5101:3-10-21 Incontinence garments and related supplies.

(A) Incontinence garments and related supplies, including disposable underpads, are covered by the medicaid program under the following conditions:

(1) The medicaid consumer is more than thirty-six months of age;

(2) The consumer is not a resident of a nursing facility or intermediate-care facility for the mentally retarded. Coverage of incontinence garments and related supplies is provided as part of the per diem payment to the facility; and

(3) The type of incontinence is:

(a) Secondary to disease which results in irreversible loss of control of the urinary bladder and/or anal sphincter; or

(b) Secondary to injury of the brain or the spinal cord which results in irreversible loss of control of the urinary bladder and/or anal sphincter; or

(4) Stress incontinence is considered a type of incontinence, but does not meet the definition of disease or injury as specified in paragraph (A)(3) of this rule. Consumers with stress incontinence that is secondary to other disease or injury causing irreversible loss of control of the urinary bladder and/or anal sphincter may be eligible for incontinence garments and related supplies provided that all requirements of this rule are met.

(B) A prescription that is written, signed, and dated by the treating physician must be obtained at least every twelve months. The prescription must be obtained by the provider prior to the first date of service in the applicable twelve-month period and must specify:

(1) The applicable diagnosis of the specific disease or injury causing the incontinence; or

(2) The developmental delay or disability, including applicable diagnoses; and,

(3) The type of incontinence.

(C) A prescription that only lists incontinence or incontinence supplies and does not specify the disease or injury that has resulted in the incontinence in accordance with paragraph (B) of this rule does not meet the requirements of this rule.

(D) Providers must ascertain from the consumer or the consumer’s caregiver on a monthly basis the required type and number of of [sic] incontinence garments and/or related supplies.

(1) The providers must maintain on file written documentation of the required type and amount of incontinence garments and/or related supplies requested for each month. The documentation must include the date that the provider ascertained the required type and amount from the consumer or consumer’s care giver. The date that the provider ascertained the required type and amount must be prior to but not more than fourteen days prior to the date that the incontinence supplies are dispensed.

(2) The type and amount required may be ascertained verbally or in writing. For each month’s worth of incontinence garments and supplies, the date of service entered on the medicaid claim (dispensing date) should not be prior to the date that the provider ascertained the type and amount of incontinence supplies required for the month.

(3) Documentation of the type and amount of incontinence garments and/or related supplies requested must include the first and last name of the provider’s employee that took the request and the first and last name of the consumer, or consumer’s care giver, making the request.

(4) Documentation of the type and amount required must be obtained and on file prior to dispensing the incontinence garments and/or related supplies.

HISTORY: Eff 5-1-90; 9-1-98; 10-1-04

Rule promulgated under: RC 119.03

Rule authorized by: RC 5111.02

Rule amplifies: RC 5111.01, 5111.02

REPLACES RULE 5101:3-10-21

R.C. 119.032 review dates: 07/08/2004 and 10/01/2009