Subsection 144-101-II-60.10 - REIMBURSEMENT60.10-1General Reimbursement MethodologyEffective January 1, 2023, reimbursement for medical supplies and DME will be the lowest of the following, unless otherwise specified in this section:
A. The maximum MaineCare allowed amount, which the Department will establish based on: 1. 100% of the current Medicare DMEPOS Fee Schedule amount; or2. If no Medicare fee schedule amount is established, the average cost of the relevant services/codes from other state Medicaid agencies. These allowed amounts will receive an inflation adjustment on January first of each year based on the Consumer Price Index for All Urban Consumers for medical equipment and supplies (CUUR0000SEMG); orB. The provider's usual and customary charge.60.10-2Reimbursement for Incontinence SuppliesIncontinence supplies are reimbursed based on invoice cost (excluding shipping) plus 40% (forty percent), not to exceed the maximum amount allowed on the MaineCare fee schedule published on the Department's website.
Effective January 1, 2023, these allowed amounts will receive an inflation adjustment on January first of each year based on the Consumer Price Index for All Urban Consumers for medical equipment and supplies (CUUR0000SEMG). To request alternative incontinence supplies that are not on the MaineCare fee schedule, the provider must do the following for the request to be considered:
A. The provider must submit the billing code, brand name, and the cost of the requested item.B. The provider must show that the member has trialed and failed at least three alternatives that are available at the set allowable amount or document the medical reason why they should not be or were not trialed.C. The provider must document that the requested item is a cost-effective alternative to possible side-effects of current items available at the allowable amounts. For example, a member may need higher absorbency rate items due to skin break down or other adverse side-effects that occur with current supplies available at allowable amount. If the item(s) are deemed medically necessary and a cost-effective alternative based on the above criteria, the reimbursement is not to exceed cost plus 40%.
60.10-3Contract with the Department for DME/Medical SuppliesWhere the Department has entered into a contract (separate from the MaineCare Provider Agreement) with a manufacturer or provider for the provision of DME/Medical Supplies, the following shall apply:
A. If the manufacturer/provider serves as a supplier only and does not provide direct services to MaineCare members, the manufacturer/provider shall bill the MaineCare provider who purchases the DME/Medical Supplies, in accordance with normal business practices, and at a price that is contained in the contract with the Department.B. After the MaineCare provider who purchases the DME/Medical Supplies has paid the manufacturer/provider, the MaineCare provider can then bill MaineCare following the billing instructions outlined in this Section. The Department will provide advance written notice to all providers that are required to purchase certain DME items from such manufacturers/providers.
60.10-4Reimbursement for DME/Medical supplies considered to be "miscellaneous DME/Medical Supplies""Miscellaneous DME/Medical Supplies" means those DME/Medical Supplies billed under the Healthcare Common Procedure Coding System (HCPCS) code E1399 or any other DME/Medical Supplies billed under another code, which contains the phrase "miscellaneous," "accessories," "not otherwise specified" or "not otherwise classified" in its description. Miscellaneous codes can be used only if there has not been a nationally accepted code assigned to a product/service. Please reference the Healthcare Common Procedure Coding System (HCPCS) guide to identify whether a specific item has been assigned a nationally accepted code before billing the item as Miscellaneous. Miscellaneous DME/Medical Supplies will be reimbursed as follows:
A. If there is a Manufacturers' Suggested Retail Price (MSRP) the reimbursement will be MSRP minus twenty percent (20%). Documentation must be submitted supporting the MSRP.B. If there is no listed MSRP, reimbursement will be invoice cost plus thirty percent (30%). Providers will need to submit an invoice for payment. 60.10-5 Specialty modified low protein food reimbursement will be invoice cost plus fifteen percent (15%). Providers must include invoice at the time of claims submission.60.10-6 The Department shall reimburse rental items at the monthly rate published on the Department's website for a period not to exceed the rental period. Effective January 1, 2023, except for oxygen, rental periods shall follow Medicare rental periods: A. Capped rental items (category code: CR) shall have a 13-month rental period;B. Inexpensive and routinely purchased items (category code: IN) shall have a ten month rental period;C. Enteral and parenteral items (category code: EP) shall have a 15-month rental period; andD. Items requiring frequent and substantial servicing (category code: FS) shall be rented until no longer medically necessary.E. DME covered by the Department that is not covered by Medicare (category code: MC) shall have a 12-month rental period.60.10-7 Oxygen (category code: OX) shall be rented for as long as it is medically necessary. Providers may bill for the appropriate oxygen equipment codes that include oxygen contents for as long as it is medically necessary. Providers do not need to bill for "content only" oxygen codes after thirty-six (36) months of renting oxygen equipment, as is required by Medicare. Oxygen requires annual PA.60.10-8 Any manufacturer's rebate shall be paid to the Treasurer, State of Maine. Providers shall forward or otherwise pay to the Treasurer of the State of Maine all manufacturers' rebates associated with Durable Medical Equipment or Medical Supplies provided to members pursuant to this Section of the MaineCare Benefits Manual.60.10-9 In accordance with Chapter I of the MaineCare Benefits Manual, it is the responsibility of the provider to seek payment from any other resource that is available for payment of a rendered service prior to billing the MaineCare Program. Special provisions apply for Power Mobility Devices (PMD):
A. Prior to the provision of a PMD, providers must submit a request for reimbursement to MaineCare for those members who are dually eligible for MaineCare and Medicare, see Prior Authorization Requirements in this Section;B. The total payment will be no more than the established MaineCare allowance for PMDs;C. The payment to the provider shall be reduced by any amounts paid by Medicare;D. MaineCare's allowance in non-assigned cases shall not be limited by the Medicare determination of medical necessity or allowable reimbursement rate; and E. Services initially prior authorized by MaineCare will reflect a reduction in reimbursement equal to the Medicare average payment. Subsequent adjustments will be authorized following a review of all Medicare Explanations of Benefits or written correspondence.60.10-10 Payment by the Department for any good or service provided shall constitute full payment for the supplies or equipment furnished and no additional charge shall be made to, or on behalf of, the eligible member, except for required co-payments. Some services and procedures require Prior Authorization in order for MaineCare to provide payment. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-60, subsec. 144-101-II-60.10