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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2 Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.6 Durable Medical Equipment (DME) Supplier (CCP) : 2.6.2 Services, Benefits, and Limitations

Medicaid clients who are birth through 20 years of age are entitled to all medically necessary DME and expendable medical supplies. DME or supplies are medically necessary when required to correct or ameliorate disabilities or physical or mental illnesses or conditions. Any numerical limit on the amount of a particular item of DME or expendable medical supply can be exceeded if medically necessary for Medicaid clients who are birth through 20 years of age. Likewise, time periods for replacement of DME and expendable medical supplies do not apply to Medicaid clients who are birth through 20 years of age if the replacement is medically necessary.
DME is defined as medical equipment that is manufactured to withstand repeated use, ordered by a physician for use in the home, and required to correct or ameliorate the client’s disability, condition, or illness.
Because there is no single authority (such as a federal agency) that confers the official status of “DME” on any device or product, HHSC retains the right to make such determinations with regard to DME covered by Texas Medicaid. DME covered by Texas Medicaid must either have a well-established history of efficacy or, in the case of novel or unique equipment, valid peer-reviewed evidence that the equipment corrects or ameliorates a covered medical condition or functional disability.
Requested DME may be a benefit of Texas Medicaid when it meets the Medicaid definition of DME.
The majority of DME and expendable medical supplies are covered through Texas Medicaid (Title XIX) Home Health Services.
If a service cannot be provided through Texas Medicaid (Title XIX) Home Health Services, the service may be covered through CCP if it is determined to be medically necessary for the client and if FFP is available.
If a DME provider is unable to deliver a piece of equipment, the provider must allow the client the option of obtaining the DME or expendable medical supplies from another provider.
Periodic rental payments are made only for the lesser of the following:
DME will be purchased when a purchase is determined to be medically necessary and more cost effective than leasing the device with supplies. Only new, unused equipment will be purchased. When a provider is replacing a piece of rental DME with purchased DME, the provider must supply a new piece of DME to the client.
Purchase is justified when the estimated duration of need multiplied by the rental payments would exceed the reasonable purchase cost of the equipment or it is otherwise more practical to purchase the equipment.
DME repair will be considered based on the age of the item and cost to repair it. A request for repair of DME must include:
A statement or medical information that is provided by the attending physician and that substantiates the medical appliance or equipment continues to serve a specific medical purpose.
Rental equipment may be provided to replace purchased medical equipment for the period of time it will take to make necessary repairs to purchased medical equipment.
All adjustments and modifications that are made within the first six months after delivery are considered part of the purchase price. However, DME that has been delivered to the client’s home and then found to be inappropriate for the client’s condition will not be eligible for an upgrade within the first six months following purchase unless there had been a significant change in the client’s condition, as documented by the physician familiar with the client.
Rental reimbursement to the same provider cannot exceed the purchase price, except as addressed in specific policies.
All DME purchased for a client becomes the Medicaid client’s property upon receipt of the item. Delivered equipment will become the Medicaid client’s property in the following instances even though it will not be prior authorized or reimbursed:
As long as the client is eligible for CCP services on the date the custom equipment is ordered from the manufacturer, the provider must use the order date as the date of service since custom equipment is client specific and cannot be used for another client.
To establish medical necessity of the equipment for the client, the provider must have on file in the client’s records current documentation that is signed by a physician (e.g., a signed and dated prescription) showing the following:

Texas Medicaid & Healthcare Partnership
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