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Durable Medical Equipment

Provider Requirements and Service Limitations

From The May 2010 Florida Medicaid Provider Handbook

Durable Medical Equipment and Supplies -
Requirements To Receive

Description:

Durable medical equipment includes specified, prescriptive equipment required by the recipient. Durable medical equipment generally meets all of the following requirements: a) can withstand repeated use; b) is primarily and customarily used to serve a medical purpose; c) is generally not useful to a recipient in the absence of a disability; and d) is appropriate for use in the home. Examples of durable medical equipment covered by the DD waiver are listed in the Limitations segment of this section.

This service is not available to individuals enrolled on the DD Waiver – Tier Four.

Limitations:

Durable medical equipment and supplies cannot duplicate DME and supplies provided through 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 DME and Medical Supplies Program state plan services 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 are related to the recipient’s disability. The following is a list of equipment that the DD waiver will cover under the category of durable medical equipment. Some items have specific requirements or limitations.

  1. Van adaptations, including lifts, tie downs, raised roof or doors in a familyowned or individually owned full-size van. The conversion of mini-vans is limited to the same modifications, but exclude the cost to modify the frame (e.g., lower the floor) to accommodate a lift. Van modifications must be necessary to ensure accessibility of the recipient with mobility impairments and when the vehicle is the recipient’s primary mode of transportation. Only one set of modifications per vehicle is allowed, and only one modification will be approved in a five-year period. No adaptations will be approved for an additional vehicle if the Department has paid for adaptations to another vehicle during the preceding five-year period. The vehicle modified must also have a life expectancy of at least five years. This is to be documented with an inspection by an Automotive Service Excellence (ASE) certified mechanic. The lift approved cannot then exceed 2 ½ times the NADA (blue book) value for the make, model and mileage on the van. Purchase of a vehicle and any repairs or routine maintenance to the vehicle are the responsibility of the recipient or family. Payments for repair to adaptations after the warranty expires may be approved by APD. Many automobile manufacturers offer a rebate of up to $1,000 to recipients purchasing a new vehicle requiring modifications for accessibility. To obtain the rebate the recipient or family is required to submit documented expenditures of modifications to the manufacturer. If the rebate is available it must be applied to the cost of the modifications. If a recipient or a family purchases a used vehicle with adaptive equipment already installed, the waiver may not be used to fund the vehicle purchase or any portion of the purchase related to the adaptive equipment already installed. A rehabilitation engineer or other certified professional may be reimbursed under home accessibility assessment to assess the appropriateness of any van conversion including identification of an appropriate lift system.
  2. Wheelchair carrier for the back of the car is limited to one carrier for a five-year period.
  3. Wheelchairs, to the extent that they are medically necessary and not covered by the Medicaid DME and Medical Supplies Program state plan services. A physician must prescribe the specific item. Coverage in this category will typically only be provided when the following criteria are met:
    a. The recipient has a customized power wheelchair funded through Medicare or Medicaid, which is used as his primary mode of ambulation; or the recipient is ambulatory, but has a documented medical condition that prevents walking for sufficient lengths of time to go about his daily activities, for example cardiac insufficiency or emphysema. This condition must be documented by a physician and include a statement addressing how the recipient is limited in normal daily activities by the condition;
    b. The recipient needs a manual wheelchair to facilitate movement within his own home, and to enable the recipient to be safely transported in an automobile. It must be documented that the vehicle does not have a lift or that the recipient’s primary chair, if applicable, cannot be collapsed to fit into a trunk or on a wheelchair carrier;
    c. The requested wheelchair is the most cost-beneficial device that meets the needs of the recipient;
    d. The wheelchair covered by this service is a standard (manual) wheelchair and not intended for a recipient who cannot use a standard chair for any length of time without adaptation.

    If the recipient usually uses a customized wheelchair but needs a standard wheelchair to transfer to an automobile that does not have a lift or for around the home to avoid the need for accessibility adaptations, an additional second (standard) wheelchair should be considered. Any adaptive wheelchair, including a customized power wheelchair, is covered through the Medicaid DME and Medical Supplies Program state plan services.

    Payments for repair to wheelchairs after the warranty expires may be approved by APD (if not covered by Medicare or Medicaid). Only one manual wheelchair may be purchased in a five-year period. The waiver will not fund the purchase of both a manual wheelchair and a stroller in a five-year period. Excluded from coverage are wheelchairs requested to facilitate recreational activities such as beach wheelchairs, sports wheelchairs, or wheelchairs that are not the most cost-beneficial way to meet the needs of the recipient. Waiver services are not used to cover any copayments, with the exception of patient responsibility for Medicare-funded wheelchairs.
  4. Strollers, subject to the same criteria and limitations for wheelchairs, as stated above, except reimbursement for a stroller will be limited to $1,200. Only one stroller or manual wheelchair can be purchased in any five-year period. As a cost-effective alternative the base unit for an adaptive car seat could be covered in lieu of a stand-alone stroller unit. Payments for repair to strollers after the warranty expires may be approved by APD, if not covered by Medicare or Medicaid DME and Medical Supplies Program state plan services. APD will respond to requests for repairs to strollers within 10 working days of receipt of such requests.
  5. Portable ramps when the recipient requires access to more than one nonaccessible structure.
  6. Patient lift, hydraulic or electric with seat or sling, when the recipient requires the assistance of more than one person to transfer between a bed, a chair, wheelchair or commode are limited to adults and limited to one lift every eight years,. Cost not to exceed $2,000. Payments for repair to lifts after the warranty expires may be approved by APD, if not covered by Medicare or Medicaid DME and Medical Supplies Program state plan services.
  7. Patient lifts are available through DME and Medical Supplies Program state plan services. The DD waiver will fund ceiling lifts only when the lift systems available through the Medicaid DME and Medical Supplies Program will not meet the recipient’s need. A ceiling lift requires a home accessibility assessment by a rehabilitation engineer or appropriate professional to insure the structural integrity of the home to support the ceiling lift and track system. When this system is requested, it must be documented that it is the most cost-effective means of meeting the recipient’s need and that the specific item selected does not exceed the medically necessary needs of the recipient. Medical necessity is usually limited to necessary access to an individual bedroom and bath. Only one system will be allowed for any recipient. If after at least five years the recipient moves, it will be determined if the most costefficient means to meet the recipient’s need is by moving the current system or purchasing a new system if still required by the recipient. A new assessment and determination must be made. The cost may not exceed $10,000. Payments for repair to ceiling lifts after the warranty expires may be approved by APD, if not covered by Medicare or Medicaid DME and Medical Supplies Program state plan services.
  8. Adaptive car seat, for recipients being transported in the family vehicle and who cannot use the standard restraint system or can no longer fit into a standard child’s car seat. The seat must be prescribed by a physical therapist that will determine that the recipient cannot use standard restraint devices or car seats. The physical therapist will identify appropriate equipment for the recipient. Adaptive car seats are limited to one per recipient every three years and cost no more than $1,000.
  9. Bidet, limited to recipients who are able to transfer onto commodes independently, but whose physical disability limits or prevents thorough cleaning. This item requires a prescription by a physician and assessment by a physical or occupational therapist to determine that the recipient can use the item independently. The bidet and installation must cost no more than $1,000.
  10. Single room air conditioner, when there is a documented medical reason for the recipient’s need to maintain a constant external temperature. Conditions for which a single room air conditioner may be appropriate include congestive heart failure, severe cardiac disease, COPD (emphysema), or damage or disease of the hypothalamus. Only one single room air conditioner with a maximum of 250 square feet capacity will be approved per recipient for a five-year period. The air conditioning unit must cost no more than $300.
  11. Single room air purifier, when there is a documented medical reason for the equipment. The documentation necessary for this equipment would be a prescription from a pulmonologist along with a medical statement explaining the medical diagnosis, the reason why the equipment is necessary and the expected outcome of the treatment. Conditions for which a single room air purifier may be appropriate include severe asthma with documented sensitivity to indoor airborne particles, chronic obstructive pulmonary disease, emphysema or pulmonary dysplasia. The air purifier unit must cost no more than $250. Only one air purifier unit will be approved per recipient for a fiveyear period.
  12. Adaptive switches and buttons to operate equipment, communication devices, environmental controls, such as heat, air conditioning, and lights, for a recipient living alone or who is alone without a caregiver for a major portion of the day. Excluded are adaptive switches or buttons to control devices intended for entertainment, employment, or education.
  13. Adaptive door openers and locks for recipients living alone or who are alone substantial portions of the day or night and have a need to be able to open, close or lock the door and cannot do so without special adaptation.
  14. Environmental safety devices limited to door alarms, anti-scald device, and grab bars for the bathroom.
  15. Bath or shower chair when medically indicated and not covered through Medicaid DME and Medical Supplies Program state plan services. Coverage is limited to the most cost-beneficial item necessary to meet the recipient’s need for bathing. Items that exceed the basic needs of the recipient are not covered.
  16. Adaptive eating devices, including adaptive plates, bowls, cups, drinking glasses, and eating utensils, that are prescribed by a physical therapist, occupational therapist or Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) certified provider. Adaptive bathing aids, to facilitate independence, as prescribed by a physical, occupational therapist, or RESNA certified provider.
  17. Picture communication boards and pocket charts, selected and prescribed by a speech therapist.
  18. Gait belts for safety during transfers and ambulation, and transfer boards.
  19. Egg crate padding for a bed, when medically indicated and prescribed by a physician.
  20. Hypoallergenic covers for mattress and pillows, ordered by a physician, who documents necessity based upon severe allergic reaction to airborne irritants.
  21. Generators, may be covered for a recipient when:
    a. The recipient is ventilator-dependent;
    b. The recipient requires daily use of oxygen via a concentrator;
    c. The recipient requires continuous, 24-hour total parenteral nutrition via an electric pump;
    d. The recipient requires continuous, 24-hour infusion of total nutritional formula through a jejunostomy or gastrostomy tube via an electric pump;
    e. The recipient requires continuous, 24-hour infusion of medication via an electric pump; or
    f. The recipient meets the medical need for a single room air-conditioner. The size of the generator is limited to the wattage necessary to provide power to the essential life-sustaining equipment. When a generator is requested, it must be documented that the specific model identified is the most cost-beneficial that meets but does not exceed the recipient’s need. One generator per recipient may be purchased per 10-year period. Payments for repair to generators after the warranty expires may be approved by APD, if no other funding is available.
  22. Bolsters, pillows, or wedges, necessary for positioning that are prescribed by a physical or occupational therapist.
  23. Therapy mat prescribed by a physical therapist when a recipient is involved in a home-therapy program designed by a therapist and carried out by the family or caregiver in the recipient’s own or family home.
  24. Pulse oximeters may be purchased for recipients with respiratory or cardiac disease, who use supplemental oxygen on a continuous or intermitted basis. This equipment must be prescribed by the recipient’s pulmonologist, cardiologist or primary care physician.

Items not contained on this list that meet the definition of durable medical equipment 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, without which the recipient can not continue to reside in the community or in his current placement. The request will be reviewed by an appropriate, qualified professional to determine whether the standards for medical necessity are met, and to determine whether the requested item fairly meets the service definition.

Items specifically excluded in this handbook will not be approved through exception.

If multiple vendors are enrolled to provide this service, the recipient shall select from among all eligible vendors based on the item’s availability, quality and best price. No more than five items per day may be purchased.

A prescription submitted for a piece of equipment, which has general utility or is generally used for physical fitness or personal recreational choice, does not change the character of the equipment for purposes of coverage in this category. For example, a physical therapist, occupational therapist or physician recommending or prescribing a stationary bicycle or hot tub, does not covert that item from personal fitness or recreational choice equipment to durable medical equipment covered under the DD Waiver. Items covered in this category generally include those specifically designed for a medical purpose, and are not used by the general public for physical fitness purposes, recreational purposes, or other general utility uses. It is the general character and not the specific use of the equipment that determines its purpose, for coverage under this category.

Items usually found or used in a physician’s office, therapist’s office, hospitals, rehabilitation centers, clinics or treatment centers, or items designed for use by a physician or trained medical personnel are not covered. This includes items such as prone or supine standers, gait trainers, activity streamers, vestibular equipment, paraffin machines or baths, therapy balls, etc.

Also excluded are experimental equipment, weighted vests and other weighted items used for the treatment of autism, facilitated communication, hearing and vision systems, institutional type equipment, investigational equipment, items used for cosmetic purposes, personal comfort, convenience or general sanitation items, or routine and first aid items.

Excluded Services:

Items for diversional or entertainment purposes are not covered. Items that would normally be available to any child or adult, and would ordinarily be provided by families are also excluded. Examples of excluded items are toys, such as crayons, coloring books, other books, and games; electronic devices, such as videotapes, CD players, radios, cassette players, tape recorders, television, VCRs, cameras, film, computers and software; exercise equipment, such as treadmills and exercise bikes; indoor and outdoor play equipment, such as swing sets, slides, bicycles, tricycles (including adaptive types), trampolines, play houses, and merry-go-rounds; and furniture or appliances. Items that are considered family recreational choices are also not covered (i.e., air conditioning for campers, swimming pools, decks, spas, patios, hot tubs, etc.).

Documentation Requirements:

Prior to the provider submitting the claim for payment, the recipient’s waiver support coordinator must document that the equipment was received and it works according to the manufacturer’s description, either by conducting a site visit or obtaining verbal verification from the recipient or family.

Reimbursement* and monitoring documentation to be maintained by the provider:

  1. *Copy of the pre-approved claim(s) form submitted for payment. 2. Original prescription for the medical equipment, if prescribed by a physician. Documentation to be submitted to the waiver support coordinator by the provider: 1. Service log listing equipment provided and documenting waiver support coordinator verification that equipment was received and works, per manufacturer’s description, prior to submission of claim for payment; and
  2. Copy of original prescription, if prescribed by physician.

*Indicates reimbursement documentation.

Special Considerations:

Recipients and their family members shall not be reimbursed for equipment they purchase. Any durable medical equipment must be determined to be cost-beneficial. Once the most reasonable alternative has been identified and specifications developed, three competitive bids must be obtained for all items $1,000 and over to determine the most economical option. If three bids cannot be obtained, it must be documented to show what efforts were made to secure the three bids and explain why less were obtained. For items under $1,000, one bid is required as long as it can be demonstrated that the bid is consistent with local market value.

The DD waiver shall not provide durable medical equipment that is available for purchase through Medicaid DME and Medical Supplies Program state plan services. Medicaid often covers like equipment, but not the specific brand requested. When this occurs, the recipient is limited to the Medicaid covered device. The lack of coverage for a specific brand name is not a medically necessary justification for waiver purchase. Only the equipment that is not covered through Medicaid DME and Medical Supplies Program state plan services or not in a sufficient quantity to meet the needs of the recipient may be purchased through the DD waiver, and then only consistent with what is described above.

All equipment shall have direct medical or remedial benefit to the recipient, shall be related to the recipient’s developmental disability and shall be necessary to prevent institutionalization. Assessment and recommendation of appropriateness by a licensed physician, physical therapist or occupational therapist is required.

In accordance with rule 65G-8.001 F.A.C., totally enclosed cribs and barred enclosures are considered restraints and are not covered under the waiver. Strollers and wheelchairs, when used for restraint are also not covered.

Durable Medical Equipment Provider Requirements

Provider Qualifications:

Providers of durable medical equipment (DME) include home health or hospice agencies, pharmacies, medical supply companies, durable medical equipment suppliers and vendors such as discount stores and department stores. In accordance with 59G- 4.070, F.A.C., to enroll as a Medicaid provider, a DME and medical supply entity must comply with all the enrollment requirements outlined in the Durable Medical Equipment and Medical Supply Services Coverage and Limitations Handbook.

In accordance with 42 C.F.R. 440.70, part providers must be in compliance with all applicable laws relating to qualifications or licensure.

In accordance with section 409.907, F.S., 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 other regulatory body.

Home health and hospice agencies shall be licensed in accordance with Chapter 400, parts III or 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 400, part VII, F.S.