No. 29535: R414-70. Medical Supplies, Durable Medical Equipment, and Prosthetic Devices

DAR File No.: 29535
Filed: 05/31/2007, 01:54
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This proposed rule is changed based on public comments that Medicaid received regarding its wheelchair policy. It is also changed to clarify Medicaid policy regarding mandatory and optional services, in relation to durable medical equipment (DME), medical supplies, and prosthetic devices.

Summary of the rule or change:

This change clarifies policy for providing wheelchairs for use in the home by correcting an error from the previous filing. It also clarifies policy for DME, medical supplies, and Medicaid coverage and noncoverage of prosthetic devices. It further removes language which states that medical necessity determines the provision of a prosthetic device because medical necessity does not govern the provision of optional services. (DAR NOTE: This change in proposed rule has been filed to make additional changes to a proposed new rule that was published in the March 15, 2007, issue of the Utah State Bulletin, on page 21. Underlining in the rule below indicates text that has been added since the publication of the proposed rule mentioned above; strike out indicates text that has been deleted. You must view the change in proposed rule and the proposed new rule together to understand all of the changes that will be enforceable should the agency make this rule effective.)

State statutory or constitutional authorization for this rule:

Sections 26-18-3 and 26-1-5

Anticipated cost or savings to:

the state budget:

There is no budget impact because the clarifications of Medicaid policy do not restrict ongoing services for Medicaid clients.

local governments:

There is no budget impact because local governments do not provide medical supplies, durable medical equipment, or prosthetic devices for Medicaid clients.

other persons:

There is no budget impact because the clarifications of Medicaid policy do not restrict ongoing services for Medicaid clients.

Compliance costs for affected persons:

There is no budget impact because the clarifications of Medicaid policy do not restrict ongoing services for Medicaid clients.

Comments by the department head on the fiscal impact the rule may have on businesses:

No fiscal impact on business is anticipated as a result of the changes in this rule. No change from current practice is intended by this rule. David N. Sundwall, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

Direct questions regarding this rule to:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [e-mail]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

07/16/2007

This rule may become effective on:

07/23/2007

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-70. Medical Supplies, Durable Medical Equipment, and Prosthetic Devices.

R414-70-1. Introduction and Authority.

(1) Medically necessary medical supplies, including disposable medical supplies, durable medical equipment, and prosthetic devices are available to recipients who are living at home.

(2) This rule is authorized by Sections 26-18-3 and 26-1-5, Utah Code Annotated.

(3) The authority for this program is found in 42 CFR 440.120(c), 440.130(d), 441.15(a)(3), and 440.70(b)(3).

(4) Durable Medical Equipment (DME) and medical supplies are mandatory services. Prosthetic devices are optional services as referenced in 42 CFR 440.225.

 

. . . . . . .

 

R414-70-6. Durable Medical Equipment.

(1) Medically necessary durable medical equipment, such as manual and power wheelchairs, commodes, bathing aids, oxygen concentrators, hospital beds, ventilators, CPAP machines, BiPAP machines, and ambulatory aids, such as canes and crutches, are benefits for recipients residing at home. All special adaptations and design of DME is limited to utilization in the home.

(2) Medicaid covers repairs to DME.

(3) The Department will pay for a particular DME item once every five years from the original purchase date. Additional replacement DME may be provided if the recipient demonstrates medical necessity to the Department.

(4) The Department may purchase or rent DME at its option.

(5) Wheelchairs which are suitable for use in the home are a benefit.[ if the recipient's condition is of such severity that without the use of a wheelchair, the recipient would be confined to bed or chair at least 19 hours or more each day without functional ambulation.]

(a) Medicaid will pay for one wheelchair for a recipient.

(b) If Medicaid has supplied a wheelchair, Medicaid will not repair or service an alternate, patient-owned wheelchair.

(c) A standard wheelchair with attachments, components or accessories; a customized, manual wheelchair; or a motorized wheelchair may be provided if the recipient demonstrates medical necessity to the Department and the wheel chair is designed for use in the home. Special attachments, accessories and modifications for use outside the home are not covered.

(d) The recipient or primary care giver must be capable of routine wheelchair care and management.

(e) Wheelchair repairs

(i) Medicaid covers repairs for only one wheelchair. The provider must obtain authorization from the Department before making any repairs.

(ii) Repairs do not include routine maintenance, such as changing tires, inspecting the chair, changing batteries, grease, and oil.

(iii) Repairs to a rental chair are not a benefit.

(iv) Re-upholstery is a benefit if the warranty has expired, the original upholstery is beyond repair, not the result of abuse and neglect, and is medically necessary.

(f) A recipient who requires a wheelchair for employment, vocational development, or educational purposes must seek this benefit through the appropriate funded state agency. Medicaid coverage is limited to use in the home and not for employment, educational, or recreational needs.

 

R414-70-7. Prosthetic Devices and Appliances.

(1) [Prosthetic devices,]Medicaid covers prosthetic devices that include hearing aids, special orthopedic appliances, prosthetic limbs, prosthetic eyes, braces, and orthoses[ are covered]. Medicaid does not cover prosthetic devices that include special shoes, cochlear implants, augmentative speech devices, and wigs or hair replacement after chemotherapy.[DME devices including wheelchairs and standers are not prosthetic devices under this rule.]

(2) Repairs and parts for artificial limbs are a benefit if medically necessary.

(3) Attachments and modifications to artificial limbs are a benefit.

(4) Duplicative appliances such as an artificial leg plus a wheelchair are not a benefit unless there is documentation that it is medically necessary to have both devices.

(5) The Department will pay for a particular item once every five years from the original purchase date. A replacement prosthetic device may be provided more often[ but only if the recipient demonstrates medical necessity to the Department].

 

. . . . . . .

 

R414-70-9. Non Covered Items.

The following are not benefits:

(1) Items used primarily for hygiene, education, exercise, convenience, cosmetic purposes, social interaction, or comfort of the recipient.

(2) Modifications of DME or supplies for reasons of convenience, cosmetics, or comfort.

(3) DME for use outside the home, including wheelchair, wheelchair attachments, accessories and modifications for use outside the home.

(4) Equipment permanently attached or mounted to a building or a vehicle such as ramps, lifts, and bathroom rails.

(5) Routine maintenance such as cleaning, greasing and oiling of purchased equipment.

(6) Repairs to DME or prosthetic devices if:

(a) the recipient does not own the device or use the device in his home;

(b) the repair or part is for equipment which is not a benefit;

(c) the repair is covered by a warranty; or

(d) the damage is the result of abuse or neglect.

(7) First aid supplies not referenced in Section 5(2)(c).

(8) Non-medical supplies, devices, or products that are not primarily and customarily used to serve a medical purpose or generally are not useful to an individual in the absence of an

illness or injury

(9) Lifts in furniture to aid a patient to a standing position;

(10) Specialized or non-standard tires or wheels on wheelchairs are not a benefit unless medically necessary for use in the patient's home.

(11) Cervical pillows;

(12) Shoes not attached to a brace;

(13) Shoe repair;

(14) Non-prescription braces and supports;

(15) Reflux boards;

(16) Items purchased by the patient through mail order;

(17) A second oxygen system;[ and]

(18) Glucose monitors;

(19) Cochlear implants;

(20) Augmentative speech devices; and

(21) Wigs or hair replacement following chemotherapy.

 

R414-70-10. Reimbursement.

Medical supplies, DME and prosthetic devices are reimbursed using the established fee schedule as established in the Utah Medicaid State Plan and incorporated by reference in R414-1-5.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: 2007

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3