Ala. Admin. Code r. 560-X-13-.01

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-13-.01 - Durable Medical Equipment, Supplies, Appliances, Prosthetics, Orthotics And Pedorthics-General

(1) Durable Medical Equipment (DME), supplies, and appliances are available as Medicaid program benefits to eligible Medicaid beneficiaries for use in any setting in which normal life activities take place.

(2) The covered DME, supplies, and appliances, and Prosthetics, Orthotics and Pedorthics (POP) are for medical therapeutic purposes, and must be ordered by the prescriber in connection with the plan of treatment, and the items will minimize the necessity for hospitalization, nursing home, or other institutional care. The prescriber of these items must comply with 42 C.F.R. § 440.70 as well as all other federal and state rules and regulations in order to receive reimbursement.

(3) DME is equipment:

(a) that can withstand repeated use;

(b) is primarily and customarily used to serve a medical purpose;

(c) generally is not useful to a person in the absence of an illness, disability or injury; and

(d) can be removable or reusable.

All requirements of the definition must be met before an item can be considered to be DME.

(4) Refer to Rule No. 560-X-13-.18 for Prosthetics, Orthotics and Pedorthics (POP) guidelines.

(5) The cost of the item must not be disproportional to the therapeutic benefits or more costly than a reasonable alternative. The item must not serve the same purpose as equipment already available to the recipient. DME may be purchased or rented for a Medicaid recipient meeting the established criteria. Please refer to Chapter 14, DME, of the Medicaid Provider Manual published on Medicaid's website.

(a) Medicaid covers the purchase of DME items for long term use. Long term use is defined as the use of DME which exceeds six months.

(b) Medicaid covers the rental of DME items for six months or less.

(6) A recipient does not have to be a Home Health Care patient in order to receive coverage for products covered under this Chapter.

(7) The provider is responsible for educating the recipient in the use of the DME. The provider is also responsible for delivery and set up of the DME.

(8) All appliances and standard DME approved for payment by Medicaid must have a warranty of a minimum of one year; this may include the manufacturer's warranty. Please refer to Rule No. 560-X-13-.19.

(9) Requirements for Placing the Initial Written Prescription or Order for Certain Medical Supplies, Equipment, and Appliances.

(a) The authorized practitioner who develops the recipient's written plan of care ("the ordering practitioner") is required to sign and place the initial prescription or order for certain medical supplies, equipment, and appliances.

(b) Subsequent written prescriptions or orders for refills, ancillary supplies, repairs or services, or re-certifications do not require the ordering practitioner's signature or an additional face-to-face visit.

(c) Either an enrolled physician or one of the following authorized non-physician practitioners (NPP) may both conduct and document the clinical findings from the required face-to-face visit and write the initial written prescription or order for certain medical supplies, equipment, and appliances:

1. Certified registered nurse practitioners (CRNP) or clinical nurse specialists (CNS) working under a collaboration agreement under Alabama law with the ordering physician;

2. Physician assistants (PA) under the supervision of the ordering physician; or

3. Attending acute or post-acute physicians, if recipients are admitted to home health services immediately after discharge from an acute or post-acute stay.

(d) The required face-to-face visit for the initial written prescription or order for certain medical supplies, equipment, and appliances must be related to the primary reason why the recipients require the certain medical supplies, equipment, and appliances and must occur no more than 6 months prior to the start of services. The required face-to-face visit may be conducted using telehealth systems.

(e) The ordering practitioner is also required to review the recipient's written plan of care annually to determine the recipient's continued need for all medical supplies, equipment, and appliances.

(f) Not all initial written prescriptions or orders for medical supplies, equipment, and appliances require a face-to-face visit be conducted. The face-to-face visit requirement is limited only to the certain medical supplies, equipment, and appliances that are also subject to a face-to-face requirement under the Medicare DME program as "Specific Covered Items" in 42 C.F.R. 410.38(g).

Ala. Admin. Code r. 560-X-13-.01

Rule effective October 1, 1982. Amended: Effective November 11, 1985. Amended: Filed February 3, 1997; effective March 10, 1997. Amended: Filed June 4, 1997; effective July 9, 1997. Amended: Filed August 11, 2004; effective September 15, 2004. Amended: Filed May 11, 2012; effective June 15, 2012. Amended: Filed April 11, 2014; effective May 16, 2014.

Amended by Alabama Administrative Monthly Volume XXXIV, Issue No. 04, January 29, 2016, eff. 2/25/2016.

Amended by Alabama Administrative Monthly Volume XXXV, Issue No. 05, February 28, 2017, eff. 3/27/2017.

Amended by Alabama Administrative Monthly Volume XXXVI, Issue No. 11, August 31, 2018, eff. 9/24/2018.

Amended by Alabama Administrative Monthly Volume XXXIX, Issue No. 01, October 30, 2020, eff. 12/14/2020.

Author: Kelli Littlejohn Newman, PharmD, Director, Clinical Services

Statutory Authority: State Plan; 42 CFR § 440.70; Title XIX, Social Security Act.