205.6333 Reimbursement for in-network suppliers of durable medical equipment,
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/ky/205-6333A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
prosthetics, orthotics, and supplies -- Reimbursement rate -- Timeframe for
claim submissions.
(a)As used in this section, "durable medical equipment" means equipment which:
1. Can withstand repeated use;
2. Is primarily and customarily used to serve a medical purpose;
3. Generally is not useful to a person in the absence of an illness or injury;
and
4. Is appropriate for use in the home.
(b)As used in this section, "durable medical equipment" does not include:
1. Enteral nutrition;
2. Eye prosthetics;
3. Home infusion;
4. Orthotics;
5. Prosthetics; or
6. Automated external defibrillators under Healthcare Common Procedure
Codes K0606 and E0617.
(2)The Department for Medicaid Services shall reimburse a supplier of durable
medical equipment, prosthetics, orthotics, and supplies at no less than ninety
percent (90%) of the state Medicaid program durable medical equipment fee
schedule and shall require Medicaid managed care organizations to reimburse the
same amount as the Department for Medicaid Services reimburses for the same
service or item of durable medical equipment, prosthetics, orthotics, and supplies.
This subsection shall apply to those healthcare codes and services included in
Section 1903(i)(27) of Title XIX of the Social Security Act.
(3)The department shall require Medicaid managed care organizations to reimburse
suppliers of durable medical equipment, prosthetics, orthotics, and supplies for
manually priced items in the Medicaid program durable medical equipment fee
schedule at the manufacturer's suggested retail price minus eighteen percent (18%)
pricing where there is a manufacturer's suggested retail price, and at invoice price
plus twenty percent (20%) for miscellaneous Healthcare Common Procedure
Coding System codes where there is no manufacturer's suggested retail price.
(4)The department shall require Medicaid managed care organizations to cover, at a
minimum, the same Healthcare Common Procedure Coding System codes and the
same quantities of medical supplies, equipment, or services as are established on the
Kentucky Medicaid program durable medical equipment fee schedule or Kentucky
Medicaid medical policy.
(5)The department shall ensure that the allowable timeframe for claim submissions by
suppliers of durable medical equipment, prosthetics, orthotics, and supplies shall
equal the timeframe allowed for any discrepancy during the Medicaid managed care
organization audit or recoupment process for that claim.
(6)The reimbursement for suppliers of durable medical equipment established pursuant
to this section shall only be available to a durable medical equipment supplier who
is an in-network provider of the beneficiary's Medicaid managed care organization.