Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 1 - Medicaid Services › Section 907 KAR 1:479 - Durable medical equipment covered benefits and reimbursement

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				205.520,
				205.560,
				42
				C.F.R. Part 414, 424.57,
				440.230,
				45 C.F.R. Part 160,
				162.1002, Part 164,
				42
				U.S.C. 1320d,
				1395m,
				1395w-4,
				1396d(i)
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
				Family Services, Department for Medicaid Services, has responsibility to
				administer the Medicaid Program.
				KRS
				205.520(3) authorizes the
				cabinet, by administrative regulation, to comply with any requirement that may
				be imposed, or opportunity presented, by federal law to qualify for federal
				Medicaid funds. This administrative regulation establishes the provisions
				relating to coverage and reimbursement requirements for durable medical
				equipment, medical supplies, prosthetics, and orthotics.
Section 1. Definitions.
(1) "Certificate of Medical Necessity" or
			 "CMN" means a form required by the department to document medical necessity for
			 durable medical equipment, medical supplies, prosthetics, or
			 orthotics.
(2) "CMS" means the
			 Centers for Medicare and Medicaid Services.
(3) "Covered benefit" or "covered service"
			 means an item of durable medical equipment, a prosthetic, an orthotic, or a
			 medical supply for which coverage is provided by the department.
(4) "Customized" means that an item has been
			 constructed, fitted, or altered to meet the unique medical needs of an
			 individual Medicaid recipient and does not include the assemblage of modular
			 components or the addition of various accessories that do not require unique
			 construction, fitting, or alteration to individual specifications.
(5) "Date of service" means:
(a) The date the durable medical equipment,
			 prosthetic, orthotic, or supply (DMEPOS) is provided to the
			 recipient;
(b) For mail order
			 DMEPOS, the later of the shipping date or the date the recipient was discharged
			 home from an inpatient hospital stay or nursing facility;
(c) For DMEPOS delivered to a recipient's
			 home immediately subsequent to a hospital inpatient stay, the date of final
			 discharge; or
(d) Up to two (2)
			 calendar days prior to discharge from a hospital or nursing facility if:
1. The item was provided for purposes of
			 fitting or training of the patient;
2. The item is ready for use in the
			 recipient's home; and
3. Billing is
			 not done prior to the date of the recipient's discharge from the
			 facility.
(6)
			 "Department" means the Department for Medicaid Services or its
			 designee.
(7) "DMEPOS" means
			 durable medical equipment, prosthetics, orthotics, or supplies.
(8) "Durable medical equipment" or "DME"
			 means medical equipment that:
(a) Withstands
			 repeated use;
(b) Is primarily and
			 customarily used to serve a medical purpose;
(c) Is generally not useful to a person in
			 the absence of an illness or injury; and
(d) Is appropriate for use in the
			 home.
(9) "Healthcare
			 common procedure coding system" or "HCPCS" means a collection of codes
			 acknowledged by the Centers for Medicare and Medicaid Services (CMS) that
			 represents procedures or items.
(10) "Home" means a place where the recipient
			 resides excluding:
(a) A nursing
			 facility;
(b) A hospital;
(c) An intermediate care facility for
			 individuals with an intellectual disability; or
(d) An institution for mental diseases as
			 defined by
			 42
			 U.S.C.
			 1396d(i).
(11) "Incidental" means that a medical
			 procedure or service:
(a) Is performed at the
			 same time as a more complex primary procedure or service; and
(b)
1.
			 Requires little additional resources; or
2. Is clinically integral to the performance
			 of the primary procedure or service.
(12) "Invoice price" means an itemized
			 account of a manufacturer's actual charges that are billed to a supplier for
			 goods or services provided by the manufacturer or distributor.
(13) "Medicaid Program DME Fee Schedule"
			 means a list, located at
http://chfs.ky.gov/dms
., that:
(a) Contains the current Medicaid maximum
			 allowable amount established by the department for a covered item of durable
			 medical equipment, a prosthetic, an orthotic, or a medical supply;
			 and
(b) Is updated at least
			 quarterly to coincide with the quarterly updates made by the Centers for
			 Medicare and Medicaid Services as required by
			 42 U.S.C.
			 1395m and
			 1395w-4
			 and 42 C.F.R. Part 414 .
(14) "Medical supply" means an item that is:
(a) Consumable;
(b) Nonreusable;
(c) Disposable; and
(d) Primarily and customarily used to serve a
			 medical purpose.
(15)
			 "Medically necessary" or "medical necessity" means that a covered benefit is
			 determined to be needed in accordance with
			 907
			 KAR 3:130.
(16) "Medicare accreditation" means having
			 met the quality standards established in
			 42 U.S.C.
			 1395m(a)(20).
(17) "Mutually exclusive" means that two (2)
			 DMEPOS items:
(a) Are not reasonably provided
			 in conjunction with each other during the same patient encounter on the same
			 date of service;
(b) Represent
			 duplicate or very similar items; or
(c) Represent medically inappropriate use of
			 HCPCS codes.
(18)
			 "Nutritional supplement" means a liquid or powder administered enterally or
			 orally that is specially formulated to supply complete diagnosis-appropriate
			 nutrition, including kilocalories, protein, vitamins, and minerals.
(19) "Orthotic" means a mechanical device or
			 brace that is designed to support or correct a defect or deformity or to
			 improve the function of a movable part of the body.
(20) "Prescriber" means a physician,
			 podiatrist, optometrist, dentist, advanced practice registered nurse, physician
			 assistant, or chiropractor who:
(a) Is acting
			 within the legal scope of clinical practice under the licensing laws of the
			 state in which the health care provider's medical practice is
			 located;
(b) If the individual is
			 an enrolled Kentucky Medicaid provider, is in compliance with all requirements
			 of:
1.
											907
			 KAR 1:671; and
2.
											907
			 KAR 1:672;
(c) Is in good standing with the appropriate
			 licensure board and CMS; and
(d)
			 Has the legal authority to write an order for a medically necessary item of
			 durable medical equipment, a medical supply, a prosthetic, or an orthotic for a
			 recipient.
(21) "Prior
			 authorization" means approval that a supplier shall obtain from the department
			 before being reimbursed.
(22)
			 "Prosthetic" means an item that replaces all or part of the function of a body
			 part or organ.
(23)
			 "Reasonableness" means:
(a) The expense of the
			 item does not exceed the therapeutic benefits that could ordinarily be derived
			 from use of the item;
(b) The item
			 is not substantially more costly than a medically-appropriate alternative;
			 and
(c) The item does not serve the
			 same purpose as an item already available to the recipient.
(24) "Supplier" means a
			 Medicare-certified provider of durable medical equipment, medical supplies,
			 prosthetics, or orthotics who is enrolled in the Kentucky Medicaid
			 Program.
(25) "Usual and customary
			 charge" means the uniform amount that a supplier bills to the general public
			 for a specific covered benefit.