Current through Vol. 41, No. 20, July 1, 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.
