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Durable Medical Equipment Fee Schedule Update Frequently Asked Questions

Audience: Durable Medical Equipment Providers

Our bulletin issued December 30, 2021 notified you that we have delayed implementation of an update to our durable medical equipment reimbursement schedules for Medicare and Safety Net lines of business until March 1, 2022.

We would now like to provide you with a Frequently Asked Questions document that may be helpful as you prepare for this update. 

For additional information about the update, please refer to our December 30 bulletin. You will need to login with your password to view the notice. Other helpful details are outlined in Administrative policy (AP-41) Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) for Government and Special Programs effective March 1, 2022. AP-41 applies to New York State Government Programs Medicaid Managed Care, Health and Recovery Plan, Child Health Plus, and Special Programs (Healthy NY and Essential Plan) lines of business. You will need your login and password to view this policy.

Thank you for the quality service that you provide to our valued members. If you have further questions, contact your Provider Relations representative.

Durable Medical Equipment Reimbursement Update Effective March 1, 2022 Frequently Asked Questions

  1. Will the capped rental items rent for 13 months to purchase as Medicare allows, or remain at 10 months?

    The Health Plan will apply Medicare rental timeframes and logic for Medicare members. The New York state Medicaid timeframe and rules will apply to Safety Net products.
  2. Will the rental modifiers KH, KI, KJ be required for capped rentals for Medicare?

    For new services provided to Medicare members for dates of service on or after March 1, 2022, the Health Plan will require use of modifiers consistent with Centers for Medicare & Medicaid Services (CMS) guidelines.  
  3. How should providers bill Medicare member claims for items/services where rental began prior to the March 1, 2022, transition date?

    For Medicare members, the Health Plan requests that providers bill using modifier RR only for these circumstances.  Please do not include the other rental modifiers KH, KI or KJ on the rentals started prior to March 1, 2022.
  4. Why bill only the -RR modifier for rental initiated prior to March 1, 2022?

    Billing the -RR modifier will result in you receiving the 'initial Medicare rental rate' equal to 10% of the new fee schedule rate for the remainder of the 10-month rental without Medicare's typical reduction to 7.5% of the purchase price starting in month 4 under Medicare methodology.

    Note: This applies only to rentals initiated prior to March 1, 2022.
  5. Will the Medicare fee schedule be the published fee rate, rural rate, or non-rural rate?

    The Health Plan will apply the non-rural rate to provide consistent reimbursement across our market.
  6. Will the Health Plan now require the use of K codes (K0553, K0554) for diabetic supplies?

    Effective March 1, 2022, the Health Plan will require use of K codes of diabetic supplies for Medicare and Safety Net products. For members who have an authorization prior to March 1, 2022, we will allow the billing of A codes to satisfy authorization.

    However, new requests and authorization extensions will be transitioned to K codes for Medicare and Safety Net products. K0553 includes all supplies needed for the continued glucose monitoring and will only receive 1 unit per month. The authorizations are for a full year, therefore, will be a total of 12 units per year. K0554 should only be billed once a year for 1 unit.
  7. Will the Safety Net products allow a purchase on the CPAP/BIPAP?
    The Health Plan will pay as a rental for 10 months for Safety Net products at which time the title will transfer to the member. The supplies can be billed after rental is complete. We will consider purchase of BiPap if there is proof of compliance with CPAP. If compliance is not shown, the Health Plan will pay the rental price of BiPap up to the MCD fee For Service purchase price.
  8. Will the Safety Net products cover the same items and frequency that state Medicaid follows?

    The Health Plan will adhere to the items/services listed on eMedNY fee schedule. Items not listed on the eMedNY fee schedule will not be covered. The Health Plan will follow Medicaid guidelines relative to frequency and unit limits.
  9. Will the Safety Net products require proof of compliance and/or authorization?

    Authorizations or proof of compliance may be required depending on service or item provided. Please refer to the medical management policies found on our website.
  10. Will the Medicare plan cap oxygen rentals?

    The Health Plan will apply CMS capped rental methodology and apply a cap after 36 months for oxygen service for Medicare members.
  11. Will the cap date begin March 1, 2022, or from the original set-up date?

    For Medicare members, oxygen rentals that began prior to March 1, 2022 will apply the CMS capped rental methodology beginning with month number one in March 2022.
  12. Will the patients be eligible to restart again as with Medicare?

    The Health Plan will follow Medicare's rules regarding restarting rentals after a break in service and what qualifies as a break in service.
  13. Will the Medicare and Medicaid fee schedule update quarterly to copy the current fee schedule or will they be the March 2021 fee schedules?

    The Health Plan will apply Medicare updates annually. State Medicaid updates will be applied as available to the Health Plan.
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