Provider Requirements and Service Limitations
From The May 2010 Florida Medicaid Provider Handbook
The handbook took affect on December 3, 2008
Information highlighted in yellow indicates a change since the July 2007 version of this handbook.
Consumable Medical Supplies- Requirements To Receive
Consumable medical supplies are those non-durable supplies and items that enable
recipients to increase their ability to perform activities of daily living. Consumable
medical supplies are of limited usage and must be replaced on a frequent basis.
Supplies covered under the Developmental Disabilities waiver must meet all of the
following conditions: a) be related to a recipient’s specific medical condition; b) not be
provided by any other program; c) be the most cost-beneficial means of meeting the
recipient’s need; and d) not primarily for the convenience of the recipient, caregiver, or
family. Consumable medical supplies covered by the DD waiver are listed under
Consumable medical supplies cannot duplicate supplies provided by the Medicaid
Durable Medical Equipment (DME) and Medical Supplies Program state plan services.
Refer to the Florida Medicaid Durable Medical Equipment and Medical Supply Services
Coverage and Limitations Handbook for additional information on Medicaid state plan
coverage. Supplies not available under the Medicaid State Plan or that are available in
insufficient quantity to meet the needs of the recipient may be purchased by the waiver.
All supplies shall have direct medical or remedial benefit to the recipient and must be
related to the recipient’s developmental disability.
If multiple vendors are enrolled to provide this service, the recipient shall be
encouraged to select from among the eligible vendors based on an item’s availability,
quality and best price. No more than ten items per day may be purchased.
Consumable medical supplies covered by the DD waiver are listed below. Some items
have specific requirements or limitations.
- Diapers, including pull-ups, adult diapers or adult disposable briefs.
- Disposable gloves, when a recipient requires personal care that exposes the caregiver to body fluids. Latex-free gloves will be authorized when the recipient’s or the caregiver’s physician certifies that the recipient or caregiver has a latex allergy or that there is a probable expectation that the recipient or caregiver may have a latex allergy (i.e., recipients with spina-bifida). Disposable gloves are only available for purchase through the waiver when Medicaid DME and Medical Supplies Program state plan services allowable units are exhausted and additional gloves are determined to be medically necessary.
- Surgical masks, when prescribed by a physician and are:
a. Worn by a recipient with a compromised immune system as a protection from infectious disease; or
b. Worn by a caregiver who must provide a treatment that requires strict, sterile procedure in which they are trained to provide care to a recipient who has a compromised immune system and who must be protected at all cost from exposure to any airborne organisms or substances.
c. The physician must renew the prescription quarterly.
- Disposable or washable bed or chair pads and adult sized bibs.
- Ensure or other food supplements, not covered by the Medicaid DME and Medical Supplies Program state plan services, when determined necessary by a licensed dietitian. Recipients that require nutritional supplements must have a dietitian’s assessment documenting such need. The assessment shall include documentation of weight fluctuation.
- Feeding tubes and supplies, not covered by Medicaid State Plan and prescribed by a physician. Excludes supplies for a recipient who qualifies for food supplements under the Florida Medicaid Durable Medial Equipment and Medical Supplies Program or the Medicare Program.
- Dressings not covered by the Medicaid DME and Medical Supplies Program state plan services that are required for a caregiver to change wet to dry dressing over surgical wounds or pressure ulcers, and prescribed by a physician.
- Hearing aid batteries, cords and routine maintenance and cleaning prescribed by an audiologist.
- Bowel management supplies purchased under the waiver are limited to $150.00 every 3 months. These supplies include laxatives, suppositories and enemas determined necessary for bowel management by the recipient’s physician.
Items not contained on this list that meet the definition of consumable medical supplies may be approved through exception by APD. To request an exception, a physician must prescribe the item. The statement from the physician must delineate how the item is medically necessary, how it is directly related to the recipient’s developmental disability, and without which the recipient cannot continue to reside in the community or in his current placement. Items specifically excluded in this handbook will not be approved through exception.
The request will be reviewed by the APD physician or nurse to determine compliance with the standards for medical necessity and to determine whether the requested item fairly meets the service definition. Consumable medical supplies must be directly and specifically related to the recipient’s disability. Items of general use such as: toothbrushes, toothpaste, toothpicks, floss, deodorant, feminine hygiene supplies, bath soap, lotions, razors, shaving cream, mouthwash, shampoo, cream rinse, tissues, aspirin, Tylenol, Benadryl, nasal spray, creams, ointments, vapor rub, powder, over-the-counter antihistamines, decongestants and cough syrups, clothing, etc., are not covered. Supplies for investigational or experimental use are not covered.
A prescription submitted for supplies, diets, over-the-counter medications, vitamins, herbs, etc., which has general utility or is generally available to the general population without a prescription, does not change the character of the item for purposes of coverage in this category. For example, a physical therapist, occupational therapist or physician recommending or prescribing items like Tylenol, Ginkgo Biloba, vitamins, gluten-free foods, cotton balls or Q-tips, does not convert that item from general utility items to consumable medical supplies covered under the DD waiver. Items covered in this category generally include only those items that are specifically designed for a medical purpose, and are not used by the general public or other general utility uses. It is the general character and not specific use of the item that governs for purposes of coverage under this category.
Consumable medical supplies are approved for a year at a time. Supplies may be ordered for 3 months at a time. The waiver does not allow for payment or reimbursement of copayments for consumable medical supplies covered by third party insurance.
Note: The Florida Medicaid Durable Medical Equipment and Medical Supply Services Coverage and Limitations Handbook is available on the Medicaid fiscal agent’s Web site at www.mymedicaid-florida.com. Select Public Information for Providers, then on Provider Support, and then on Provider Handbooks. The handbook is incorporated by reference in 59G-4.070. F.A.C.
Reimbursement* and monitoring documentation to be maintained by the provider:
- *Copy of claim(s) submitted for payment;
- *Copy of service log, listing supplies purchased; and
- Original prescription for the supply (if prescribed).
Documentation to be submitted to the waiver support coordinator by the provider:
- Copy of service log listing supplies purchased prior to or at the time of claim submission; and
- Copy of original prescription for the supply (if prescribed).
*Indicates reimbursement documentation.
Educational supplies are not consumable medical supplies and are not covered by the waiver. These supplies are expected to be furnished by the local school system. Recipients or their family members shall not be reimbursed for consumable medical supplies they purchase.
Consumable Medical Supplies Provider Requirements
Providers of consumable medical supplies include home health or hospice agencies, pharmacies, medical supply companies, durable medical equipment suppliers and vendors such as discount stores and department stores. Independent vendors may also provide these services.
Home health agencies and durable medical equipment companies must provide a bond, letter of credit or other collateral at the time of application, unless the agency has been a Medicaid enrolled provider for at least one year prior to the date it applies to become a waiver provider and has had no sanctions imposed by Medicaid or any regulatory body.
Home health and hospices shall be licensed in accordance with Chapter 400, parts III and IV F.S.
Pharmacies shall hold a permit to operate, issued in accordance with Chapter 465, F.S.
Medical supply companies and durable medical equipment suppliers shall hold local occupational licenses or permits, in accordance with Chapter 205, F.S., and shall be currently licensed in accordance with Chapter 400, part VII, F.S.
Assistive technology suppliers and practitioners shall be certified through the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA). Retail stores shall hold local occupational licenses or permits, in accordance with Chapter 205, F.S.