DOH Reminds Plans and Providers About Medicaid DME Coverage Policy

In a notice circulated last week, the Department of Health (DOH) reminded nursing homes; providers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); and Medicaid managed care plans, including Managed Long Term Care (MLTC) plans, of the rules governing DMEPOS billing. Unless custom made for a Medicaid member, DMEPOS for nursing home residents are included in the Medicaid rate. Consistent with Section 505.5 of Social Services regulations (18 NYCRR 505.5(d)(1)(iii)), Medicaid cannot be billed for items provided by a facility or organization when the cost of these items is included in the rate. To meet the definition of custom made, the DMEPOS must require that the Medicaid member be measured and that the custom-made item be fabricated from these measurements solely for a particular Medicaid member. It cannot be readily changed to conform to another member's needs. DMEPOS that do not meet the definition of custom made and are provided to a nursing home resident are included in the nursing home Medicaid rate.

The DOH notice specifies that DMEPOS providers should be confirming where the member resides and ensuring that items are not included in the facility’s rate before billing Medicaid fee-for-service (FFS) or the member’s Medicaid managed care plan. Where nursing home services are included in a managed care plan’s benefit package, the plan is responsible for educating providers and monitoring claims to eliminate any potential duplicate payments.

For individuals served through Medicaid FFS, questions regarding the policy should be directed to OHIPMEDPA@health.ny.gov. For individuals enrolled in Medicaid managed care and MLTC, questions should be addressed to the individual’s plan.

LeadingAge NY Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841