Current through Vol. 42, No. 1, September 16, 2024
(a)
Medical supplies, equipment and appliances. Reimbursement for
medical supplies, equipment, and appliances will be made using an amount
derived from the lesser of the Oklahoma Health Care Authority (OHCA) maximum
allowable fee or the provider's usual and customary charge. The maximum
allowable fee is the maximum amount that the OHCA will pay a provider for an
allowable procedure. When a code is not assigned a maximum allowable fee for a
unit of service, a fee will be established.
(1) The fee schedule will be reviewed
annually. Adjustments to the fee schedule may be possible at any time based on
efficiency, budget considerations, federal regulations, and quality of care as
determined by the OHCA.
(2) Payment
for medical supplies, equipment, and appliances will be calculated using the
rate methodologies found in the Oklahoma Medicaid State Plan.
(3) Payment is not made for medical supplies,
equipment, and appliances that are not deemed as medically necessary or
considered over-the-counter.
(4)
OHCA does not reimburse medical supplies, equipment, and appliances providers
separately for services that are included as part of the payment for another
treatment program. For example, all items required during inpatient stays are
paid through the inpatient payment structure.
(5) Medical supplies, equipment, and
appliance products purchased at a pharmacy are paid the equivalent to the
Medicare Part B allowed charge. When the Medicare Part B allowed charge is not
available, an equivalent price is calculated using ASP or wholesale acquisition
cost (WAC). If no Medicare, ASP, or WAC pricing is available, then the price
will be calculated based on invoice cost.
(b)
Manually-priced medical equipment
and supplies. There may be instances when manual pricing is required.
When it is, the following pricing methods will be used:
(1)
Invoice pricing.
Reimbursement is at the provider's documented manufacturer's suggested retail
price (MSRP) minus thirty percent (30%) or at the provider's invoice cost plus
thirty percent (30%), whichever is the lesser of the two.
(2)
Fair market pricing. OHCA
may establish a fair market price through claims review and analysis. For a
list of medical equipment and supplies that are fair market-priced, refer to
the OHCA website at
www.okhca.org for the
fair market value list (Selected medical supplies, equipment, and appliance
items priced at fair market price).
(c)
Oxygen equipment and
supplies. Payment for stationary oxygen systems (liquid oxygen systems,
gaseous oxygen systems, and oxygen concentrators) is based on continuous
rental, i.e., a continuous monthly payment that is made as long as it is
medically necessary. The rental payment includes all contents and supplies,
e.g., regulators, tubing, masks, etc. Portable oxygen systems are considered
continuous rental. Ownership of the equipment remains with the supplier.
(1) Separate payment will not be made for
maintenance, servicing, delivery, or for the supplier to pick up the equipment
when it is no longer medically necessary. In addition, the provider/supplier
will not be reimbursed for mileage.
(2) Payment for oxygen and oxygen equipment
and supplies will not exceed the Medicare fee for the same procedure
code.
(3) For residents in a
long-term care facility, durable medical equipment products, including oxygen,
are included in the facility's per diem rate.
