5101:3-10-02 Coverage and limitations for medical supplier services.

(A) Definitions.

(1) "Medically necessary services."

Those health services which that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted standards of medical practice.

(2) "Medical supplies."

Items that are consumable, disposable, or have a limited life expectancy. Examples are: atomizers and nebulizers, catheters, hypodermic syringes and needles.

(3) "Durable medical equipment (DME)."

Equipment that can stand repeated use, is primarily and customarily used to serve a medical purpose, is not useful to a person in the absence of illness or injury, and is appropriate for use in the home. Examples are: hospital beds, wheelchairs, and ventilators.

(4) "Orthoses."

Devices that assist in correcting or strengthening a distorted body part. Examples are: arm braces, leg braces, hearing aids.

(5) "Prostheses."

Devices that replace all or part of a body organ to prevent or correct physical deformity or malfunction. Examples are: artificial arms, artificial legs.

(6) "Medical equipment."

Durable medical equipment, orthoses, and prostheses.

(7) "Medical supplier services."

Any covered medical supply, durable medical equipment, orthosis, prosthesis, or related service provided by an eligible provider to an eligible recipient.

(8) "Personal residence."

Recipient's place of residence if such residence is not a hospital, nursing facility (NF) or intermediate care facility for the mentally retarded (ICF-MR).

(9) "Professional service."

Service provided by a physician, home health agency, orthotist, prosthetist, certified therapist, or other health care professional, including supplies furnished as incident to the service and that are commonly either furnished as a part of the service without charge or included in the professional charge.

(B) Scope of coverage.

The medical supplier services listed as covered in appendix A to rule 5101:3-10-03 and appendix A to rule 5101:3-10-20 of the Administrative Code have been designated as being within the scope of the medicaid program. Any services not included on the list or designated as noncovered, are outside the scope of the program, or are components of other services. For those within the scope of the program, the department will cover the rental and/or purchase of medical supplier services after third party resources have been exhausted pursuant to rule 5101:3-1-08 of the Administrative Code, and when the item requested:

(1) Is prescribed by a physician (M.D. or D.O.), a doctor of podiatric medicine (D.P.M.), an advanced practice nurse (APN) or an individual who is a certified nurse-midwife, certified nurse practitioner, clinical nurse specialist or a certified nurse anesthetist who is legally authorized under Ohio law to prescribe and/or order the covered medical supplier services;

(2) Is determined by the department or its designee to be medically necessary;

(3) Is provided to an eligible recipient;

(4) Is not a component of a service that is reimbursed by:

(a) A DRG payment;

(b) Per diem rate, such as in NFs; or

(c) Any other payment mechanism that is designed to include coverage of the requested item;

(5) Is not incidental to a professional service;

(6) Is not covered under manufacturer or dealer warranty;

(7) Unless otherwise stated, is not duplicative of any similar equipment or service currently in possession of the recipient;

(8) Is the most cost-effective alternative that will meet the recipient's need as defined in paragraph (F) (8) of rule 5101:3-10-05 of the Administrative Code; and

(9) Is for a recipient who is a resident of a NF or ICF-MR and the item is eligible for direct reimbursement as set forth in appendix A to rule 5101:3-10-03 and appendix A to rule 5101:3-10-20 of the Administrative Code, and will be used exclusively by the recipient for whom it is requested.

(C) Service limitations.

(1) Certain devices and equipment are considered presumptively nonmedical in nature and therefore not within the scope of the medicaid fee-for-service program. Devices and equipment presumptively nonmedical include but are not limited to:

(a) Environmental control devices (e.g., air cleaners, air conditioners);

(b) Comfort and convenience devices (e.g., seat lift chairs, elevators);

(c) Physical fitness equipment (e.g., exercycle);

(d) First aid or precautionary-type equipment (e.g., preset portable oxygen units, emergency alert systems);

(e) Training equipment (e.g., speech teaching machines);

(f) Communication aids, except as covered in rule 5101:3-10-24 of the Administrative Code;

(g) Educational aids; and

(h) Hygiene equipment (e.g., bidets, bed baths).

(2) Routine and minor first aid needs, such as band aids, antiseptics, etc., are not a benefit of the program. Likewise, personal hygiene items such as soap, or diapers for children under the age of three are not a benefit of the program.

(3) Only standard equipment will be authorized and must be dispensed, unless specific medical information indicates a need, and prior approval has been given, for specialized equipment.

(4) Requests for medical supplier services must originate with the recipient's prescriber, family, or caseworker, and must proceed with the recipient's full knowledge and consent.

(a) It is not the intent of the medicaid program that large groups of recipients in institutional or group settings be examined for defects or disabilities to determine the need for medical supplier services, whether examinations are performed in facilities of different types or in a provider's office or store.

(b) When requests for prior authorization of services, submitted either intermittently or en masse, indicate that group examinations have been made, such requests will be referred to the office of research, assessment and accountability.This office, at its discretion, will do an on-site review of mass requests. Those requests determined to be a part of mass screenings will be denied and returned to providers.

(5) Devices and services generally considered by the medical profession, or designated by the federal food and drug administration, as experimental or investigational, are not covered by the program.

(6) Equipment, devices, applications, or services are presumed to be not covered until they have been reviewed by the department for medical applications and appropriateness, safety and effectiveness, and have been designated "covered" or "noncovered"in appendix DD to rule 5101:3-1-60 of the Administrative Code.

Replaces: 5101:3-10- 02.1

Effective: 04/16/2007
R.C. 119.032 review dates: 08/21/2006 and 04/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 1/1/80, 3/1/84, 10/1/88, 5/1/90, 12/10/93, 12/12/02