Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 60 - Durable Medical Equipment Program › Section 13 CSR 70-60.010 - Durable Medical Equipment Program

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment incorporates the requirements
				  of federal regulation,
				  42 CFR
				  440.70. These changes include a definition of
				  where durable medical equipment (DME) services may be provided, and adds
				  face-to-face encounter and documentation requirements. In addition, this
				  amendment updates terminology, the MO HealthNet Division website address, and
				  the incorporated by reference date.
(1) Administration. The MO HealthNet Durable
				Medical Equipment (DME) program shall be administered by the Department of
				Social Services, MO HealthNet Division. The services and items covered and not
				covered, the program limitations, and the maximum allowable fees for all
				covered services shall be determined by the Department of Social Services, MO
				HealthNet Division and shall be included in the DME provider manual, which is
				incorporated by reference and made a part of this rule as published by the
				Department of Social Services, MO HealthNet Division, 615 Howerton Court,
				Jefferson City, MO 65109, at its website at
http://manuals.momed.com/collections/collection_dme/print.pdf
,
				September 6, 2019. This rule does not incorporate any subsequent amendments or
				additions.
(2) Persons Eligible.
				Any person who is eligible for MO HealthNet benefits as determined by the
				Family Support Division is eligible for DME when the DME is medically necessary
				. DME must be prescribed by the participant's physician and reviewed by the
				physician annually. Covered services are limited as specified in the DME
				provider manual.
(3) Reimbursement.
				Payment will be made for each unit of service or item provided in accordance
				with the fee schedule determined by the MO HealthNet Division. Reimbursement
				will not exceed the lesser of the maximum allowed amount determined by the MO
				HealthNet Division or the provider's billed charge. Reimbursement for DME
				services is made on a fee-for-service basis. The MO HealthNet maximum allowable
				fee for a unit of service has been determined by the MO HealthNet Division to
				be a reasonable fee, consistent with efficiency, economy, and quality of care.
				Sales tax is not covered by MO HealthNet, nor can it be billed to the
				participant. Providers must accept the MO HealthNet payment as the full and
				complete payment and may not accept additional payment from the participant.
				Charges for shipping, freight, COD, handling, delivery, and pickup are included
				in the reimbursement for items covered under the DME program and are not
				billable to the MO HealthNet participant.
(4) Definition for Durable Medical Equipment
				and appliances. DME is equipment and appliances that can withstand repeated
				use, can be reusable or removable, is primarily and customarily used to serve a
				medical purpose, generally is not useful to a person in the absence of a
				disability, illness, or injury, and is appropriate for use in any setting in
				which normal life activities take place as defined in
				42 CFR
				440.70(c)(1). All
				requirements of the definition must be met in order for the equipment to be
				covered by MO HealthNet.
				42 CFR
				440.70 is published by the Federal Register,
				at
https://www.ecfr.gov/
. A copy of
				42 CFR
				440.70 as of January 3, 2020, is incorporated
				by reference and made part of this rule as published by the Department of
				Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO
				65109, at its website at
https://dssruletracker.mo.gov/dss-proposed-rules/welcome.action
.
				This rule does not incorporate subsequent amendments or additions.
(5) Provider Participation.
(A) The following types of providers may be
				reimbursed by MO HealthNet for items covered under the DME program if they are
				enrolled MO HealthNet DME providers and enrolled with Medicare as a durable
				medical equipment prosthetic and orthotic supplier: rental and sales providers,
				prosthetic fabricators, rehabilitation centers, orthotic fabricators,
				physicians (includes M.D., D.O., podiatrists-may dispense orthotic devices and
				artificial larynx), advanced practice nurses in a collaborative practice
				arrangement, pharmacies, and hospitals.
(B) MO HealthNet participants are required to
				obtain services from Missouri or bordering state providers. MO HealthNet will
				consider enrollment of an out-of-state (non-bordering) durable medical
				equipment provider only if-
1. Medicare
				covered services are provided to patients who have both MO Health-Net and
				Medicare; or
2. The item needed is
				not available or does not have a comparable substitute from Missouri or
				bordering state providers.
(C) If the provider requests authorization
				for equipment or supplies for a MO Health-Net patient who is not also Medicare
				eligible or requests authorization for services that are available or have a
				comparable substitute in Missouri or a bordering state, the out-of-state
				(non-bordering) provider may be subject to sanctions and any amounts paid by
				the MO HealthNet Division will be recouped.
(D) The enrolled MO HealthNet provider shall
				agree to-
1. Keep any records necessary to
				disclose the extent of services the provider furnishes to participants;
				and
2. On request, furnish to the
				MO HealthNet Division or State Medicaid Fraud Control Unit any information
				regarding payments claimed by the provider for furnishing services under the
				plan.