TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES

Amends 405 IAC 5-3-5 to remove the requirement for rehabilitative potential for wheelchairs for child recipients in a nursing facility in accordance with IC 12-15-5-12. Amends 405 IAC 5-19-1 and 405 IAC 5-19-2 to update and clarify definitions and terminology. Adds 405 IAC 5-19-2.5 to implement the requirement for documentation of a face-to-face encounter for home health durable medical equipment (DME) items in accordance with 42 CFR 440.70(f). Amends 405 IAC 5-19-7 to revise state regulations for prior authorization to implement the requirement for documentation of a face-to-face encounter for home health DME items in accordance with 42 CFR 440.70(f) and to remove the requirement for rehabilitative potential for wheelchairs for child recipients in a nursing facility in accordance with IC 12-15-5-12. Amends 405 IAC 5-19-13 to update and clarify definitions and terminology. Amends 405 IAC 5-19-18, 405 IAC 5-26-5, and 405 IAC 5-26-6 to comply with court order requiring coverage of orthotics regardless of age. Effective 30 days after filing with the Publisher.

SECTION 1. 405 IAC 5-3-5 IS AMENDED TO READ AS FOLLOWS:

Affected: IC 12-15-30-1

Sec. 5. (a) Written evidence of physician involvement and personal patient evaluation will be required to document the acute medical needs. A current plan of treatment and progress notes, as to the necessity, effectiveness, and goals of therapy services, must be submitted with the Medicaid prior authorization request and available for audit purposes.

(b) For services requiring a written request for authorization, a properly completed Medicaid prior authorization request must be submitted and approved by the contractor prior to the service being rendered.

(c) The following information must be submitted with the written prior authorization request form:

SECTION 2. 405 IAC 5-19-1 IS AMENDED TO READ AS FOLLOWS:

Affected: IC 12-13-7-3; IC 12-15-13-6

Sec. 1. (a) Medical and surgical supplies (medical supplies) are:

(b) Medical supplies include, but are not limited to, the following:

(c) Covered medical supplies do not include the following:

(d) Providers shall bill for medical supplies in accordance with the instructions set forth in the Indiana health coverage programs manual, bulletins, or banner pages.

(e) Incontinence supplies, including underpads, incontinent briefs and liners, diapers, and disposable diapers, are covered only:

(f) All medical supplies must be ordered in writing by a physician or dentist.

(g) Medical supplies that are included in facility reimbursement, or that are otherwise included as part of reimbursement for a medical or surgical procedure, are not separately reimbursable to any party. All covered medical supplies, whether for routine or nonroutine use, are included in the per diem for nursing facilities, even if the facility does not include the cost of medical supplies in their facility cost reports.

(h) Reimbursement is not available for medical supplies dispensed in quantities greater than a one (1) month supply for each calendar month, except when:

(i) Medical supplies shall be for a specific medical purpose, not incidental or general purpose usage.

(j) Reimbursement for medical supplies is equal to the lower of the following:

(k) The Medicaid allowable fee schedule amount is the Medicaid fee schedule amount in effect on June 30, 2011. If this amount is not available, the Medicaid allowable shall be the amount determined as follows:

(l) The office may review the statewide fee schedule and adjust it as necessary, subject to subsection (k)(1) through (k)(4). Any adjustments shall be made effective no earlier than permitted under IC 12-15-13-6.

(m) Providers must include their usual and customary charge for each medical supply item when submitting claims for reimbursement. Providers shall not use the Medicaid calculated allowable fee schedule amount for their billed charge unless it is less than or equal to the amount charged by the provider to the general public.

SECTION 3. 405 IAC 5-19-2 IS AMENDED TO READ AS FOLLOWS:

Affected: IC 12-13-7-3; IC 12-15

Sec. 2. As used in this rule, "durable medical equipment" or "DME" means equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, and generally is not useful to a member in the absence of a disability, illness, or injury. Items including, but not limited to, the following are examples of DME and may be authorized when medically necessary:

SECTION 4. 405 IAC 5-19-2.5 IS ADDED TO READ AS FOLLOWS:

Affected: IC 12-13-7-3; IC 12-15

Sec. 2.5. Documentation of a face-to-face encounter for home health services in accordance with 42 CFR 440.70(f) is required for the following specified items:

SECTION 5. 405 IAC 5-19-7 IS AMENDED TO READ AS FOLLOWS:

Affected: IC 12-13-7-3; IC 12-15

Sec. 7. Prior authorization requests for DME shall be reviewed on a case-by-case basis by the office, using all of the following criteria:

SECTION 6. 405 IAC 5-19-13 IS AMENDED TO READ AS FOLLOWS:

Affected: IC 12-13-7-3

Sec. 13. Medicaid reimbursement is available for the purchase, repair, or replacement of hearing aids under the following conditions:

SECTION 7. 405 IAC 5-19-18 IS AMENDED TO READ AS FOLLOWS:

Affected: IC 12-13-7-3; IC 12-15

Sec. 18. The following equipment is not covered by Medicaid:

SECTION 8. 405 IAC 5-26-5 IS AMENDED TO READ AS FOLLOWS:

Affected: IC 12-13-7-3; IC 12-15

Sec. 5. (a) Prior authorization by the office is required for the following:

(b) Medicaid reimbursement is available for the following surgical procedures without prior authorization:

SECTION 9. 405 IAC 5-26-6 IS AMENDED TO READ AS FOLLOWS:

Affected: IC 12-13-7-3; IC 12-15

Sec. 6. Medicaid reimbursement is available when a podiatrist renders for orthotic services. as covered by Medicare for all eligible members receiving both Medicare and Medicaid.

DIN: 20180822-IR-405180125FRA

Composed: May 02,2024 3:00:43PM EDT

A PDF version of this document.