Rule 23-209-1.4 - ReimbursementA. The Division of Medicaid reimburses for durable medical equipment (DME) and/or medical appliances when ordered by a physician or through the use of a collaborative practice agreement between the non-physician practitioner and the physician, and within the practitioner's scope of practice and collaborative agreement procedures. [Refer to Miss. Admin. Code Part 207 for DME coverage in a long-term care facility.]B. The Division of Medicaid requires prior authorization be submitted prior to or within thirty (30) days of delivery of the DME and/or medical appliance. The Division of Medicaid does not allow the beneficiary to be billed if the DME provider chooses to deliver the item/service prior to submitting a prior authorization request and approval is not given.C. All standard DME and/or medical appliance, excluding custom motorized/power wheelchair systems, must have a manufacturer's warranty of a minimum of one (1) year. 1. If the provider supplies DME or a medical appliance that is not covered under a warranty, the provider is responsible for any repairs, replacement or maintenance that may be required within one (1) year.2. The warranty begins on the date of the delivery to the beneficiary.3. The DME provider must keep a copy of the warranty and repair information in the beneficiary's file.4. The Division of Medicaid reserves the right to request copies of the warranty and repair information for audit/review purposes when necessary.5. The Division of Medicaid investigates cases suggesting intentional damage, neglect, or misuse of the DME and/or medical appliance. If the provider suspects such damage of DME and/or medical appliance, the provider must report it immediately to the Division of Medicaid for investigation and notify the beneficiary that the cost for repairs/replacement may be the responsibility of the beneficiary if the Division of Medicaid determines intentional damage, neglect, or misuse of the DME and/or medical appliance.6. DME providers must provide a two (2) year warranty of the major components for custom motorized/power wheelchairs. a) The main electronic controller, motors, gear boxes, and remote joystick must have a two (2) year warranty from the date of delivery.b) Cushions and seating systems must have a two (2) year warranty or full replacement for manufacturer defects, if the surface does not remain intact due to normal wear.c) Powered mobility bases must have a lifetime warranty on the frame against defects in material and workmanship for the lifetime of the beneficiary.d) If the DME provider supplies a custom motorized/power wheelchair that is not covered under a warranty, the provider is responsible for any repairs, replacement or maintenance that may be required within two (2) years.e) The warranty begins the date of delivery to the beneficiary.D. The Division of Medicaid reimburses rental of DME and/or medical appliance up to ten (10) months, or up to the purchase price, whichever is the lesser, unless specified as a "rental only" item in Miss. Admin. Code Part 209. 1. After rental benefits are paid for ten (10) months, the DME becomes the property of the beneficiary, unless otherwise authorized by the Division of Medicaid through specific coverage criteria.2. There cannot be sales tax on "rental only" items as there is no sale or purchase.3. A trial period for DME and/or medical appliance must be applied toward the ten (10) month rental. a) The Division of Medicaid applies the rental fees paid for any trial period toward the maximum reimbursement for purchase.b) The Division of Medicaid does not reimburse a rental trial period in addition to the full purchase price.4. The rental allowance includes the DME and/or medical appliance, delivery, freight and postage, set-up, all supplies necessary for operation of the DME and/or medical appliance, education of the patient and caregiver, all maintenance and repairs or replacement, labor including respiratory therapy visits, and servicing charges.5. Rental benefits beyond the ten (10) month period must be: a) Prior authorized by the Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity,b) Medically necessary, andc) Cost effective for the Division of Medicaid.6. The DME and/or medical appliance must be returned to the DME provider after it is no longer required, if the rental period is less than ten (10) months.E. The Division of Medicaid reimburses repairs, including labor and delivery, of DME and/or a medical appliance that is owned by the beneficiary not to exceed fifty percent (50%) of the maximum allowable reimbursement for the cost of replacement. 1. DME providers providing custom wheelchairs, specialty and/or alternative controls for wheelchairs, extensive modifications and seating and positioning systems must have a designated repair and service department, with a technician available during normal business hours, between eight (8) a.m. and five (5) p.m. Monday through Friday. Each technician must keep, on file, records of attending continuing education courses or seminars to establish, maintain and upgrade their knowledge base.2. The Division of Medicaid requires prior authorization by the Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity for the repair and must include an estimated cost of necessary repairs, including labor, and a statement from the physician stating that there is a continued need for the DME and/or medical appliance.3. Labor and delivery charges are included in the repair cost and are not reimbursed separately.4. The Division of Medicaid does not reimburse repair of a rental item.5. The Division of Medicaid does not reimburse repairs when it has been determined that the DME and/or medical appliance has been intentionally damaged, neglected, or misused by the beneficiary, caregiver or family.6. The Division of Medicaid reimburses, under extenuating circumstances as determined by the Division of Medicaid, UM/QIO, or designated entity rental of an item on a short-term basis while DME and/or medical appliance owned by the beneficiary is being repaired.F. The Division of Medicaid reimburses the replacement of DME and/or a medical appliance, without a trial period, under the following circumstances: The initial trial period may be waived for the replacement of an identical or existing piece of DME or medical appliance.1. Wear and tear every five (5) years, unless there are extenuating circumstances.2. Theft when there is documentation from law enforcement of a theft.3. Fire when there is documentation from the fire department.4. Natural disaster when there is documentation from the appropriate authorities.G. The Division of Medicaid reimburses for the purchase of DME and/or medical appliance when it is determined by the Utilization Management/Quality Improvement Organization, the Division of Medicaid or designated entity to be more economical than renting and when the period of need is estimated by the physician to be ten (10) or more months. H. The Division of Medicaid reimburses DME and/or medical appliances at the lesser of the provider charge or the Division of Medicaid's allowable fee set as follows: 1. Purchased items are set at eighty percent (80%) of the Medicare fee.2. Rental items are set at ten percent (10%) of the Division of Medicaid's allowable fee.3. Used DME and/or medical appliances and repairs are set at fifty percent (50%) of the Division of Medicaid's allowable fee.I. The Division of Medicaid manually prices items that do not have an assigned allowable fee. 1. The Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity performs the manual pricing of the item.2. When requesting manually priced items, the DME provider must indicate the name of the product, the product number, and the name of the manufacturer or distributor and must provide the required documentation for pricing.3. If there is no DMEPOS fee, the provider will be reimbursed a fee determined by the Division of Medicaid. The Division of Medicaid will utilize the lower of the Division of Medicaid's average/established fee or the average of the fees from other states, when available, or determine the fee from cost information from providers and/or manufacturers, survey information from national fee analyzers, or other relevant fee-related information. The fees will be updated as determined by the Division of Medicaid.4. If there is no DMEPOS fee or a fee determined by the Division of Medicaid, the provider will be reimbursed a fee calculated through the following manual pricing hierarchy: a) Manufacturer's Suggested Retail Price (MSRP) minus twenty percent (20%) or, 1) It is expected that most items will have a retail price; therefore, providers should request MSRP pricing for all manually priced items unless there is absolutely no retail price.2) Other acceptable terms that represent MSRP include suggested list price, retail price, or price.3) The provider must submit clear, written, dated documentation from a manufacturer or distributor that specifically states the MSRP for the item. This documentation must be provided with an official manufacturer's or distributor's letterhead, price list, catalog page, or other forms that clearly show the MSRP.4) A manufacturer's or distributor's quote may be substituted for an MSRP if the manufacturer does not make an MSRP available. The quote must be in writing from the manufacturer or distributor and must be dated.b) If there is no MSRP, then the provider's invoice received from a wholesaler or manufacturer plus twenty percent (20%).1) The provider must attach a copy of a current invoice indicating the cost to the provider for the item dispensed and a statement that there is no MSRP available for the item.2) If the provider purchases from the manufacturer, a manufacturer's invoice must be provided.3) If the provider purchases from a distributor and not directly from the manufacturer, the invoice from the distributor must be provided.4) Quotes, price lists, catalog pages, computer printouts, or any form of documentation other than an invoice are not acceptable for this pricing solution.5) The invoice must not be older than one (1) year prior to the date of the request. Exceptions to the one (1) year requirement may be approved only for unusual circumstances.J. When it is determined by DOM, based on documentation, that the Durable Medical Equipment, Prosthetics/Orthotics, and Supplies Fee Schedule (DMEPOS) fee is insufficient for the Mississippi Division of Medicaid population or could result in a potential access issue, then a fee will be calculated using market research from the area.L. DME, medical appliances, and medical supplies related to the terminal illness for those Division of Medicaid beneficiaries receiving benefits in the Hospice Program cannot be reimbursed through the DME and medical appliances program.M. The Division of Medicaid's fee schedule of DME is not comprehensive. The Division of Medicaid reimburses for items not listed on the DME fee schedule, on a case-by-case basis, when prior authorized as medically necessary by a UM/QIO, and the provider submits the following to the Division of Medicaid: 2. Approved prior authorization.N. The following are not reimbursed by the Division of Medicaid under the DME program: 1. Additional charges for freight, postage and/or delivery and2. Cost of replacing items that were not delivered to the beneficiary due to loss, theft or incomplete delivery.O. The Division of Medicaid reimburses for the face-to-face encounter conducted by a physician or non-physician practitioner separately according to the appropriate fee schedule.P. Evaluations and/or assessments including environmental evaluations in order to provide DME and/or medical appliances are not separately reimbursable.23 Miss. Code. R. 209-1.4
U.S.C. § 1395(m); Miss. Code Ann. § 43-13-121.