CHAPTER 2700 Specialized Medical Equipment Services

CHAPTER 2700
SPECIFIC PROGRAM REQUIREMENT
FOR
SPECIALIZED MEDICAL EQUIPMENT SERVICES
SCOPE OF SERVICES
2701 General
Specialized Medical Equipment (SME) Services include various devices, controls or appliances which are designed to enable individuals to interact more independently with their environment thus enhancing their quality of life and reducing their dependence on physical support from others. SME services also include assessment or training needed to assist participants with mobility, seating, bathing transferring, security or other skills such as operating a wheelchair, locks, door openers, or side lyers. These services additionally consist of customizing a device to meet a participant’s needs. The COMP is intended for those goods and services that are not covered by the State Medicaid Plan or those instances in which a participant’s needs exceed State Plan coverage limits and exceptions to the coverage limits are not available.
The COMP is the payer of last resource for items that are covered through the Durable Medical Equipment (DME), Orthotics and Prosthetics, and Hearing Services programs and other Medicaid State Plan programs. All items covered through these programs must be requested through the respective programs. Specialized Medical Equipment services must be documented to be the payer of last resource. The DME program prior approval process is used to determine medical necessity for medical equipment. The COMP does not cover items that have been denied through the DME and other programs for lack of medical necessity.
Providers for Specialized Medical Equipment should refer to Part II, Policies and Procedures for Durable Medical Equipment, Part II, Policies and Procedures for Orthotics and Prosthetics and Part III, Hearing Services for additional information about coverage of these services.
2702 Special Requirements of Participation
2402.1 Individual Vendor or Dealer
In addition to those conditions of participation in the Medical Assistance Program as outlined in Part I, Policies and Procedures for Medicaid/PeachCare for Kids Manual applicable to all Medicaid providers, Section 106 (General Conditions of Participation), and Part II, Chapter 600 Policies and Procedures for the COMP Program, individual vendors and dealers in Specialized Medical Equipment must meet the following requirements:
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1. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving SME services:
a. The efforts to substantiate payer of last resource, including available community, State Plan, or other resources by the participant’s support coordinator.
b. State Plan denial of coverage documentation received by the DME Program.
c. Verification of SME service delivery, including date, location, and specific equipment and assessment, training, customizing, or special circumstances repair of equipment provided.
d. Documentation of associated administrative costs for SME service delivery that delineates line item sources of costs; billing of associated administration costs cannot exceed eight to ten (8 to 10) percent of any billing for Specialized Medical Equipment.
2. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for COMP, Chapter 1200.
2702.2 Provider Agencies
In addition to those conditions of participation in the Medical Assistance Program as outlined in Part I, Policies and Procedures for Medicaid/PeachCare for Kids Manual applicable to all Medicaid providers, Section 106 (General Conditions of Participation), and Part II, Chapter 600 Policies and Procedures for the COMP Program, Specialized Medical Equipment Services provider agencies must meet the following requirements:
1. Documentation Requirement: Documentation of associated administration costs for SME service delivery that delineates line item sources of costs; billing of associated administration cost can not exceed eight to ten (8 to ten) percent of any billing for SME services. Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving SME services:
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a. The efforts to substantiate payer of last resource, including available community, State Plan, or other resources by the participant’s support coordinator.
b. State Plan denial of coverage received by the DME Program.
c. Verification of SME service delivery, including date, location, and specific equipment and assessment, training, customizing, or special circumstances repair of equipment provided.
2. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for COMP, Chapter 1200.
3. DBHDD Contract/LOA and MHDDD Community Service Standards: Providers must adhere to DBHDD Contract Standards, DBHDD Core Requirements for All Providers and all other applicable DBHDD Standards, including accreditation by a national organization (CARF, JCAHO, The Council, Council on Accreditation) or certification by the DBHDD (see Part II Policies and Procedures for COMP, Chapter 603).
2703 Licensure
Specialized Medical Equipment vendors must hold the applicable Georgia business license as required by the local, city or county government in which the services are provided.
2704 Special Eligibility Conditions
1. The need for SME services must be related to the individual disability and specified in the Health and Safety Section of the Intake and Evaluation Team approved Individual Services Plan (ISP).
2. When a participant only receives specialized services, a specific goal must be in the ISP for specialized services, which includes SME.
3. Medical necessity for SME services must be documented through an order by a Georgia licensed physician.
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2705 Prior Approval
1. Participant receives recommendation in writing from physician stating a need for SME.
2. Participant takes recommendation in writing to a DME vendor.
a. Support Coordination may assist with locating/accessing an appropriate DME vendor
3. DME vendor submits a prior approval request to the Department of Community Health using the prior approval process outlined in the policy manual for Durable Medical Equipment, Section 803, found on the web portal at www.mmis.georgia.gov.
4. The Department’s contractor approves or denies prior approval based on medical necessity criteria and notifies DME through electronic format of determination
a. If there is not enough information to make the determination, the Department’s contractor will request additional documentation from the appropriate party.
b. If approved as a State Plan Service, the DME vendor then submits a claim and provides the medically necessary supplies to the participant.
c. If denied for not meeting medical necessity criteria, the waiver will not pay for the SME.
d. If denied for reasons other than medical necessity criteria, the waiver will pay for the SME. Some DME items allowable but only through the prior approval process described in Chapter 800 of the DME Program Manual (Section 802 of this chapter reviews which items requires prior approval. The following sections of this chapter describe the procedures for obtaining prior approval. Denial of prior approval for these items allows for billing of the waiver.
e. If the DME vendor is unable to submit a prior authorization or obtain a denial because the medically necessary item is not a State Plan covered item, the provider maintains in the participant record a copy of the DME Policy Manual Section 902, 903, 904 or 905, substantiating the item is non-covered. This documentation will be accepted in lieu of a formal denial for supplies. With this documentation, the item can be purchased through the waiver.
5. If the waiver will pay for the SME, the SME services must be authorized prior to service delivery by the applicable DBHDD
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Regional Office agency at least annually in conjunction with the Individual Service Plan development and with any ISP revision
2706 Covered Services
Reimbursable SME services include the following based on the assessed need of the participant and as specified in the approved ISP:
1. Purchase of equipment or the lease of equipment when cost effective.
2. Devices, controls or appliances specified in the Individual Service Plan, which enable participants to increase their abilities to perform activities of daily living and to interact more independently with their environment, including costs of assessment or training needed to assist participants with use of devices, controls, or appliances, such as operating a wheelchair, locks, door openers, or side lyers.
3. Computers necessary for operating communication devices, scanning communicators, speech amplifiers, control switches, electronic control units, wheelchairs, locks, door openers, or side lyers.
4. Customizing a device to meet a participant’s needs.
5. Replacement or repair of equipment is covered in cases of special circumstances (e.g., from fire), normal wear and tear, or when the participant’s condition changes.
2707 Non-Covered Services
1. Equipment that has been denied through the DME and other programs for lack of medical necessity.
2. Equipment covered under the Durable Medical Equipment (DME), Orthotics and Prosthetics, and Hearing Services programs and other Medicaid non-waiver programs.
3. Environmental control equipment (e.g., air conditioners, dehumidifiers, air filters or purifiers).
4. Comfort or convenience equipment (e.g., vibrating beds, over-the-bed trays, chair lifts).
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5. Institutional-type equipment (e.g., cardiac or breathing monitors).
6. Equipment designed specifically for use by a physician and trained medical personnel (e.g., EKG monitor, oscillating bed and laboratory testing equipment).
7. Physical fitness equipment (e.g., exercise cycle, exercise treadmill).
8. Furnishing-type equipment (e.g., infant cribs).
9. Home security items, (e.g., alarm systems, burglar bars, security cameras, personal emergency response systems and deadbolt locks).
10. Elevators, chair lifts, and indoor ceiling lift systems.
11. Equipment considered experimental or under investigation by the Public Health Service.
12. Equipment associated with experimental medical practices or treatments.
13. Infant and child car seats.
14. Blood pressure monitors and weight scales.
15. Computers, such as desktop and personal computers.
16. Cell phones and minutes.
17. Hot tubs, spas, and whirlpool tubs.
18. Items that add value to a property, such as a fence.
19. Equipment commonly used for recreational purposes, including but not limited to bicycles, trampolines, swimming pools, swing sets, slides, stereos, radios, televisions, and MP3 players.
20. Equipment for education and related services by children for whom the Department of Education has primary responsibility (i.e., private schools, ABA in school, home-schooling, tutors).
21. Equipment replacement or repair that is necessitated by participant neglect, wrongful disposition, intentional misuse or abuse. Equipment will not be replaced due to the participant’s negligence
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and/or abuse (e.g., a wheelchair left outside). Equipment will not be replaced before its normal life expectancy has been attained unless supporting medical documentation of change in the physical or developmental condition of the participant.
22. Extended warranties and/or maintenance agreement.
23. Payment is not made, directly or indirectly, to members of the individual’s immediate family, except as approved as indicated in Part II Policies and Procedures for COMP, Chapter 900.
24. Payment is not made for those goods and services covered by the State Medicaid Plan except where a participant’s need exceeds State Plan coverage limits and exceptions to the coverage limits are not available.
2708 Basis for Reimbursement
A. Lifetime maximum is $13,474.76 per participant.
B. Annual maximum is $5,200.
C. Reimbursement Rate
The reimbursement rate for the purchase, replacement or repair for Specialized Medical Equipment is the established Medicaid rate, or in the absence of a Medicaid rate, the lower of three price quotes or the annual maximum. Price quotes are not required for purchases, replacements, or repairs under $200.00. The reimbursement rate is inclusive of equipment and any necessary technical assistance in its usage. The reimbursement rates for all specialized services are found in Appendix A.
2709 Participant-Direction Options
A. Participants may choose the self-direction option with Specialized Medical Equipment Services.
B. If the participant (or representative, if applicable) opts for participant direction of SME services, then this equipment will be purchased through participant-directed service delivery.
C. For details on participant-direction, see Part II Policies and Procedures for COMP, Chapter 1200.
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