Current through Register Vol. 45, No. 52, December 27, 2023
(a)
(1) The maximum permissible charge for the
purchase of durable medical equipment, medical/surgical supplies, and orthotic
and prosthetic appliances shall be the fee payable for such equipment or
supplies under the Official New York Workers' Compensation Durable Medical
Equipment Fee Schedule, third edition, January 19, 2022, prepared and published
by the Board, which is hereby incorporated by reference, available for viewing
free of charge on the Board's website.
(2) The maximum permissible monthly charge
for the rental of durable medical equipment shall be the rental price listed in
the Official New York Workers' Compensation Durable Medical Equipment Fee
Schedule multiplied by the total number of months or weeks respectively for
which the durable medical equipment is needed. In the event the total rental
charge exceeds the purchase price, the maximum permissible charge for the
durable medical equipment shall be the purchase price listed in the Official
New York Workers' Compensation Durable Medical Equipment Fee Schedule, whether
or not the claimant keeps the durable medical equipment or returns it when no
longer needed.
(3) Within six
months of the effective date of this section, all durable medical equipment and
supplies shall be provided (a) by a New York State Medicaid Enrolled Supplier
and (b) in accordance with the Ground Rules therefore as set forth in the
Official New York Workers' Compensation Durable Medical Equipment Fee Schedule,
except for durable medical equipment provided as part of medical treatment
provided in conformity with the Ground Rules of the Official New York Workers'
Compensation Medical Fee Schedule. A supplier's MMIS ID number must be
submitted with every bill for durable medical equipment. The Official New York
State Workers' Compensation Durable Medical Equipment Fee Schedule for durable
medical equipment, medical/surgical supplies, and orthotic and prosthetic
appliances incorporated by reference herein is available on the Board's website
at wcb.ny.gov.
(b)
(1) Prior authorization in accordance with
section 442.4 must be obtained when indicated on the Official New York State
Workers' Compensation Durable Medical Equipment Fee Schedule for any durable
medical equipment prior to prescribing or supplying.
(2) When a medical provider recommends
durable medical equipment that is not listed in the Official New York Workers'
Compensation Durable Medical Equipment Fee Schedule, prior authorization,
including a proposed purchase price or rental price for such equipment, must be
obtained and provided within the prior authorization request prior to
prescribing or supplying such durable medical equipment.
(d) Self-insured employers and insurance
carriers, including their agents and designees, shall not direct a claimant to
use a particular supplier of durable medical equipment, medical/surgical
supplies, and orthotic and prosthetic appliances, except as part of a certified
preferred provider organization in accordance with Workers' Compensation Law
Article 10-A and Subpart 325-8 of this Title. Self-insured employers and
insurance carriers, including their agents and designees, may recommend a
supplier of durable medical equipment, medical/surgical supplies, and orthotic
prosthetic appliances.
(e)
Notwithstanding any other provision to the contrary, the chair may make other
adjustments to the durable medical equipment fee schedule as he or she deems
appropriate, upon a finding that the reimbursement provided for a particular
piece of durable medical equipment, medical/surgical supply or other such item
under the fee schedule is grossly inadequate to meet the suppliers' or
pharmacies' costs, and following 30 days notice on its website and
consideration of any comments provided in response to such notice. Requests for
such adjustments to the fee schedule shall be submitted to the Bureau of Health
Management, 100 Broadway, Menands, Albany, NY 12241.
(f) Hearing aids are not considered durable
medical equipment for purposes of this fee schedule and the reimbursement is
the provider's usual and customary price.
(g) The Medicaid provider manual and the
policy guidance for durable medical equipment are not included as part of the
durable medical equipment fee schedule used in workers' compensation cases
except to the extent such documents contain the Medicaid durable medical
equipment fee schedule.
Amended
New
York State Register March 3, 2021/Volume XLIII, Issue 09, eff.
6/7/2021
Amended
New
York State Register December 22, 2021/Volume XLIII, Issue 51,
eff. 12/22/2021
Amended
New
York State Register April 13, 2022/Volume XLIV, Issue 15, eff.
4/13/2022
