CHAPTER 2800 Specialized Medical Supplies Services

CHAPTER 2800
SPECIFIC PROGRAM REQUIREMENTS
FOR
SPECIALIZED MEDICAL SUPPLIES SERVICES
SCOPE OF SERVICES
2801 General
Specialized Medical Supplies (SMS) Services include various supplies that enable individuals to interact more independently with their environment and contribute to an enhanced quality of life, as well as a reduced dependence on physical support from others. SMS includes items such as food supplements, special clothing, diapers, bed wetting protective chucks, and other supplies that are specified in the approved Individual Service Plan and are not available under the other Medicaid non-waiver programs. Ancillary supplies necessary for the proper functioning of approved devices are also included in this service. The COMP is intended for those goods and services that are not covered by other Medicaid programs or those instances in which a participant’s needs exceed coverage limits in other Medicaid programs and exceptions to the coverage limits are not available.
Medical supplies can be obtained through the waiver if the supplies needed are not offered through the Durable Medical Equipment (DME) program (e.g. diapers and formula for individual 21 or older). When the medical supplies are not covered by the DME program it is not necessary to first submit a request to DME program before requesting SMS.
The COMP is the payer of last resource for items that are covered through the Durable Medical Equipment (DME), Orthotics and Prosthetics (O&P), and Hearing Services programs and other non-waiver Medicaid programs. All items covered through Medicaid non-waiver programs (e.g. dental, DME services, etc.) must be requested through the respective programs. Certain DME and other specialized medical supplies services may require prior approval through the related Medicaid Program. If the specialized medical supplies are non-covered through the related Medicaid Program, the services being requested through the COMP must be supported by:
 Documentation of COMP as payor of last resort
 Service not being covered through the other Medicaid programs or documentation evidencing that coverage for the service has been exhausted
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in the other Medicaid programs
 The need for the services being reflected in the Intake and Evaluation Team approved Individual Service Plan (ISP).
The COMP does not cover items that have been denied through the DME or other Medicaid programs for lack of medical necessity. Supplies requested through the State DME program must comply with the guidelines outlined in Chapter 700 & 900 of Part II, Policies and Procedures for Durable Medical Equipment.
For specific benefit coverage and limitations, providers of DME and specialized medical supplies and services should refer to Part II Policies and Procedures manual for Durable Medical Equipment (DME), Part II, Policies and Procedures for Orthotics and Prosthetics (O&P) and Part III, Hearing Services.
2802 Special Requirements of Participation
2802. 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 Supplies must meet the following requirements:
1. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving SMS 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 from the DME Program.
The following items do not require State Plan denial of coverage documentation:
Diapers
Chucks (used to line the bed for incontinent people)
Diaper wipes
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Nutritional supplements for adults
Medication not covered by Medicaid
Hearing aides
Eye glasses
Catheter Condoms
c. Verification of SMS service delivery, including date, location, and specific supplies provided.
d. Documentation of associated administration costs for SMS service delivery that delineates line item sources of costs; billing of associated administration costs can not exceed eight to ten (8 to 10) percent of any billing for Specialized Medical Supplies..
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. Transfer of Specialized Medical Supplies with Transition to New Provider: Specialized Medical Supplies billed for a participant must transfer with the participant when the participant transitions to a new waiver provider of SMS services (e.g., SMS purchased in bulk for the participant for the entire quarter or year). This transfer of SMS includes all Specialized Medical Supplies billed for the participant but not yet provided to or used by the participant.
2802.2 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 Supplies Services provider agencies must meet the following requirements:
1. Documentation Requirement: Documentation of associated administration costs for SMS 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 SMS services. Providers, except
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for providers of participant-directed services, must document the following in the record of each participant receiving SMS 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 from the DME Program or DME policy manual citation for any item clearly not covered by the State Plan DME Program. This DME policy citation.
The following items do not require State Plan denial of coverage documentation or policy citation:
Diapers
Chucks (used to line the bed for incontinent people)
Diaper wipes
Nutritional supplements for adults
Medication not covered by Medicaid
Hearing aides
Eye glasses
Catheter condoms
c. Verification of SMS service delivery, including date, location, and specific supplies 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).
4. Transfer of Specialized Medical Supplies with Transition to New Provider: Specialized Medical Supplies billed for a participant must transfer with the participant when the participant transitions to a new waiver provider of SMS
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services (e.g., SMS purchased in bulk for the participant for the entire quarter or year). This transfer of SMS includes all Specialized Medical Supplies billed for the participant but not yet provided to or used by the participant.
2803 Licensure
Specialized Medical Supplies vendors must hold the applicable Georgia business license as required by the local, city or county government in which the services are provided.
2804 Special Eligibility Conditions
1. The need for SMS services must be related to the individual disability and specified in the Health and Safety Section of the Intake and Evaluation Team approved Individual Service Plan (ISP).
2. When a participant only receives specialized services, a specific goal must be in the ISP for any specialized services, which includes SMS.
3. Medical necessity for SMS services must be documented through an order by a Georgia licensed physician, except for incontinent supplies which are approved by the Level of Care Nurse in the review of the ISP.
2805 Prior Approval
1. Participant receives recommendation in writing from physician stating a need for SMS, except for incontinent supplies which are approved by the Level of Care Nurse in the review of the ISP as indicated in Section 2504.
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.
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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 supplies to the participant.
c. If denied for not meeting medical necessity criteria, the waiver will not pay for the SMS.
d. If denied for reasons other than medical necessity criteria, the waiver will pay for the SMS. Some DME items are allowable but only through the prior approval process described in Chapter 800 of the DME Program Policy Manual. (Section 802 of this chapter reviews which items require prior approval. The following sections of the chapter describe the procedures for obtaining prior approval. Denial of prior approval for these items allows for billing to 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 as non-covered. This documentation will be accepted in lieu of the formal denial for the supplies. With this documentation, the item can be purchased through the waiver.
5. If the waiver will pay for the SMS, the SMS services must be authorized prior to service delivery by the applicable DBHDD Regional Office agency at least annually in conjunction with the Individual Service Plan development and with any ISP revision.
NOTE: Prior approval through the DME Program will not be required for items listed above in 2501.1b and 2502.1 (1b).
The following items do not require State
Plan denial of coverage documentation:
Diapers
Chucks (used to line the bed for incontinent people)
Diaper wipes
Nutritional supplements for adults
Medication not covered by Medicaid
Hearing aides
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Eye glasses
Catheter condoms
2806 Covered Services
Reimbursable SMS services include the following based on the assessed need of the participant and as specified in the approved ISP:
1. Specialized Medical Supplies are various supplies, which enable individuals to interact more independently with their environment thus enhancing their quality of life and reducing their dependence on physical support from others.
2. Nutritional supplements, such as Ensure, Isomil, and Boost, for participants 21 years of age or older.
3. Nutritional supplements, such as Ensure, Isomil, and Boost, for participants under the age of 21 years only if State Plan coverage is exhausted.
4. Special clothing, such as specially designed vests to assist with wheelchair transfers and re-positioning, adaptive clothing for individuals with limited mobility, clothing designed with G-tube access openings, and other easy access clothing specifically designed for individuals with disabilities.
5. Diapers, bed wetting protective chucks, and other incontinent supplies.
6. Other supplies with documented medical necessity that are related to the participant’s disability, such as supplies for ongoing medical or nursing care of the participant.
7. Ancillary supplies necessary for the proper functioning of approved devices are also included in this service.
8. Infection control supplies, such as non-sterile gloves, aprons, masks and gowns, when services are provided by an individual. Supplies used by agencies are customarily included in the agency’s reimbursement rate for services. However, when supplies are required in quantity, for recurring need and are included in the ISP for a specific participant, these supplies would be considered as a separate billable item under this program. Supplies that are considered as separate billable items must meet the following criteria:
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a. The supply is directly identifiable to an individual participant.
b. The item furnished at the direction of the participant’s physician and is specifically identified in the ISP.
9. Over-the-counter (OTC) medications when prescribed by a physician and related to a diagnosed condition.
10. Medications not covered by the Medicaid State Plan when written documentation from the pharmacy for non-coverage of the medication through the State Medicaid Plan is in the participant’s record.
2807 Non-Covered Services
1. Items covered under the Durable Medical Equipment (DME), Orthotics and Prosthetics, and Hearing Services programs and other Medicaid non-waiver programs.
2. Items that have been denied through the DME and other programs for lack of medical necessity.
3. Environmental control items (e.g., air conditioners, dehumidifiers, air filters or purifiers).
4. Comfort or convenience items.
5. Physical fitness items (e.g., exercise cycle, exercise treadmill).
6. Supplies considered experimental.
7. Experimental medicines, practices, or treatments.
8. Infant and child car seats.
9. Blood pressure monitors and weight scales.
10. Computer supplies (printers, cartridges, speakers and other supplies).
11. Cell phones and minutes.
12. Ancillary supplies for the proper functioning of non-approved devices or equipment.
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13. Supplies 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).
14. Vitamins, herbal supplement, nutritional oils, and other non-nutritional supplements are not covered except when prescribed by a physician and related to a diagnosed condition.
15. 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.
16. 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.
17. Medications covered by the Medicaid State Plan are not allowed.
18. Co-pays for medications.
2808 Basis for Reimbursement
A. $1,868.16 annual maximum.
B. Reimbursement Rate
Reimbursement rate for Specialized Medical Supplies is participant specific up to the annual maximum. The reimbursement rates for all specialized services are found in Appendix A.
2809 Participant-Direction Options
A. Participants may choose the self-direction option with Specialized Medical Supplies Services.
B. If the participant (or representative, if applicable) opts for participant direction of SMS services, then these supplies 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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