N.Y. Comp. Codes R. & Regs. tit. 12 § 442.2
Current through Register Vol. 46, No. 45, November 2, 2024
Section 442.2 - Fee schedule(a)(1) The maximum permissible charge for the purchase of durable medical equipment, medical/surgical supplies, and orthotic and prosthetic appliances shall be the fee payable for such equipment or supplies under the Official New York Workers' Compensation Durable Medical Equipment Fee Schedule, fourth edition, December 2023, prepared and published by the Board, which is hereby incorporated by reference, available for viewing free of charge on the Board's website.(2) The maximum permissible monthly charge for the rental of durable medical equipment shall be the rental price listed in the Official New York Workers' Compensation Durable Medical Equipment Fee Schedule multiplied by the total number of months or weeks respectively for which the durable medical equipment is needed. In the event the total rental charge exceeds the purchase price, the maximum permissible charge for the durable medical equipment shall be the purchase price listed in the Official New York Workers' Compensation Durable Medical Equipment Fee Schedule, whether or not the claimant keeps the durable medical equipment or returns it when no longer needed.(3) Within six months of the effective date of this section, all durable medical equipment and supplies shall be provided (a) by a New York State Medicaid Enrolled Supplier and (b) in accordance with the Ground Rules therefore as set forth in the Official New York Workers' Compensation Durable Medical Equipment Fee Schedule, except for durable medical equipment provided as part of medical treatment provided in conformity with the Ground Rules of the Official New York Workers' Compensation Medical Fee Schedule. A supplier's MMIS ID number must be submitted with every bill for durable medical equipment. The Official New York State Workers' Compensation Durable Medical Equipment Fee Schedule for durable medical equipment, medical/surgical supplies, and orthotic and prosthetic appliances incorporated by reference herein is available on the Board's website at wcb.ny.gov.(b)(1) Prior authorization in accordance with section 442.4 must be obtained when indicated on the Official New York State Workers' Compensation Durable Medical Equipment Fee Schedule for any durable medical equipment prior to prescribing or supplying. (2) When a medical provider recommends durable medical equipment that is not listed in the Official New York Workers' Compensation Durable Medical Equipment Fee Schedule, prior authorization, including a proposed purchase price or rental price for such equipment, must be obtained and provided within the prior authorization request prior to prescribing or supplying such durable medical equipment.(d) Self-insured employers and insurance carriers, including their agents and designees, shall not direct a claimant to use a particular supplier of durable medical equipment, medical/surgical supplies, and orthotic and prosthetic appliances, except as part of a certified preferred provider organization in accordance with Workers' Compensation Law Article 10-A and Subpart 325-8 of this Title. Self-insured employers and insurance carriers, including their agents and designees, may recommend a supplier of durable medical equipment, medical/surgical supplies, and orthotic prosthetic appliances.(e) Notwithstanding any other provision to the contrary, the chair may make other adjustments to the durable medical equipment fee schedule as he or she deems appropriate, upon a finding that the reimbursement provided for a particular piece of durable medical equipment, medical/surgical supply or other such item under the fee schedule is grossly inadequate to meet the suppliers' or pharmacies' costs, and following 30 days notice on its website and consideration of any comments provided in response to such notice. Requests for such adjustments to the fee schedule shall be submitted to the Bureau of Health Management, 100 Broadway, Menands, Albany, NY 12241.(f) Hearing aids are not considered durable medical equipment for purposes of this fee schedule and the reimbursement is the provider's usual and customary price.(g) The Medicaid provider manual and the policy guidance for durable medical equipment are not included as part of the durable medical equipment fee schedule used in workers' compensation cases except to the extent such documents contain the Medicaid durable medical equipment fee schedule.N.Y. Comp. Codes R. & Regs. Tit. 12 § 442.2
Amended New York State Register March 3, 2021/Volume XLIII, Issue 09, eff. 6/7/2021Amended New York State Register December 22, 2021/Volume XLIII, Issue 51, eff. 12/22/2021Amended New York State Register April 13, 2022/Volume XLIV, Issue 15, eff. 4/13/2022Amended New York State Register June 26, 2024/Volume XLVI, Issue 26, eff. 6/28/2024