New York Codes, Rules and Regulations
Title 18 - DEPARTMENT OF SOCIAL SERVICES
Chapter II - Regulations of the Department of Social Services
Subchapter E - Medical Care
Article 3 - Policies and Standards Governing Provision of Medical and Dental Care
Part 505 - Charges For Professional Health Services
Section 505.5 - Durable medical equipment; medical/surgical supplies; orthotic and prosthetic appliances; orthopedic footwear
Universal Citation: 18 NY Comp Codes Rules and Regs ยง 505.5
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Definitions.
(1) Durable medical equipment means devices
and equipment, other than prosthetic or orthotic appliances, which have been
ordered by a practitioner in the treatment of a specific medical condition and
which have all of the following characteristics:
(i) can withstand repeated use for a
protracted period of time;
(ii) are
primarily and customarily used for medical purposes;
(iii) are generally not useful to a person in
the absence of an illness or injury; and
(iv) are usually not fitted, designed or
fashioned for a particular individual's use. Where equipment is intended for
use by only one person, it may be either custom-made or customized.
(2) Medical/surgical supplies
means items for medical use other than drugs, prosthetic or orthotic
appliances, durable medical equipment, or orthopedic footwear which have been
ordered by a practitioner in the treatment of a specific medical condition and
which are usually:
(i) consumable;
(ii) nonreusable;
(iii) disposable;
(iv) for a specific rather than incidental
purpose; and
(v) generally have no
salvageable value.
(3)
Orthotic appliances and devices mean those appliances and devices which are
used to support a weak or deformed body member; or to restrict or eliminate
motion in a diseased or injured part of the body.
(4) Orthopedic footwear means shoes, shoe
modifications, or shoe additions which are used to correct, accommodate or
prevent a physical deformity or range o f motion malfunction in a diseased or
injured part of the ankle or foot; or to support a weak or deformed structure
of the ankle or foot. Orthopedic shoes must have, at a minimum, the following
features:
(i) Blucher or Bal
construction;
(ii) leather
construction or synthetic material of equal quality;
(iii) welt construction with a cement
attached outsole or sewn on outsole;
(iv) upper portion properly fitted as to
length and width; no unit sole; bottom sized to the last;
(v) closure appropriate to foot condition.
Velcro strap or lace closure preferred except in circumstances when a patient
is unable to use them;
(vi) full
range of width, not just narrow, medium, wide; and
(vii) extended medial counter and firm heel
counter.
(5) Prosthetic
appliances and devices mean those appliances and devices (excluding artificial
eyes and dental prostheses) ordered by a qualified practitioner which replace
any missing part of the body.
(6)
Practitioner means a physician, dentist, podiatrist, physician assistant, or
nurse practitioner.
(7) Provider,
for purposes of this section, means a pharmacy, certified home health agency,
medical equipment and supply dealer, hospital, residential health facility, or
clinic enrolled in the medical assistance program as a medical equipment
dealer.
(8) The terms written order
or fiscal order are used interchangeably in this section and mean any original,
signed written order of a practitioner which requests durable medical
equipment, prosthetic or orthotic appliances and devices, medical/surgical
supplies, or orthopedic footwear.
(9) Acquisition cost means the line item cost
to the provider. Shipping and handling charges are not reimbursable under the
medical assistance program.
(10)
Acquisition price means that price determined and periodically adjusted by the
State Health Department, which it deems a prudent Medicaid provider would pay
for a reasonable quantity of generically equivalent enteral products.
(b) Written order required.
(1) All durable medical
equipment, medical/surgical supplies, orthotic and prosthetic appliances and
devices, and orthopedic footwear may be furnished only upon a written order of
a practitioner.
(i) The ordering of durable
medical equipment, medical/surgical supplies, orthotic and prosthetic
appliances and devices, and orthopedic footwear is limited to the
practitioner's scope of practice.
(ii) The ordering of durable medical
equipment, medical/surgical supplies, orthotic and prosthetic appliances and
devices, and orthopedic footwear is limited to practitioners not excluded from
participating in the medical assistance program.
(2) All orders must show the name, address,
telephone number of the practitioner and the name and identification number of
the recipient for whom ordered.
(3)
When used in the context of an order for a prescription item, the order must
also meet the requirements for a prescription under section 6810 of
the Education Law. When used in the context of a nonprescription item, the
order must also contain the following information: name of the item, quantity
ordered, size, catalog number as necessary, directions for use, date ordered,
and number of refills, if any.
(4)
An original fiscal order for medical/surgical supplies must not be filled more
than 14 days after it has been written by the practitioner unless prior
approval or prior authorization is required for the item.
(i) An order for medical/surgical supplies
will not be refilled unless the ordering practitioner has indicated the number
of refills on the order. All refills must reference the original
order.
(ii) The maximum number of
refills permitted for medical/surgical supplies is found in the fee schedule
for durable medical equipment, medical/surgical supplies, orthotic and
prosthetic appliances and orthopedic footwear. The fee schedule for such
equipment and supplies is available free of charge from the Medicaid fiscal
agent's website.
(iii) No order can
be refilled more than 180 days from the original date ordered.
(c) Review of claims.
(1) The identity of the
practitioner who ordered the durable medical equipment, medical/surgical
supply, prosthetic or orthotic appliance or device, or orthopedic footwear must
be recorded by the provider on the claim for payment by entering in the license
or MMIS provider identification number of the practitioner where
indicated.
(2) Written orders for
durable medical equipment, medical/surgical supplies, prosthetic or orthotic
devices, or orthopedic footwear must be maintained by the provider submitting
the claim for audit by the department or other authorized agency for six years
from the date of payment.
(3) The
financial liability of the ordering practitioner as well as the provider of any
durable medical equipment, medical/surgical supplies, orthotic and prosthetic
appliances or devices or orthopedic footwear determined on audit not to be
medically necessary is set forth in Part 518 of this Title.
(d) Payment.
(1) General payment policy. General payment
policy.
(i) Payment for durable medical
equipment, medical/surgical supplies, orthotic and prosthetic appliances and
devices, and orthopedic footwear is limited to providers enrolled in the
medical assistance program as medical equipment dealers. Payment for
medical/surgical supplies is also available to providers enrolled in the
medical assistance program as pharmacies.
(ii) Reimbursement amounts are payment in
full. No separate or additional payments will be made for shipping, handling,
delivery or necessary fittings and adjustments.
(iii) Payment will not be made for items
provided by a facility or organization when the cost of these items is included
in the rate.
(iv) Payment for items
provided by a not-for-profit provider will be made at the acquisition
cost.
(v) Any insurance payments
including Medicare must be applied against the total purchase price of the
item.
(vi) Reimbursement amounts
for unlisted items are determined by the New York State Department of Health
and must not exceed the lower of:
(a) the
acquisition cost to the provider plus 50 percent; or
(b) the usual and customary price charged to
the general public.
(vii) The provider is responsible for any
needed replacements or repairs that are due to defects in quality, or
workmanship.
(2) Payment
for durable medical equipment. Payment for durable medical equipment.
(i) Payment for purchase of durable medical
equipment must not exceed the lower of:
(a)
the maximum reimbursable amount as shown in the fee schedule for durable
medical equipment, medical/surgical supplies, orthotics and prosthetic
appliances and orthopedic footwear; the maximum reimbursable amount will be
determined for each item of durable medical equipment based on an average cost
of products representative of that item; or
(b) the usual and customary price charged to
the general public for the same or similar products.
(ii) When there is no price listed in the fee
schedule for durable medical equipment, medical/surgical supplies, orthotics
and prosthetic appliances and orthopedic footwear, payment for purchase of
durable medical equipment must not exceed the lower of:
(a) acquisition cost as established by
invoice detailing the line item cost to the provider from a manufacturer or
wholesaler net of any rebates, discounts or valuable consideration, mailing,
shipping, handling, insurance or sales tax plus 50 percent; or
(b) the usual and customary price charged to
the general public for the same or similar products.
(iii) When the primary payor is Medicare,
payment for the purchase of durable medical equipment shall be the amount
approved by title XVIII of the Medicare Program.
(iv) All rentals of durable medical
equipment, except those subject to partial reimbursement under the Medicare
program, require prior approval from the New York State Department of Health.
The rental payment must not exceed the lower of the monthly rental charge to
the general public or the price determined by the New York State Department of
Health. The total accumulated monthly rental charges may not exceed the actual
purchase price of the item. Rental payment includes all necessary equipment,
delivery, maintenance and repair costs, parts, supplies and services for
equipment set-up, maintenance and replacement of worn essential accessories or
parts.
(3) Payment for
medical/surgical supplies. Payment for medical/surgical supplies.
(i) Payment for medical/surgical supplies
listed in the fee schedule for durable medical equipment, medical/surgical
supplies, orthotic and prosthetic appliances and orthopedic footwear must not
exceed the lower of:
(a) the price as shown
in the fee schedule for durable medical equipment, medical/surgical supplies,
orthotic and prosthetic appliances and orthopedic footwear; or
(b) the usual and customary price charged to
the general public.
(ii)
The fee schedule for medical/surgical supplies is available from the department
and is also contained in the department's MMIS Provider Manual (Durable Medical
Equipment, Medical/Surgical Supplies, Orthotic and Prosthetic Appliances).
Copies of the manual may be obtained by writing Computer Sciences Corporation,
Health and Administrative Services Division, 800 North Pearl St., Albany, NY
12204. Copies may also be obtained from the Department of Social Services, 40
North Pearl St., Albany, NY 12243. The manuals are provided free of charge to
every provider of durable medical equipment, medical/surgical supplies,
orthotic and prosthetic appliances and orthopedic footwear at the time of
enrollment in the MA program.
(4) Payment for orthotic and prosthetic
appliances and devices.
(i) Payment for
prosthetic and orthotic appliances and devices must not exceed the lower of:
(a) the price as shown in the fee schedule
for durable medical equipment, medical/surgical supplies, orthotic and
prosthetic appliances and orthopedic footwear; or
(b) the usual and customary price charged to
the general public.
(ii)
Payment for orthotists and prosthetists for home visits is set forth in the fee
schedule for durable medical equipment, medical/surgical supplies, prosthetic
and orthotic appliances and orthopedic footwear.
(iii) The fee schedule for orthotic and
prosthetic appliances and devices is available free of charge from the Medicaid
fiscal agent's website.
(5) Payment for orthopedic footwear. Payment
for orthopedic footwear.
(i) Payment for
orthopedic footwear must not exceed the lower of:
(a) the maximum reimbursable amount as shown
in the fee schedule for durable medical equipment, medical/surgical supplies,
orthotics and prosthetic appliances and orthopedic footwear; the maximum
reimbursable amount will be determined for each item of footwear based on an
average cost of products representative of that item; or
(b) the usual and customary price charged to
the general public for the same or similar products.
(ii) Orthopedic shoes must be provided by a
provider who has submitted proof of certification or approval from the American
Board for Certification in Orthotics and Prosthetics.
(6) Payment for oxygen must not exceed the
lower of:
(i) the acquisition cost to the
provider plus 50 percent; or
(ii)
the usual and customary price charged to the general public.
(7) Payment for hearing aid
batteries is reimbursed at retail less 20 percent updated on a periodic
basis.
(8) Payment for enteral
therapy must not exceed the lower of:
(i) the
acquisition price plus 30 percent for generically equivalent products as shown
in the fee schedule for durable medical equipment, medical surgical supplies,
prosthetic and orthotic appliances and orthopedic footwear; or
(ii) the usual and customary charge to the
general public.
(e) Service limitations.
(1) Items of durable medical equipment,
medical/surgical supplies, orthotic and prosthetic appliances and devices, and
orthopedic footwear are limited in their amount and frequency and require prior
authorization. Service limits and prior authorization requirements are listed
in the provider manual at the Medicaid fiscal agent's website.
(2) From time to time the department may
impose additional service limitations on items of durable medical equipment,
medical/surgical supplies, orthotic and prosthetic appliances and devices or
orthopedic footwear. The department will notify providers in writing before it
implements additional limitations.
(3) The department may allow exceptions to
the limitations established under this paragraph where the ordering
practitioner attests to medical necessity and the item must be replaced because
it is worn or has been lost or stolen.
(f) Prior approval and prior authorization requirements.
(1)
Orthopedic shoes can be provided only on the basis of an examination by and a
signed, original written fiscal order of, a qualified physician or podiatrist
and upon the prior authorization of the department.
(2) From time to time the department may
require the prior authorization of items of durable medical equipment,
medical/surgical supplies, orthotic or prosthetic appliances and devices, or
orthopedic footwear. When prior authorization is required for these items, the
items can be provided only on the basis of an examination by, and a signed,
original written fiscal order of, a qualified practitioner and upon the prior
authorization of the department. Providers will be notified in writing by the
department before it implements requirements for the prior authorization of any
item.
(3) When an appliance or
device is recommended by a qualified practitioner on the staff of a state
mental hygiene facility for a medical assistance recipient in the family care
program, prior approval or authorization is not required.
(g) Benefit limitations. The department shall establish defined benefit limits for certain Medicaid services as part of its Medicaid State Plan. The department shall not allow exceptions to defined benefit limi tations. The department has established defined benefit limits on enteral nutritional formulas. Enteral nutritional formulas are limited to coverage for:
(1) tube-fed individuals who
cannot chew or swallow food and must obtain nutrition through formula via tube;
(2) individuals with rare inborn
metabolic disorders requiring specific medical formulas to provide essential
nutrients no t available through any other means;
(3) children under age 21 when caloric and
dietary nutrients from food cannot be absorbed or metabolized; and
(4) persons with a diagnosis of HIV
infection, AIDS, or HIVrelated illness, or other disease or condition, who are
oral-fed and who:
(i) require supplemental
nutrition, demonstrate documented compliance with an appropriate medical and
nutritional pla n of care, and have a body mass index under 18.5 as defined by
the Centers for Disease Control, up to 1,000 calories per day; or
(ii) require supplemental nutrition,
demonstrate documented compliance with an appropriate medical and nutritio nal
plan of care, and have a body mass index under 22 as defined by the Cente rs
for Disease Control and a documented, unintentional weight los s of five
percent or more within the previous six month period, up to 1,000 calories per
day; or
(iii) require total
nutritional support, have a permanent structural limitation that prevents the
chewing of food, and the placement of a feeding tube is medically
contraindicated.
Disclaimer: These regulations may not be the most recent version. New York may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
