D.C. Mun. Regs. tit. 29, r. 29-997

Current through Register Vol. 72, No. 2, January 10, 2025

Rule 29-997 - DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND SUPPLIES

997.1

The Department of Health Care Finance (DHCF), the single state agency for the administration of medical assistance programs authorized under titles XIX and XXI of the Social Security Act, shall ensure the provision of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) to qualified Medicaid beneficiaries in accordance with the requirements of this section and the D.C. Medicaid DMEPOS Provider Billing Manual. All providers of DMEPOS shall be enrolled as such by DHCF in accordance with Provider Screening and Enrollment regulations and policies and § 996 of Title 29 District of Columbia Municipal Regulations (DCMR).

997.2

DHCF shall ensure that each Medicaid beneficiary retains their freedom of choice of DMEPOS providers, in accordance with 42 CFR § 431.51.

997.3

To be eligible for Medicaid reimbursement of DMEPOS provided to a beneficiary under these rules, the following requirements shall be met:

(a) The cost of the item shall be reasonable;

(b) The item shall be ordered by a physician or other licensed practitioner of the healing arts operating within the scope of practice allowed under the District of Columbia Health Occupations Revision Act of 1985, as amended, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code §§ 3-1201.01et seq.) and implementing rules, as well as all other applicable federal and District laws;

(c) The ordering practitioner shall be enrolled as a provider in the District Medicaid Program;

(d) The ordering practitioner and DMEPOS provider shall provide their National Provider Identification (NPI) numbers on the prescription, DMEPOS Request and Prior Authorization Form (Form 719(A)), and claim;

(e) In accordance with 42 CFR § 440.70, DMEPOS under the home health services benefit shall be provided to a beneficiary at their place of residence, or in any setting in which normal life activities take place.

(f) DMEPOS shall not be provided to a beneficiary in the following settings:

(1) A hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities (ICF/IID) (except for DMEPOS in an ICF/IID that is not required to be provided by the facility under 42 CFR Part 483, Subpart I); or

(2) Any setting in which payment is or could be made under Medicaid for inpatient services that include room and board; and

(g) The beneficiary's need for the DMEPOS shall be reviewed annually by the ordering practitioner operating within the scope of practice as set forth under District law.

997.4

Prior to DHCF making any payment for DMEPOS, the following requirements must be met:

(a) The ordering practitioner shall ensure that DHCF Form 719(A) Prior Authorization Request and any supporting documentation include, at minimum, descriptions of the following:

(1) The beneficiary's condition;

(2) The diagnosis related to the need for the DMEPOS item;

(3) Any complicating medical conditions;

(4) The functional abilities and limitations of the beneficiary, using assessments based on the standards described in § 997.8;

(5) The anticipated duration of the condition;

(6) The physical examination findings; and

(7) The potential for rehabilitation, if applicable.

(b) No more than six (6) months prior to the start of services, a face-to-face encounter, which may be provided via telehealth, with the beneficiary shall be conducted by one of the following practitioners:

(1) The beneficiary's physician;

(2) A nurse practitioner;

(3) A physician assistant; or

(4) For beneficiaries admitted to home health immediately after an acute or post-acute stay, the attending acute or post-acute practitioner.

(c) The ordering physician or allowed non-physician practitioner shall document that there was a face-to-face encounter with the beneficiary in accordance with the following requirements:

(1) The face-to-face encounter must be related to the primary reason the beneficiary requires DMEPOS and must occur no more than six (6) months prior to the start of services; and

(2) The order must indicate the name of the practitioner who conducted the face-to-face encounter and the date of the encounter.

997.5

For a beneficiary up to twenty-one (21) years of age, who is entitled to the early and periodic screening, diagnosis, and treatment (EPSDT) benefit, covered items shall be limited to DMEPOS that are included within the scope of the definition set forth in Section 1905(r) of the Social Security Act (42 USC § 1396d(r)) .

997.6

Medicaid reimbursement of DMEPOS shall require prior authorization by DHCF or its designee for the following:

(a) DMEPOS items that exceed specific criteria and/or require prior authorization, as set forth in the D.C. Medicaid Provider Billing Manual and D.C. Medicaid Fee Schedule, available online at www.dcmedicaid.com;

(b) DMEPOS items that are billed using miscellaneous codes or that require manual pricing;

(c) Items of durable medical equipment (DME) that exceed five-hundred dollars ($500) in purchase price, unless exempted from the requirement as indicated on the fee schedule;

(d) Customized equipment; and

(e) DME, prosthetics, and orthotics, outside of the warranty period, that require repair or replacement.

997.7

For items that require prior authorization in order to be reimbursed by Medicaid, as set forth in § 997.6, the following tasks shall be completed:

(a) The prescribing clinician, as identified on the prescription provided in accordance with § 997.3(b), shall complete the clinical portion of DHCF Form 719(A) and provide the form to the DMEPOS provider for completion;

(b) The DMEPOS provider shall present the completed Form 719(A), including the corresponding prescription, to DHCF or its designee for approval; and

(c) The DMEPOS provider shall collect and submit supporting documentation and invoices to DHCF or its designee for review and approval.

997.8

DHCF or its designee shall use national standards, such as InterQual or other nationally recognized assessment tools, to assess the reasonableness and necessity of all DMEPOS items that require prior authorization.

997.9

A provider shall not receive Medicaid reimbursement for a DMEPOS item requiring prior authorization under § 997.6, if the item is delivered before DHCF or its designee has issued a prior authorization.

997.10

To receive Medicaid reimbursement for DMEPOS, a qualified physician or other practitioner of the healing arts, operating within the scope of practice outlined in the District of Columbia Health Occupations Revision Act of 1985, effective March 25, 1986, as amended (D.C. Law 6-99; D.C. Official Code §§ 3-1201.01et seq.) and implementing rules, shall review a beneficiary's continued need for any DMEPOS item as appropriate based on the beneficiary's condition, but on at least an annual basis, subject to the following exception:

(a) DHCF shall not require a review of a beneficiary's continued need for DMEPOS in the case of a child with respect to either prescribed oxygen or oxygen equipment or both.

997.11

Information set forth in the D.C. Medicaid DMEPOS Provider Billing Manual shall govern specific criteria regarding Medicaid reimbursement for the following categories of DMEPOS:

(a) Mobility assistive equipment; and

(b) Oxygen and oxygen equipment.

997.12

Where a previously approved prior authorization period has expired, a DMEPOS provider shall not provide to a beneficiary any new item for which prior authorization is required, as set forth in § 997.6, until DHCF or its designee has issued a new prior authorization number for the new period. If a prior authorization has previously been issued for an item to a different DMEPOS provider, the current DMEPOS provider shall include a reference to the original prior authorization number on the Form 719(A) submitted to DHCF or its designee for approval.

997.13

Medicaid reimbursement of DMEPOS shall be subject to the following standards:

(a) DHCF shall establish maximum reimbursement rates for items included under the DMEPOS benefit and shall set forth these rates in the D.C. Medicaid Fee Schedule, available online at www.dc-medicaid.com;

(b) All rates for DMEPOS shall be subject to a pricing analysis by DHCF or its designee. The pricing analysis may consider the following:

(1) Beneficiary's condition;

(2) Brand comparison;

(3) Anticipated duration of beneficiary's need for the item;

(4) Warranty coverage and conditions;

(5) Medicare local coverage and pricing determinations;

(6) Pricing under other jurisdictions' Medicaid programs;

(7) Usual and customary pricing; or

(8) Discounts;

(c) For any DMEPOS item that is determined to be covered under the District Medicaid program, but is not included on the D.C. Medicaid Fee Schedule, DHCF shall price the item using the process described in § 997.13(b);

(d) For a beneficiary enrolled in both Medicare or other private insurance and Medicaid, a DMEPOS provider shall first bill the private insurance or Medicare program when providing any item to the beneficiary. If private insurance or Medicare denies the claim, the provider may then submit the remittance advice along with the claim to DHCF or its designee. A DMEPOS provider shall not bill a dual eligible beneficiary for any amount not paid by Medicare. Failure to adhere to these requirements may subject the DMEPOS provider to termination of its Medicaid Provider Agreement;

(e) If a prescribing clinician or DMEPOS provider receives a discount for an item ordered for use by a Medicaid beneficiary, the prescribing clinician and/or DMEPOS provider shall subtract the amount of the discount from the amount for which reimbursement is sought prior to submitting the claim to DHCF. Failure to comply with the requirements of this paragraph may result in denied claims, temporary suspension of payments, or termination of the Medicaid Provider Agreement;

(f) A DMEPOS provider shall provide original documentation reflecting all discounts that apply to the cost of any item provided to a Medicaid beneficiary;

(g) A DMEPOS provider shall produce proof of delivery for all items that are provided to a Medicaid beneficiary, which may include:

(1) Receipts that are signed by the beneficiary who requires DMEPOS, or their legal representative; or

(2) Delivery confirmation; and

(h) Except for items deemed necessary under the EPSDT benefit, the following shall not be covered under the DMEPOS benefit:

(1) Replacement of an item while it is still under warranty or before the item meets the associated life expectancy, unless prior authorization is obtained;

(2) Ventilators;

(3) Acquisition, maintenance, or repair of DME, prosthetic, and orthotic items that do not require prior authorization or are for general use in an institutional provider facility where a beneficiary resides;

(4) Consumable medical supplies for general or non-beneficiary specific use in an ICF/IID;

(5) Items solely for comfort and convenience of the beneficiary or their caregivers, such as air conditioners;

(6) Home or vehicle modifications covered under waiver programs operating pursuant to Section 1915(c) of the Social Security Act;

(7) Rehabilitative equipment, for beneficiaries age twenty-two (22) and older, if designed to bring a beneficiary into an upright position to stimulate vestibular function or balance; and

(8) Supplies and other DME items used by personnel of a home health agency during the course of a home visit.

997.14

To be eligible for Medicaid reimbursement, the delivery of DME is subject to the following requirements:

(a) DME consists of equipment that:

(1) Can withstand repeated use;

(2) Is primarily and customarily used to serve a medical purpose;

(3) Is generally not useful to a beneficiary in the absence of a disability, illness, or injury;

(4) Is appropriate for use in any setting in which normal life activities take place, as defined at 42 CFR § 440.70(c)(1); and

(5) Is expected to have a useful life of at least three (3) years;

(b) For a beneficiary age zero (0) through twenty-one (21), DME shall also include equipment used in natural environments;

(c) For purposes of this section, for a beneficiary age twenty-two (22) and older, the home shall also include an assisted living center, home for the aged, or other senior living facility;

(d) DME shall be rented if the beneficiary's medical condition is anticipated to last six (6) months or less. Rental rates shall include costs of maintenance and servicing rented items. Except for fees associated with maintaining and servicing oxygen equipment, DHCF shall not reimburse for maintenance and servicing of a rented item. Any provider of rental DME seeking Medicaid reimbursement shall adhere to the following:

(1) Maintain and repair any DME item being rented to a Medicaid beneficiary;

(2) Accept returns of substandard or unsuitable items; and

(3) Provide to the beneficiary a replacement item that meets the specifications of the originally prescribed item and in such a manner as to minimize the burden on the beneficiary;

(e) The total reimbursement available for DME obtained through rental shall not exceed the purchase price of the item. At the time when rental payments equal the purchase price of the item, the item shall be considered purchased and shall become the property of the beneficiary;

(f) DME shall be purchased only under the following circumstances:

(1) If the beneficiary's medical condition is anticipated to last more than six (6) months and the equipment does not require frequent servicing or repair; or

(2) If the beneficiary's medical condition requires customized equipment;

(g) DME that is purchased shall become the property of the beneficiary for whom it was prescribed;

(h) In accordance with § 997.6(e), DHCF or its designee, shall prior authorize any repairs to purchased equipment. A DME provider shall be required to submit to DHCF or its designee a copy of the warranty for the item needing repair within thirty (30) days of the date of the request for repair;

(i) When DME is purchased for use by a beneficiary, and is under warranty, the DME provider shall be required to pay reasonable charges for maintenance and servicing of the item;

(j) A DME provider shall first seek to have a covered item maintained, serviced, or repaired by the manufacturer in accordance with the warranty;

(k) DHCF shall reimburse a DME provider for charges related to parts and labor that are not otherwise covered under a manufacturer or supplier warranty;

(l) When a beneficiary's DME item is undergoing repair, a DME provider may receive reimbursement for a substitute DME item if prior authorized by DHCF or its designee. Prior authorization of a substitute DME item is subject to the following conditions:

(1) The substitute DME item must be reasonable and necessary;

(2) The frequency of use, or the number of units requested, of the substitute DME item must be consistent with code definitions;

(3) The total cost to rent the substitute DME item must not exceed the purchase price; and

(4) The substitute DME item shall be prior authorized for a period not to exceed two (2) months, except that a substitute DME item provided during repair of customized equipment shall be prior authorized for a period not to exceed six (6) months;

(m) A DME provider/supplier responsible for maintaining, servicing, or repairing a customized item that requires repair or replacement shall perform the following:

(1) Obtain an estimated repair time from the manufacturer and provide the information to the Medicaid beneficiary and their caregivers; and

(2) Provide the beneficiary a substitute DME item with specifications that are as similar to the customized item as possible, if needed or requested, in accordance with prior authorization requirements;

(n) A DME provider of a substitute DME item shall not continue to bill DHCF for the substitute DME item once the beneficiary receives the repaired or replacement DME item;

(o) Prior to or at the time of delivery of DME, the DME provider shall perform an on-site evaluation of the beneficiary's home, if applicable, in order to verify that the beneficiary can adequately maneuver the item that is provided considering the physical layout, doorway widths and thresholds, and surfaces. There shall be a written report of this evaluation, and the provider shall make it available upon DHCF's request. Documentation required under this section shall also be subject to the record keeping requirements of 29 DCMR § 996.9;

(p) A prescribing clinician shall describe the clinical appropriateness of oxygen therapy by completing CMS Form 484 and submitting to DHCF, or its designee, along with any other required documentation. A beneficiary shall be eligible for oxygen therapy, including portable oxygen therapy, if their condition is supported by documentation of diagnosis and laboratory results reflecting any of the following conditions:

(1) Severe lung disease, including but not limited to chronic obstructive pulmonary disease, diffuse interstitial lung disease, cystic fibrosis, bronchiectasis, and widespread pulmonary neoplasm; or

(2) Hypoxia-related symptoms or findings that might be expected to improve with oxygen therapy, including but not limited to pulmonary hypertension, recurring congestive heart failure due to chronic or pulmonale, erythrocytosis, impairment of the cognitive process, nocturnal restlessness, and morning headache;

(q) Oxygen therapy shall be subject to the following:

(1) An authorization for oxygen therapy shall be valid for twelve (12) months for adult beneficiaries age twenty-two (22) and older, and six (6) months for children age zero (0) through twenty-one (21); and

(2) A prescriber of oxygen therapy shall be required to see a beneficiary in-person within a thirty (30) day period prior to the start of therapy in order to certify the need for the items/services;

(r) Oxygen therapy shall not be covered for the following conditions:

(1) Angina pectoris in the absence of hypoxemia;

(2) Breathlessness without cor pulmonale or evidence of hypoxemia;

(3) Severe peripheral vascular disease resulting in clinically evident denaturation in one or more extremities;

(4) Terminal illnesses that do not affect the lungs;

(5) Treatment of headache, including migraine; and

(6) Treatment of other health care conditions in which oxygen therapy is determined to be experimental or investigational; and

(s) Diabetic testing meters shall be limited to those preferred items authorized pursuant to the D.C. Medicaid Diabetic Supplies program.

997.15

The delivery of prosthetics and orthotics shall be subject to the following requirements:

(a) Covered prosthetics and orthotics include the following:

(1) Devices that can replace all or part of an internal body organ, including ostomy bags and supplies directly related to ostomy care, as described in § 997.15(b);

(2) Breast prostheses, including the surgical brassiere;

(3) Leg, arm, back, and neck braces;

(4) Artificial legs, arms, including stump cover or harness, where necessary;

(5) One pair of conventional eyeglasses or contact lenses furnished subsequent to cataract surgery that included insertion of an intraocular lens;

(6) Artificial eyes; and

(7) Therapeutic shoes, diabetic shoe inserts, splints, and supports.

(b) Coverage of prosthetic and orthotic devices includes replacements that are required based on a change in a beneficiary's physical condition or the consumable nature of the item (e.g., ostomy supplies).

(c) Replacement of prosthetic and orthotic devices shall be covered only when prescribed by a clinician meeting the requirements of § 997.3(b).

(d) Covered prosthetic and orthotic devices shall not include the following items:

(1) Intraocular lenses;

(2) Supplies and equipment related to ostomy care that is furnished by home health agency personnel during the course of a home visit; and

(3) Dental prostheses.

997.16

The delivery of supplies shall be subject to the following requirements:

(a) Covered supplies consist of health care related items that:

(1) Are required to address a specific medical disability, illness, or injury, and;

(2) Are appropriate for use in any setting in which normal life activities take place, as defined at 42 CFR § 440.70(c)(1);

(b) Supplies include, but are not limited to:

(1) Lancets;

(2) Gloves;

(3) Bandages;

(4) Enteral products; and

(5) Incontinence supplies.

D.C. Mun. Regs. tit. 29, r. 29-997

Final Rulemaking published at 61 DCR 11659 (November 7, 2014); amended by Final Rulemaking published at 69 DCR 11741 (9/30/2022)