(A) Incontinence garments and related supplies, including disposable underpads, are covered by the medicaid program under the following conditions:
(1) The medicaid consumer is thirty-six months of age or more; and
(2) The consumer is not a resident of a nursing facility or an intermediate-care facility for the mentally retarded. Coverage of incontinence garments and related supplies to these consumers is provided as part of the per diem payment already paid to the facility by the department for this consumer's monthly care; and
(3) The type of incontinence is:
(a) Secondary to disease that 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 that results in irreversible loss of control of the urinary bladder and/or anal sphincter; or
(c) Attributed to developmental delay or developmental disability.
(B) 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 other requirements of this rule are met.
(C) Unless otherwise specified, a fully completed "Certificate of Medical Necessity/Prescription Incontinence Supplies," JFS 02912 (appendix A to this rule) that is written, signed with an original signature, and dated by the treating prescriber must be obtained at least every twelve months from the date of the prescriber's attestation signature and kept on file by the provider. Existing prescriptions that are in force prior to the effective date of this rule do not require the use of JFS 02912 until the existing prescription is renewed or modified due to medical necessity. The JFS 02912 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;
(3) The type of incontinence ; and
(4) The type of incontinence garments or incontinence supplies being prescribed.
(D) A JFS 02912 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 (C) of this rule does not meet the requirements of this rule.
(E) Providers must verify from the consumer or the consumer's designated caregiver on a monthly basis the required type and number of incontinence garments and/or related supplies.
(1) The provider 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 verified the required type and amount from the consumer or consumer's care giver. The date that the provider verified 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 verified orally or in writing from the consumer or the consumer's designated caregiver. 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 verified 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 of incontinence garments and/or related supplies required by a consumer on a monthly basis must be obtained and on file prior to dispensing the incontinence garments and/or related supplies. Under no circumstances may the amount of the incontinence garments and/or related supplies exceed the amount prescribed by the consumer's prescriber as originally documented on the JFS 02912. A new JFS 02912 is required when changes in a consumer's medical condition require an increased amount of incontinence garments or related supplies within twelve months of the date of the most recent prior prescriber's attestation signature.
(5) Any prescription for incontinence garments and related supplies must be prescribed by a prescriber actively involved in managing the consumer's medical condition as defined in paragraph (A)(2) of rule 5101:3-10-05 of the Administrative Code. This prescriber should be treating the consumer under a comprehensive plan of care that addresses the underlying medical need for any supplies referenced in this rule.
(6) Any request for incontinence supplies that exceeds the limitation amounts currently referenced in appendix A to rule 5101:3-10-03 of the Administrative Code requires that the provider submit a fully completed JFS 02912 as referenced in paragraph (C) of this rule to the department for prior authorization before payment is authorized for the dispensing of these excess supplies.
(7) Incontinence garments and related supplies are reimbursed according to the department fee schedule contained in appendix DD to rule 5101:3-1-60 of the Administrative Code or the provider's usual and customary charge, whichever is less.
R.C. 119.032 review dates: 01/03/2011 and 04/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021
Prior Effective Dates: 5/1/90, 9/1/98, 10/1/04