Md. Code Regs. 10.09.12.07

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.09.12.07 - Payment Procedures

A. Payment procedures shall be as set forth in COMAR 10.09.36.04.

B. The provider's billed charges to the Program may not exceed the provider's customary charge. If the item is free to individuals not covered by Medicaid:

(1) The provider:

(a) May charge the Program; and

(b) Shall be reimbursed in accordance with the provisions of this regulation; and

(2) The provider's reimbursement is not limited to the provider's customary charge.

C. The provider shall give the Program the full advantage of any and all manufacturer's warranty offered on the item.

D. Effective July 1, 2022, the Department shall pay providers 85 percent of the lowest rural, non-rural, or competitive bidding area (CBA) Medicare rate established January 1 of each year for prosthetic devices. For prosthetic devices for which Medicare has not established a rate, the Department shall pay providers the manufacturer's suggested retail price of the item, less 26.5 percent. The payment shall include all fitting, dispensing, and follow-up care.

E. Charges for osteogenesis stimulators shall include all follow-up care, batteries, repairs, and replacement parts within the limitations of Regulation .05E and F, at the following times:

(1) Initial date of service;

(2) After 6-week evaluation;

(3) After 3-month evaluation.

F. With the exception of items free to individuals not covered by Medicaid, the Department shall reimburse providers for the purchase of covered services at the lesser of the provider's customary charge or:

(1) For the purchase of items for which Medicare has established a rate:

(a) Disposable medical supplies and durable medical equipment other than enteral nutritional products and enteral and parenteral therapy supplies at 85 percent of the lowest rural, non-rural, or competitive bidding area (CBA) Medicare purchase reimbursement rate established January 1 of each year;

(b) Enteral nutritional products given by nasogastric, jejunostomy, or gastrostomy tube in the home as established in §F-1(1) of this regulation;

(c) Enteral and parenteral therapy supplies as established in §F-1(2) of this regulation; and

(d) For medical equipment for which Medicare has established a rental rate, the purchase price shall be 10 times the lowest rural, non-rural, or competitive bidding area (CBA) Medicare monthly rental rate.

(2) For the purchase of items for which Medicare has not established a rate:

(a) Disposable medical supplies not otherwise specified in this section are reimbursed at the provider's choice of the manufacturer's suggested retail price minus 41.2 percent or the provider's wholesale cost plus 37.2 percent;

(b) Enteral nutritional products given by nasogastric, jejunostomy, or gastrostomy tube in the home as established in §F-1(3) of this regulation;

(c) Enteral and parenteral therapy supplies as established in §F-1(4) of this regulation;

(d) Incontinence supplies at the provider's wholesale cost plus 25 percent;

(e) Customized equipment at the provider's choice of the manufacturer's suggested retail price minus 30 percent or provider's wholesale cost plus 40 percent; and

(f) Durable medical equipment, not otherwise specified in this section, are reimbursed at the provider's choice of the manufacturer's suggested retail price minus 41.2 percent or provider's wholesale cost plus 27.4 percent.

F-1. Enteral Nutritional Product and Enteral and Parenteral Supply Reimbursement Rates Effective February 1, 2021.

(1) Effective February 1, 2021, enteral nutritional products given by nasogastric, jejunostomy, or gastrostomy tube in the home shall be reimbursed at the following rates per unit:

HCPCS	HCPCS Unit	Per Unit Rate
B4149	100 cal	$1.77
B4150	100 cal	$0.69
B4152	100 cal	$0.57
B4153	100 cal	$2.03
B4154	100 cal	$1.20
B4155	100 cal	$1.19

(2) Effective February 1, 2021, enteral and parenteral therapy supplies shall be reimbursed at the following rates per unit:

HCPCS	HCPCS Unit	Per Unit Rate
B4034	1 item	$5.19
B4035	1 item	$9.90
B4036	1 item	$6.80
B4081	1 item	$18.37
B4082	1 item	$13.66
B4083	1 item	$2.10
B4087	1 item	$30.32
B4088	1 item	$107.11
B4220	1 item	$7.65
B4222	1 item	$9.44
B4224	1 item	$22.69
B9002	1 item	$1,041.91
B9004	1 item	$2,411.31
B9006	1 item	$2,411.31

(3) Effective February 1, 2021, enteral nutritional products given by nasogastric, jejunostomy, or gastrostomy tube in the home shall be reimbursed at the following rates per unit:

HCPCS	HCPCS Unit	Per Unit Rate
B4102	500 ml	$3.56
B4103	500 ml	$3.33
B4158	100 cal	$0.69
B4159	100 cal	$0.69
B4160	100 cal	$0.85
B4161	100 cal	$2.03
B4162	100 cal	$3.31

(4) Effective February 1, 2021, enteral and parenteral therapy supplies shall be reimbursed at the following rates per unit:

HCPCS	HCPCS Unit	Per Unit Rate
B9998	1 item	$249.90
B9999	1 item	$249.90

G. The Department shall reimburse providers for the monthly rental of covered services as follows:

(1) For items for which Medicare has established a purchase rate, 85 percent of the lowest rural, non-rural, or competitive bidding area (CBA) Medicare purchase reimbursement rate divided over 10 months;

(2) For items for which Medicare has not established a purchase rate, items will be rented at the provider's choice of:

(a) The manufacturer's suggested retail price minus 41.2 percent, divided over 10 months; or

(b) The provider's wholesale cost plus 27.4 percent, divided over 10 months; and

(3) After 10 months of monthly rental, the item will be considered purchased.

H. The Department reserves the right to prorate the monthly rental amount for daily rentals.

I. The Department shall pay for repairs to purchased durable medical equipment according to the following:

(1) The provider's choice of wholesale cost plus 37.2 percent or the manufacturer's suggested retail price minus 31.4 percent to the provider for all materials;

(2) Labor costs shall be billed in quarter hour increments using the appropriate procedure code and shall be reimbursed the lesser of:

(a) The supplier's customary charge unless the service is free to individual not covered by Medicaid; or

(b) The reimbursement rate specified in the Medicaid Durable Medical Equipment Program's approved list of items.

J. The determination to purchase or rent medical equipment shall be based on the prescriber's best faith estimate of length of time the equipment will be needed by the recipient. When the equipment is ordered for:

(1) 10 or more months, the provider shall charge the Program for a purchase, unless:

(a) The items cannot be purchased, in which case the items shall continue to be rented for the duration of their need at the amount determined on the fee schedule or elsewhere in this chapter; or

(b) There is justification to request a rental rather than a purchase of the item, and a request for prepayment authorization is submitted to and approved by the Program before the submission of the invoice for the item; and

(2) Less than 10 months, the provider shall charge the Program for rental of the item for the duration of the medical necessity except that:

(a) If the equipment is still medically necessary after 10 months of rental and the equipment is purchasable, the tenth rental payment is the final rental payment, and the equipment is considered purchased by the Program; or

(b) If there is justification to request a purchase rather than a rental of the item, a request for prepayment authorization shall be submitted to the Program and approved by the Program before the submission of the invoice.

K. Medical equipment that is determined by the Department to require frequent and substantial servicing in order to avoid risk to the recipient's health shall be reimbursed at the rental rate in accordance with §G of this regulation until either the equipment is no longer medically necessary or the recipient is no longer eligible for Medical Assistance fee-for-service benefits.

L. Every 90 days during the rental term the provider shall obtain recertification from the prescriber and keep in the provider's records a recertification of continuous medical need that the equipment is still medically necessary.

M. The Department shall review purchase prices and rental charges for items for which Medicare has not established a rate at least every 3 years.

N. If services are provided under a contract pursuant to Regulation .04F of this chapter, the Department shall reimburse the contracted vendor or vendors at rates and under conditions in accordance with the contract or contracts.

O. Once an item has been purchased in full, then title to the equipment shall remain with the Department, and the equipment, after use by the recipient, shall be recovered by the Department or its designee. The Department may arrange for the provision of recycled equipment under an exclusive contract with a vendor or vendors that have been awarded in accordance with State regulations and policies governing contracts and procurement. The Department also may determine the geographical scope and the types of equipment, or both, to be included under the contract. The vendor or vendors shall be reimbursed at a rate and under terms established in the contract.

P. For equipment that is not covered under a contract awarded under §O of this regulation, the provider that originally furnished the equipment to the recipient shall recover the equipment after it is no longer required by the recipient. After recovery of the equipment, the provider shall determine the viability of recycling the item and, upon its reissue, bill the Program 75 percent of the Program's original payment.

Q. To the extent that the Department chooses to use an exclusive contract to provide recycled equipment under §O of this regulation, the Department shall reimburse providers for evaluation of a recipient for equipment that is subsequently provided through the Department's recycling program at 11.5 percent of the reimbursement rate established under §§A-H of this regulation.

R. The Department will authorize payment on Medicare claims if:

(1) The provider accepts Medicare assignments;

(2) Medicare makes direct payment to the provider;

(3) Medicare has determined that services were medically justified;

(4) The services are covered by the Program;

(5) Initial billing is made directly to Medicare according to Medicare guidelines.

S. Supplemental payments on Medicare claims are made subject to the following provisions:

(1) Deductible insurance will be paid in full;

(2) Coinsurance will be paid in full;

(3) Services not covered by Medicare, but by the Program, will be paid in accordance with the limitations of §I of this regulation.

T. The provider may not bill the Department for:

(1) Completion of forms and reports;

(2) Broken or missed appointments;

(3) Professional services rendered by mail or telephone; or

(4) Fitting, dispensing, or follow-up care except as set forth in §D of this regulation.

U. The methodology in §§F and G of this regulation shall be used to establish a list of approved items with the corresponding procedure code, maximum allowable reimbursement amount, useful life expectancy, and maximum number allowed. This list shall be made available to the providers for ease of administration of the Program. When the approved list of items contains a price for a procedure code, the Department shall reimburse providers the lesser of the price listed in the approved list or the provider's customary charge unless the service is free to individuals not covered by Medicaid.

V. The provider shall ensure that the equipment is in good working condition both throughout the rental of the equipment and at the end of the rental term.

W. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.

X. Durable medical equipment and disposable medical supply rates may be increased at the Program's discretion, when the Program determines in its sole discretion that the Medicare rate creates a barrier to accessing medical equipment and supplies.

Y. Refills.

(1) For durable medical equipment or disposable supplies, or both that are supplied as refills to the original order, providers shall contact the recipient or designee before dispensing the refill in order to ensure that the refilled item is necessary and to confirm any changes and modifications to the order.

(2) The provider shall maintain documentation of contact and confirmation of any changes and modifications of the order for audit purposes.

(3) The provider shall contact the recipient or designee regarding refills no earlier than 7 business days before the anticipated delivery date or anticipated shipping date.

(4) For subsequent deliveries of refills, the provider shall deliver the items no earlier than 5 days before the end of usage for the current product.

Z. The disposable medical supplies or durable medical equipment provider shall identify the individual who ordered the disposable medical supplies and durable medical equipment by recording the individual practitioner's National Provider Identifier (NPI) number on the claim.

Md. Code Regs. 10.09.12.07

Regulation .07 amended effective July 2, 1984 (11:13 Md. R. 1176); October 29, 1984 (11:21 Md. R. 1812); June 2, 1986 (13:11 Md. R. 1273); May 29, 1989 (16:10 Md. R. 1108)
Regulation .07 amended as an emergency provision effective October 1, 1986 (13:22 Md. R. 2392); amended permanently effective February 9, 1987 (14:2 Md. R. 129)
Regulation .07D amended as an emergency provision effective July 1, 1982 (9:13 Md. R. 1347); adopted permanently effective November 1, 1982 (9:21 Md. R. 2106)
Regulation .07D amended effective October 1, 1983 (10:19 Md. R. 1691); June 2, 1986 (13:11 Md. R. 1273); March 23, 1987 (14:6 Md. R. 715); July 1, 1987 (14:13 Md. R. 1473); July 1, 1988 (15:13 Md. R. 1554); July 11, 1988 (15:13 Md. R. 1553); July 25, 1988 (15:14 Md. R. 1655)
Regulation .07D amended as an emergency provision effective July 1, 1984 (11:13 Md. R. 1170); emergency status expired October 28, 1984
Regulation .07D amended as an emergency provision effective October 1, 1986 (13:22 Md. R. 2393); adopted permanently effective February 1, 1987 (14:2 Md. R. 129)
Regulation .07F amended effective April 9, 1984 (11:7 Md. R. 625); June 2, 1986 (13:11 Md. R. 1273)
Regulation .07L amended effective January 30, 1984 (11:2 Md. R. 113); September 10, 1984 (11:18 Md. R. 1584)
Regulation .07Q amended as an emergency provision effective January 28, 1991 (18:3 Md. R. 301); emergency status expired April 8, 1991 (18:9 Md. R. 1004))
Regulation .07Q amended as an emergency provision effective April 9, 1991 (18:9 Md. R. 1005); amended permanently effective October 7, 1991 (18:18 Md. R. 2004)
Regulation .07 amended effective September 29, 2003 (30:19 Md. R. 1331); August 1, 2005 (32:15 Md. R. 1320); September 11, 2006 (33:18 Md. R. 1505); April 19, 2010 (37:8 Md. R. 615); April 30, 2012 (39:8 Md. R. 534)
Regulation .07B-1 adopted effective August 12, 1985 (12:16 Md. R. 1606)
Regulation .07C-1 repealed effective August 12, 1985 (12:16 Md. R. 1606)
Regulation .07C-1 adopted effective June 2, 1986 (13:11 Md. R. 1273); amended effective March 23, 1987 (14:6 Md. R. 715)
Regulation .07C-2 adopted effective July 1, 1987 (14:13 Md. R. 1473)
Regulation .07D, F-1 adopted effective August 12, 1985 (12:16 Md. R. 1606)
Regulation .07F-2 adopted effective June 2, 1986 (13:11 Md. R. 1273); amended effective March 23, 1987 (14:6 Md. R. 715)
Regulation .07D amended effective 41:2 Md. R. 91, eff.2/3/2014
Regulation .07F amended effective February 9, 2009 (36:3 Md. R. 208);41:2 Md. R. 91, eff. 2/3/2014 ; amended effective 43:13 Md. R. 712, eff.7/4/2016; amended effective 44:26 Md. R. 1214, eff. 1/1/2018; amended effective 48:12 Md. R. 472, eff. 6/14/2021; amended effective 50:20 Md. R. 887, eff. 10/16/2023