of an item and make it
available to MAD or its designee upon request;
(6) set-up fees are considered to be included
in the payment for the equipment or supplies and are not reimbursed as a
separate charge.
C.
Reimbursement for home infusion drugs: Unless otherwise specified
in this rule, the provider's billed charges must be the usual and customary
charge for the item or service. Home infusion drugs are reimbursed at the
lesser of:
(1) the provider's billed charge;
or
(2) the MAD fee
schedule;
(3) for home infusion
drugs for which a fee schedule price has not been established by MAD, or for
which the description associated with the appropriate billing code is too broad
to establish a reasonable payment level, payment is limited to the provider's
acquisition cost plus 20 percent; a provider must retain a copy of his or her
acquisition invoice showing the provider's purchase of an item and make it
available to MAD or its designee upon request.
D.
Reimbursement for delivery and
shipping charges: Delivery charges are reimbursed at the MAD maximum
amount per mile. Shipping charges are reimbursed at actual cost if the method
used is the least expensive method. MAD does not pay for charges for shipping
items from a supplier to the provider.
E.
Reimbursement limitations:
MAD does not cover DME or medical supplies that do not meet the definition of
DME as described in Section 12 of this rule. The following criteria are applied
to each request as part of the determination of non-coverage:
(1) items that do not primarily serve a
therapeutic purpose or are generally used for comfort or convenience
purposes;
(2) environment-control
equipment that is not primarily medical in nature;
(3) institutional equipment that is not
appropriate for home use;
(4) items
that are not generally accepted by the medical profession as being
therapeutically effective or are determined by medicare regulations to be
ineffective or unnecessary;
(5)
items that are hygienic in nature;
(6) hospital or physician diagnostic
items;
(7) instruments or devices
manufactured for use by PCP;
(8)
exercise equipment not primarily medical in nature or for the sole purpose of
muscle strengthening or muscle stimulation without a medically necessary
purpose;
(9) support exercise
equipment primarily for institutional use;
(10) items that are not reasonable or
necessary for monitoring the pulse of a homebound MAP eligible recipient with
or without a cardiac pacemaker;
(11) items that are used to improve
appearance or for comfort purposes;
(12) items that are precautionary in nature
except those needed to prevent urgent or emergent events; and
(13) a provider or medical supplier that
routinely supplies an item to a MAP eligible recipient must document that the
order for additional supplies was requested by the MAP eligible recipient or
his or her authorized representative and the provider or supplier must confirm
that the MAP eligible recipient does not have an excess of a 15 calendar day
supply of the item before releasing the next supply to the MAP eligible
recipient.
