KRS § 205.6333 Reimbursement for in-network suppliers of durable medical equipment, prosthetics, orthotics, and supplies -- Reimbursement rate -- Timeframe for claim submissions.
AI-assisted research summary: The Department for Medicaid Services must pay in-network durable medical equipment suppliers at specified minimum rates, and it must make Medicaid managed care organizations use matching reimbursement, coverage, and claim-submission timing rules.
205.6333 Reimbursement for in-network suppliers of durable medical equipment, prosthetics, orthotics, and supplies -- Reimbursement rate -- Timeframe for claim submissions. (1) (a) As used in this section, "durable medical equipment" means equipment which: 1. Can withstand repeated use; 2. Is primarily and customarily used to serve a medical purpose; 3. Generally is not useful to a person in the absence of an illness or injury; and 4. Is appropriate for use in the home. (b) As used in this section, "durable medical equipment" does not include: 1. Enteral nutrition; 2. Eye prosthetics; 3. Home infusion; 4. Orthotics; 5. Prosthetics; or 6. Automated external defibrillators under Healthcare Common Procedure Codes K0606 and E0617. (2) The Department for Medicaid Services shall reimburse a supplier of durable medical equipment, prosthetics, orthotics, and supplies at no less than ninety percent (90%) of the state Medicaid program durable medical equipment fee schedule and shall require Medicaid managed care organizations to reimburse the same amount as the Department for Medicaid Services reimburses for the same service or item of durable medical equipment, prosthetics, orthotics, and supplies. This subsection shall apply to those healthcare codes and services included in Section 1903(i)(27) of Title XIX of the Social Security Act. (3) The department shall require Medicaid managed care organizations to reimburse suppliers of durable medical equipment, prosthetics, orthotics, and supplies for manually priced items in the Medicaid program durable medical equipment fee schedule at the manufacturer's suggested retail price minus eighteen percent (18%) pricing where there is a manufacturer's suggested retail price, and at invoice price plus twenty percent (20%) for miscellaneous Healthcare Common Procedure Coding System codes where there is no manufacturer's suggested retail price. (4) The department shall require Medicaid managed care organizations to cover, at a minimum, the same Healthcare Common Procedure Coding System codes and the same quantities of medical supplies, equipment, or services as are established on the Kentucky Medicaid program durable medical equipment fee schedule or Kentucky Medicaid medical policy. (5) The department shall ensure that the allowable timeframe for claim submissions by suppliers of durable medical equipment, prosthetics, orthotics, and supplies shall equal the timeframe allowed for any discrepancy during the Medicaid managed care organization audit or recoupment process for that claim. (6) The reimbursement for suppliers of durable medical equipment established pursuant to this section shall only be available to a durable medical equipment supplier who is an in-network provider of the beneficiary's Medicaid managed care organization. Effective: June 27, 2019 History: Created 2019 Ky. Acts ch. 176, sec. 1, effective June 27, 2019.