60.06-1Face-to-Face EncounterA face-to-face encounter is a mandatory encounter (including encounters through telehealth (as described in Chapter I, Section 4) and other than encounters incidental to services involved) between the member and a Qualified Provider that takes place within the six (6) months prior to the date of a written order for DME. The written order may be, but does not have to be, prescribed by the provider who performed the face-to-face encounter.
60.06-2Medical Supplies and DME RequirementsMedical Supplies and DME must meet all of the following requirements:
A. Comply with the criteria in Section 60, including the definitions in Section 60.01;B. Be prescribed by a Qualified Provider;C. Be provided to a member who is not in a hospital, unless necessary for transition to home, in which case the provider must comply with the criteria for emergency rental in this Section;D. Have scientifically valid clinical evidence of their efficacy and not be considered investigational or experimental by the Department;E. Be approved and defined by the Food and Drug Administration;G. Have a warranty that includes parts and labor;H. Be provided by a MaineCare authorized provider of Medical Supplies and DME who has a location where members can procure repairs and servicing of items with warranties and guarantees or meet one of the exceptions outlined in this Section; andI. A member's need for medical supplies, equipment, and appliances must be reviewed by a physician or other Qualified Provider annually.J.Durable Medical Equipment Only. The prescribing provider must maintain documentation that includes a statement verifying the date of the face-to-face encounter for that specific piece of DME and the name of the Qualified Provider who performed the face-to-face encounter.60.06 -3Reasonable and Necessary for TreatmentAll DME and supplies must be certified as reasonable and necessary by the prescribing provider. In making such a determination, the following criteria shall be met:
A. The equipment is medically necessary;B. The equipment serves a different purpose than equipment already available to the member; and the equipment is not an upgrade for currently functioning equipment that meets members' basic needs and already supplied to the member;C. The equipment is not more costly than a medically appropriate and realistically feasible alternative plan of care;D. The cost of the item is not disproportionate to the therapeutic benefits which could ordinarily be derived from use of the equipment;E. The item is not Home/Environmental modifications, which do not meet the definition of Medical Supplies or DME and are not covered under this Section; andF. Providers must retain documentation, if applicable, indicating the equipment can freely pass through all entryways without the need for modification or, if applicable, retain documentation indicating that necessary modifications or structural changes have occurred prior to the request for authorization.60.06 -4Rental and/or PurchaseThe Department shall rent and/or purchase items consistent with Medicare practices. If Medicare makes an item available for both purchase and rental, the Department or its authorized entity shall decide between rental and purchase of the item on a case by case basis based on medical necessity.
A.Rental1. All rental equipment except for emergency equipment must receive PA. Please refer to the PA section regarding emergency equipment. The request for continued PA of services must indicate the emergency dates of services.2. The Department decides when to purchase rented equipment if a member requires its use for an extended period of time. If the Department decides to purchase the rented equipment, the total rental paid to date will be applied to the MaineCare allowed purchase price as listed in the fee schedule or as otherwise set by the Department.3. Unless otherwise authorized under this section, rental rates include the cost of servicing, repairs or other maintenance and include replacement parts for defective equipment and disposable items. The Department is not responsible for the cost of repairs (including labor or replacement parts) for rented items or equipment.4. All rented equipment must be clean and in proper working condition when delivered.B.Outright Purchase of New DME1. The Department may purchase outright any DME if the member will use it for an extended period of time. Once an item is purchased, it becomes the property of the member.2. The Department reserves the right to purchase the necessary equipment at the lowest price available and to preferentially choose equipment that includes a warranty.3. All purchased equipment must be new and unused, clean, in proper working condition, free from defects, and meet all implied and expressed warranties.C.Outright Purchase of Used EquipmentUsed equipment will be reimbursed on a prorated basis using the remaining useful life of the equipment based on Generally Accepted Accounting Principles (GAAP) applied to the MaineCare rate of reimbursement. To qualify for payment, a DME provider must complete a PA form(see Section 60.06). The equipment being reconditioned must not exceed the expense for new equipment.
D.Delivery, Installation, and Member Instructional TimeThe maximum allowable fee for purchase or rental of equipment includes the following:
1. Cost of delivery to the inside of the member's residence and, when appropriate, to the room in which the equipment will be used;2. Assembly of parts, installation, and set-up of the equipment or customized fitting;3. Instruction to the member or caregivers in the safe and proper use of the equipment or supplies, sufficient to ensure that they have demonstrated they can provide necessary service and/or use of the equipment or supplies. Instructions to ensure safe and proper use of the equipment or supplies and any limitations on replacement.60.06-5Emergency DMEIn an emergency, the Department will reimburse rental of standard DME for up to thirty (30) days, subject to the PA requirements in this Section.
If the Department decides to purchase the rented equipment, the total amount paid to date will be applied to the MaineCare allowed purchase price as listed in the fee schedule or as otherwise set by the Department.
60.06-6LaborLabor charges are reimbursable for repairs to outright purchased DME only. Such charges are not reimbursed when the DME has a current warranty. Labor charges are not reimbursed for evaluation, assembly, fitting, or other installation on both new and used purchased DME. The Department is not responsible for labor charges for rented DME. Labor is also subject to the PA requirements of this Section (see Section 60.06).
60.06-7Replacement of DMEReplacement will not be allowed in cases of malicious damages, culpable neglect, or when the member or responsible party has sold, given away, thrown out, or wrongfully disposed of the DME. DME that is functioning properly will not be replaced, unless a change in the member's condition requires a change of DME.
A.Replacement of all DME is allowed for the following reasons:1. Irreparable damage or wear that affects the essential performance of the DME;2. A change in the member's condition that requires a change of DME. In such cases, the Department requires a current prescribing provider's order documenting the need for the change; or3. Repairing the DME (parts and labor) would cost more than sixty (60) percent of the replacement cost of the DME.B.Additional Rules for Hearing Aids1. Members age twenty-one (21) years and older, in addition to the criteria above, are eligible to receive one (1) hearing aid or one (1) replacement pair every five (5) years. PA will be required and must meet the criteria specified in section 60.06-2.2. Members under the age of twenty-one (21), are eligible to receive a replacement hearing aid once per year as medically necessary and as identified and referenced in the MaineCare Benefits Manual, Section 94. C.Additional Rules for Automatic Positive Airway Pressure (APAP) andContinuous Positive Airway Pressure (CPAP) Devices [GREATORE THAN OR EQAL TO] five (5) years old 1. The DME supplier is required to perform an assessment on the device before the Department will consider replacement or repair;2. If there is no obvious external reason as to why the device is no longer functioning properly, the DME supplier is required to submit a written attestation detailing this; OR3. If the reason the device is not functioning is obvious, the DME supplier is required to submit documentation, including repair cost information, to the Department. Repair criteria can be viewed in section 60.06-2. Prior Authorization for repair is required and must meet the criteria specified in section 60.06-2.D.Additional Rules for Bilevel Positive Airway Pressure (Bi-PAP) Devices [GREATORE THAN OR EQUAL TO]five (5) years old1. The DME supplier is required to perform an assessment on the device before the Department will consider replacement or repair;2. If there is no obvious external reason as to why the device is no longer functioning properly, the DME supplier is required to send the device to the Manufacturer for assessment;3. Once the assessment has been completed, the DME supplier is required to submit documentation, including repair cost information, to the Department. Repair criteria can be viewed in section 60.06-2. Prior Authorization for repair is required and must meet the criteria specified in section 60.06-2.60.06-8Requirements for Medical Supplies and DME for Members Residing in Their HomeA. Covered Medical Supplies and DME may be provided to members for use in any setting in which normal life activities take place, other than a hospital or any setting in which payment is or could be made under MaineCare for inpatient services that include room and board. Special rules apply for Medical Supplies provided to members in Nursing Facilities (NF) and intermediate care facility for individuals with intellectual disabilities (ICF- IID).B. Providers may not bill under this section for routine Medical Supplies essential for the home health agency to carry out the physician's plan of care for members receiving home health services (see Section 40 of the MaineCare Benefits Manual).C. Post-surgical supplies will be covered as long as medically necessary as certified by the prescribing provider. Providers may not dispense more than a thirty-four (34) day supply at a time, with the exception of items specified in section 60.0713. D. Equipment or items that are used primarily for purposes of safety or physical restraint are not covered, including enclosed cribs and beds and barred enclosures. Physical restraints are defined as any physical or mechanical device, material, or equipment, attached or adjacent to the member's body that the member cannot remove easily and which restricts freedom of movement or normal access to one's body.E. Items used for positioning that meet the definition of Medical Supplies or DME are not considered restraints and are covered when medically necessary.60.06-9Medical Supplies and DME Not Covered for Members in an NF or ICF-IIDThe Department will not reimburse DME providers for Medical Supplies and DME, including upgrades and add-ons, provided to MaineCare members residing in a NF or ICF-IID that are considered part of that facility's regular rate of reimbursement. Some supplies and equipment provided to members in a NF or ICF-IID as part of the regular rate are listed below and are included for reference only.
Facilities that serve a special group of individuals with disabilities are expected to furnish that equipment which is normally used in their care (e.g. children's wheelchairs) as a part of their reasonable cost.
The following items may not be billed by either the facility or supplier.
1. Alcohol, swabs and rubbing2. Analgesics, non-prescription: a) aspirin: plain buffered and coated suppositories.b) Acetaminophen: tablets, liquids, and suppositories.3. Antacids, non-prescription: a) aluminium/magnesium hydroxyde (ex. Maalox)b) Aluminium/magnesium hydroxyde with simethicone (ex. Mylanta, Maalox Plus)c) Calcium carbonate tablets (ex. Tums)d) Calcium carbonate/ magnesium hydroxyde tablets (ex. Rolaids).4. Alternating pressure pads, air mattresses, "egg crate" mattresses, gel mattresses9. Beds, standard hospital type, not therapy12. Blood pressure equipment15. Calcium supplements, non-prescription (ex. Tums, Oscal).17. Catheter trays, disposable18. Chairs, standard and geriatric22. Cough syrup and expectorants, all non-prescription brands24. Cushions (e.g., comfort rings), excluding wheelchair cushions that require mounting hardware27. Douche trays, disposable30. Enteral feeding, supplies, and equipment.32. Gauze bandages, sterile or non-sterile34. General service supplies such as administration of oxygen and related medications, hand feeding, incontinency care, tray service, and enemas35. Gloves, sterile or non-sterile38. Incontinency supplies (full brief- all sizes; bed pad; undergarment liners, disposable or reusable; under pads)40. Laundry services, personal (including supplies and equipment)41. Laxatives, non-prescription: Stool softeners (ex. Docusate sodium liquid or capsule). Bulk: (ex. Psyllium). Stimulants: (ex. Bisacodyl tablets and suppositories; docusate casanthranol, liquid and/or capsule). Enemas: (ex. Saline, phosphate types-except Fleets); oil retention. Misc.: milk of magnesia; glycerin suppositories; lactulose and analogs (when used as a laxative); mineral oil.42. Lubricants, skin, bath oil44. Ointments and creams, available over the counter, including petroleum jelly and hydrocortisone 0.5%45. Ophthalmic lubricants, tears and ointments46. Oxygen, for emergency and prn use only, including portable oxygen and equipment47. Parenteral supplies and equipment50. Powders, medicated and baby52. Restraints, poseys, thoracic chest supports, wedge pillows, etc.53. Sand and water tables - ICF- IID only54. Sensory stimulation materials- ICF- IID only55. Sheepskin pads, any size or style57. Soap, including hypoallergenic58. Special dietary supplements60. Sterile I.V. or irrigation solution62. Supplies, non-prescription, necessary for the treatment for decubitis64. Swabs, medicated or unmedicated67. Testing materials to be used by staff of facility, not to include materials normally included in psychometric testing - ICF- IID only74. Tubes, gavage, lavage, etc.77. Urinary drainage equipment and supplies (disposable)78. Velcro strips - ICF- IID only79. Vestibular boards - ICF- IID only80. Vitamins, non-prescription, all brands82. Wheelchairs, standard, including those with removable or adjustable trays, arm and leg rests including elevators, pediatric, "hemi" chairs, reclining wheelchairs, lightweight wheelchairs, high strength light-weight wheelchairs, ultra-light-weight wheelchairs, heavy duty wheelchairs, extra heavy-duty wheelchairs and other manual wheelchairs/base.83. Wipes, rectal medicated84. Routine personal hygiene and grooming items to include, but not be limited to items for shaving, shampooing, bathing, nail clipping (unless specified as a covered service when performed by a podiatrist as covered under the MaineCare Benefits Manual), haircutting or the services of a barber when requested and paid for by the member. Examples of items include but not limited to: combs, lotions, mouthwash, toothbrushes, toothpaste, shampoo (regular, medication and non-tears baby shampoo), sunscreen and tissues. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-60, subsec. 144-101-II-60.06