Rule 23-209-2.2 - [Effective until 1/1/2025] Covered Medical SuppliesThe Division of Medicaid covers the following medical supplies when they are medically necessary and considered standard care for the treatment of a beneficiary's medical condition and dispensed in quantities that meet a beneficiary's medical needs without excessive utilization, including, but not limited to: [Refer to Miss. Admin. Code Part 207 for coverage of medical supplies in a long-term care facility.]
A. Alcohol preps, swabs, wipes and bottle are covered for quantity or number of pints appropriate for the plan of care for all beneficiaries for injection site cleanings, for self-administration, or care giver administration of intramuscular or subcutaneous injections ordered by a practitioner.B. Apnea monitor supplies for beneficiaries who have an apnea monitor. C. Diabetic supplies for all beneficiaries who meet the criteria for:1. Blood glucose monitors (BGM):g) Autoclix lancets (spring), andh) Urine test or reagent strips.2. Continuous glucose monitoring (CGM): a) CGM supply allowance covers supplies as a bundle which includes disposable sensors and transmitter. Supplies billed separately will not be covered.b) DME receiver to display glucose data, 1) A DME receiver is covered if used alone or in conjunction with a non-DME device including, but not limited to: a watch, smartphone, tablet, laptop computer.2) Non-DME devices will not be covered.3) If a DME receiver is never used, the supply allowance will not be covered.c) Replacement batteries.D. Dressing supplies for all beneficiaries.1. 4x4 non-sterile gauze pads,2. 4x4 sterile gauze pads, including drain sponges,4. Sterile normal saline solution, 1000 ml, and5. Gloves, sterile and non-sterile.E. Biofeedback/Electromyography (EMG) supplies for all beneficiaries who meet criteria for biofeedback/EMG. F. Enteral Feeding supplies for all beneficiaries who meet criteria for enteral feeding pump. 1. 4x4 non-sterile gauze,2. 4x4 sterile gauze, including drain sponges,4. Sterile solution, 1000ml,5. Gloves, sterile and non-sterile,8. Sterile water, 1000ml.G. Elbow and heel protectors for all beneficiaries when one (1) of the following criteria is met: 1. The beneficiary is bed/chair confined and has a history of decubitus ulcers on a heel or elbow.2. The patient is bed/chair confined and currently has a decubitus ulcer on a heel or elbow.3. The beneficiary exhibits signs of redness or discomfort at bony prominences or other areas of potential breakdownH. Hydrogen peroxide for all beneficiaries who have a tracheostomy and a wound.I. Insulin pen needles or pre-filled insulin syringe needles for all beneficiaries receiving a prefilled insulin injection device through the pharmacy program. Needles are covered through the medical supply program only if one (1) of the following criteria is met: 1. The patient has very poor eyesight and is unable to read the markings on a standard insulin syringe.2. The patient has a condition of the hands that will not allow them to manipulate a vial and syringe to draw up their insulin.J. Insulin pump supplies for all beneficiaries who meet criteria for insulin pump. 2. Infusion sets with cannula,7. Replacement batteries, andK. Intravenous (IV) Pump, also referred to as an Infusion Pump, and supplies for all beneficiaries who meet criteria for an IV pump. 1. Cassette appropriate for pump type, and2. Replacement batteries.L. IV Supplies for all beneficiaries who meet criteria for an IV pump or an IV pole. 1. Central line supplies,6. Butterfly needles, all sizes,7. IV catheters, all sizes,11. Syringe, any size without needles,12. Syringe, any type with needle,18. Sterile normal saline for injection - 2ml, 2.5ml, 3ml, 5ml, 10ml, 20ml, 30ml, and 50ml supplied in bottles, ampules or vials, andM. Nebulizer supplies for all beneficiaries when criteria for nebulizer are met. 1. Administration set, disposable, non-filtered,2. Administration set, non-disposable, non-filtered,3. Administration set, filtered,N. Neuromuscular Electrical Stimulator (NMES) supplies for all beneficiaries who meet criteria for neuromuscular electrical stimulator.O. Ostomy supplies for all beneficiaries who have a surgically established opening, or stoma to divert urine, feces, or illegal contents outside the body.P. Oxygen and oxygen related supplies are covered for all beneficiaries who meet criteria for oxygen therapy. 1. E cylinders, including delivery,2. H or K Cylinders, including delivery,Q. Pulse oximeter supplies, which include an oxygen probe, are covered for all beneficiaries who meet criteria for pulse oximeter monitoring.R. A sling for all beneficiaries who have an injury or diagnosis which requires support or immobilization of an upper extremity to control pain, restrict motion, prevent further deformity, or protect the limb following trauma or surgery. The request for coverage must be supported by the beneficiary's diagnosis, the goals for use of the sling, and the expected duration of use.S. Suction pump supplies (respiratory or gastric) for all beneficiaries who meet criteria for a suction pump. 1. Respiratory suction supplies include: a) Catheter kit, sterile,b) Suction catheter, 8-15 FR,c) Yankauer type respiratory suction,d) Respiratory suction tubing,e) Canister, disposable, and2. Gastric suction supplies include: a) Gastric suction catheter kit,b) Gastric suction catheter, 8-15 FR,c) Gastric suction whistle tip, with valve,d) Gastric suction tubing,T. Supplies for maintenance of drug infusion catheter, per week, for all beneficiaries who meet criteria for an IV pump. 1. Catheter insertion devices,2. Dressing for catheter site,3. Flush solutions not directly related to drug infusion,6. Infusion supplies, excluding the insulin reservoir, andU. Supplies for external drug infusion pump, per cassette or bag, for all beneficiaries who meet criteria for an IV pump.5. Other administration supplies,6. Port charges, not used for syringe-type reservoir,V. Syringes and needles are covered for self-administration of intramuscular and/or subcutaneous injectable medication for all beneficiaries that are performing the administration of injections in any non-institutional setting where the beneficiary's normal life activities take place.W. Transcutaneous Electrical Nerve Stimulator (TENS) supplies for all beneficiaries who meet criteria for Transcutaneous Electric Nerve Stimulator.X. Tracheostomy supplies for all beneficiaries who have a tracheostomy with documentation of the specific respiratory condition.2. Trach or laryngectomy tube,4. Replacement tracheal suction catheter, any type,5. Trach care kit, for new trach,6. Trach care kit, for established trach,7. Suction catheter kit, sterile,8. Sterile water, 1000 ml,9. Sterile normal saline for instillation, supplied in 2ml, 2.5ml, 3ml, 5ml, 10ml, 20ml, 30ml, and 50 ml bottle, ampule, or vial.11. Trach cleaning brush,12. Heat and Moisture Exchangers (HME),13. Trach shower protector,14. Tracheostomy/laryngectomy, tube plug/stop,Y. Urinary catheters 1. Urinary catheters are covered for all beneficiaries when one (1) of the following criteria is met: a) Beneficiary must have an acute condition which requires intermittent catheterization for measuring residual, instilling medication, or other medically necessary indication,b) Beneficiary has an acute condition which requires the short-term use of an indwelling catheter,c) Beneficiary has a chronic condition which incontinence is exacerbating pressure sores that will not heal,d) Beneficiary has a condition that requires accurate measurement of intake and output on a short-term basis, ore) Beneficiary has urinary retention that cannot be relieved by medication.2. Supplies include: b) Irrigation tray, with bulb or piston syringe,c) Irrigation syringe, bulb or piston,d) Sterile solution for irrigation,e) Female external collection device,f) Indwelling catheter, foley, two-way,g) Indwelling catheter, three-way,h) Male external catheter, with or without adhesive,i) Intermittent catheter, straight tip,k) Leg bag with or without strap,3. The Division of Medicaid requires the beneficiary and/or caregiver to be capable of performing the catheterization procedure and report results and have been instructed in the procedure and properly demonstrated the ability to perform the procedure.4. The Division of Medicaid covers condom catheters for beneficiaries with paraplegia, neurogenic bladder, or other medically necessary indications when requested with appropriate documentation.Z. The Division of Medicaid covers supplies for manual and electric breast pumps.AA. Incontinence Garments 1. The Division of Medicaid covers the following disposable incontinence garments:2. The Division of Medicaid covers up to six (6) units of incontinence garments per day for beneficiaries aged three (3) and above only when certified as medically necessary. Prior authorization is required for quantities in excess of the limit. a) One (1) unit is equal to one (1) diaper or one (1) pull-on or one (1) underpad.b) The six (6) units can consist of any combination of diapers, pull-ons and/or underpads.3. A beneficiary must have a diagnosis of incontinence or must meet one (1) of the following criteria due to a documented medical condition in order for the incontinence garments to be considered medically necessary:a) Inability to utilize regular toilet facilities.b) Inability to physically turn self or reposition self.c) Inability to transfer self from bed to chair or wheelchair without assistance.4. The physician must order all incontinence garments and maintain documentation of the medical necessity and diagnosis of incontinence in the beneficiary's medical record.5. The durable medical equipment (DME) provider must maintain in the beneficiary's record a current certificate of medical necessity (CMN), signed by the ordering physician and must include: a) An initial physician's order,b) The beneficiary's diagnosis along with associated diagnoses and code(s),c) The anticipated frequency and duration of need,d) The requested quantity per month,e) A detailed description of the item(s) including the type, size and corresponding Healthcare Common Procedure Coding System (HCPCS) code for each,f) The ordering physician's signature and date of signature. Signature stamps, date stamps, or the signature of anyone other than the ordering physician is not acceptable.6. The DME provider must have a current physician's order and CMN to initiate or continue the provision of incontinence garments to a beneficiary.a) The CMN must be renewed every six (6) months.b) For those cases where there is documentation justifying the need for incontinence garments for beneficiaries whose medical condition is chronic, recertification is only required every twelve (12) months.7. The DME provider must maintain documentation of proof of delivery of incontinence garments including: b) Date of delivery which must be the date the beneficiary received the item; including the dates of service the delivered quantity is expected to last,d) Detailed description of incontinence garments delivered,e) Quantity delivered, andf) The signature of the beneficiary, caregiver, or family member who received the supplies. 1) During a national or statewide emergency, a signature is not required.2) During a national or statewide emergency, the provider must document the emergency and confirmation of delivery by an alternate means including, but not limited to: (c) Other electronic communication.8. DME providers: a) Are allowed to deliver incontinence garments in quantities expected to last no more than a one (1) month's supply.b) Are not allowed to dispense items to a beneficiary who already has at least a one (1) month's supply on hand.c) Must make contact, either orally or in writing, with each beneficiary and/or their legal representative or guardian to confirm the current need before delivering additional incontinence garments.d) Must keep documentation of the monthly contact on file.9. DME providers must supply size, waist, and weight appropriate incontinence garments based on the beneficiary's current measurements.10. The DME provider must submit a new CMN form signed and dated by the ordering physician detailing changes and medical necessity to the Division of Medicaid or designee if DME provider needs to amend the initial order for incontinence garments being delivered due to a change in the beneficiary's size or underlying medical condition.11. DME providers must maintain documentation of measurements and medical conditions in the beneficiary's record which supports reimbursement for the specific size of incontinence garments.23 Miss. Code. R. 209-2.2
42 U.S.C. § 1395 m; Miss. Code Ann. §§ 43-13-117, 43-13-121.Revised Miss. Admin, Code Part 209, Rule 2.2.O eff. 01/02/2015; Added Miss. Admin. Code Part 209, Rule 2.2.Z., eff. 05/01/2014; Revised eff. 01/01/2013; Amended 7/1/2015