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Utah Administrative Code (Current through November 1, 2019) |
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R414. Health, Health Care Financing, Coverage and Reimbursement Policy |
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R414-70. Medical Supplies, Durable Medical Equipment, and Prosthetic Devices |
| R414-70-1. Introduction and Authority |
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(1) This rule governs the provision of medical supplies, durable medical equipment (DME), and prosthetic device services. (2) This rule is authorized by Sections 26-18-3 and 26-1-5. (3) As required by Section 26-18-2.3, the Department provides these services in an efficient, economical manner, safeguarding against unnecessary, unreasonable, or inappropriate use of these services. |
| R414-70-2. Definitions |
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As used in this rule: (1) "Durable medical equipment" or "DME" means equipment that: (a) can withstand repeated use; (b) is primarily and customarily used to serve a medical purpose; and (c) generally is not useful to a person in the absence of an illness or injury. (2) "Entitled to nursing facility services" means an individual who: (a) is in a nursing facility and whose nursing facility stay is covered by Medicaid; or (b) is receiving services in a waiver program for individuals who require nursing facility level of care. (3) "Individual eligible for optional services" means an individual who is not entitled to nursing facility services. (4) "Individual entitled to mandatory services" means an individual who is entitled to nursing facility services. (5) "Medical supplies" means items for medical use that are disposable or semi-disposable and are non-reusable. (6) "Medical Supplies and Durable Medical Equipment Manual" means services described in the Utah Medicaid Provider Manual, Section 2, Medical Supplies and Durable Medical Equipment, as incorporated in Section R414-1-5. (7) "Prosthetic device" means replacement, corrective, or supportive devices such as braces, orthoses, or prosthetic limbs prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice as defined by state law to: (a) artificially replace a missing portion of the body; (b) prevent or correct physical deformities or malfunction; or (c) support a weak or deformed portion of the body. |
| R414-70-3. Services |
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(1) Medical supplies, DME, and prosthetic devices are optional services. (2) Medical supplies, DME, and prosthetic devices are limited to services described in the Medical Supplies and Durable Medical Equipment Manual. (3) The Medical Supplies and Durable Medical Equipment Manual specifies the reasonable and appropriate amount, duration, and scope of the service sufficient to reasonably achieve its purpose. (4) Medical supplies, DME, and prosthetic devices may be provided to an individual only as part of a written plan that is reviewed at least annually by a physician. (5) The home health agency must meet the face-to-face requirement, as stated in Section R414-1-30, or the Department may deny or recover reimbursement. |
| R414-70-4. Services for Individuals Eligible for Optional Services |
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(1) An individual eligible for optional services may receive medical supplies, DME, and prosthetic devices as described in the Medical Supplies and Durable Medical Equipment Manual. (2) An individual eligible for optional services must meet the criteria established in the Medical Supplies and Durable Medical Equipment Manual and obtain prior approval if required. |
| R414-70-5. Services for Individuals Eligible for Mandatory Services |
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(1) An individual entitled to mandatory services may receive medical supplies, DME, and prosthetic devices as described in the Medical Supplies and Durable Medical Equipment Manual. (2) An individual eligible for mandatory services must meet the criteria established in the Medical Supplies and Durable Medical Equipment Manual and obtain prior approval if required. (3) An individual entitled to mandatory services may request an agency review to seek medical supplies and DME not listed in the Medical Supplies and Durable Medical Equipment Manual. |
| R414-70-6. Services for Individuals Residing in Long Term Care Facilities |
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(1) The Department provides medical supplies, DME, and prosthetic devices to individuals residing in a nursing care facility or an ICF/MR as part of the per diem payment. (2) An individual residing in a nursing care facility or ICF/MR may receive additional medical supplies, DME, and prosthetic devices only as specifically indicated in the Medical Supplies and Durable Medical Equipment Manual. (3) An individual residing in a nursing care facility or an ICF/MR may request an agency review to seek medical supplies and DME not listed in the Medical Supplies and Durable Medical Equipment Manual. |
| R414-70-7. Less Costly Alternative |
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The Department may provide at its discretion services not described in the Medical Supplies and Durable Medical Equipment Manual as provided in Section R414-1-6. |
| R414-70-8. Reimbursement |
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Medical supplies, DME, and prosthetic devices are reimbursed using the fee schedule in Attachment 4.19-B of the Medicaid State Plan and incorporated by reference in Section R414-1-5. |