Sec. 10.14.02.10. Disposable Medical Supplies and Durable Medical Equipment

A. To be considered a participating medical supply company in the Program, the provider of disposable medical supplies and durable medical equipment shall:

(1) To the extent required by law, be licensed and legally authorized to practice or deliver services in Maryland or a jurisdiction bordering Maryland;

(2) Agree to abide by the provisions set forth in this regulation by signing and sending to the Department the designated Departmental form;

(3) Agree to accept, as payment in full, the amount paid by the Department pursuant to §F of this regulation plus, if applicable, the amount paid by the eligible patient's health insurer and the patient contribution amount;

(4) Agree not to bill an eligible patient for an additional charge for the eligible disposable medical supplies and eligible durable medical equipment other than the patient contribution amount, excluding the deductible; and

(5) Maintain adequate records for a minimum of 6 years and, upon request, allow the Department access to the records.

B. The Department shall reimburse for the following:

(1) Eligible disposable medical supplies, including but not limited to:

(a) Central catheter for administration of intravenous solutions;

(b) Administration set for intravenous medication;

(c) Parenteral feeding equipment, as follows:

(i) Administration set;

(ii) Dravon clamp;

(iii) Filter; and

(iv) Injection cap; and

(d) Enteral feeding equipment, as follows:

(i) Adapter;

(ii) Administration set;

(iii) Feeding syringe; and

(iv) Nasogastric tube;

(2) Eligible durable medical equipment for purchase or rental, including but not limited to:

(a) A delivery system comprised of a pump and pole assembly for an enteral or parenteral feeding;

(b) An individually form-fitted arm support stocking for a recipient prescribed by the participating physician as medically necessary, not to exceed two stockings at one time or three stockings in a 12-month period for a non-institutionalized individual;

(c) IV pole for use with parenteral administration of medication;

(d) External ambulatory infusion pump with administrative equipment, when the usual and customary mode of therapy has been tried and shown to be unsuccessful or impractical;

(e) Breast prosthesis, including surgical brassiere; and

(f) A wig when the following conditions are met:

(i) Hair loss is a direct result of the administration of chemotherapy or radiation for the treatment of breast or cervical cancer;

(ii) The cost does not exceed $350; and

(iii) The wig is prescribed by an oncologist.

C. The Department may not reimburse for the following:

(1) A disposable medical supply which is not directly related to the diagnosis and treatment of breast cancer or cervical cancer; and

(2) Durable medical equipment as follows:

(a) Head covering; and

(b) An item not directly related to the diagnosis and treatment of breast cancer or cervical cancer.

D. Preauthorization is required for the disposable medical supply and durable medical equipment pursuant to COMAR 10.09.12.06A-F and H.

E. Reimbursement Procedures. The participating medical supply company:

(1) Shall submit the request for payment for the reimbursed service on the form designated by the Department within 12 months of the date of service as follows:

(a) If an eligible patient is uninsured, or is insured but the insurance does not provide coverage for the reimbursed service, the participating medical supply company shall send the Department the bill for the service, with a denial from the patient’s insurance carrier; or

(b) If an eligible patient is covered by Medicare or other insurance, the participating medical supply company shall bill:

(i) Medicare or the other insurance for the service; and

(ii) The Department for the outstanding deductible, patient contribution amount, and if the insurer pays less than the current Medical Assistance approved rate for the service, the difference between the insurance reimbursement rate and the Medical Assistance approved rate in the State;

(2) May not bill the Program a charge exceeding the usual and customary charge to the general public for a similar item; and

(3) Shall bill the Program the usual and customary charge for the prosthetic device and an individually form-fitted arm support stocking including:

(a) Fitting;

(b) Dispensing; and

(c) Follow-up care.

F. Reimbursement Procedures.

(1) The Department shall reimburse the participating medical supply company:

(a) Pursuant to COMAR 10.09.12.07F-K for an eligible patient who is uninsured or who has insurance that does not provide coverage for the reimbursed service;

(b) Pursuant to COMAR 10.09.12.07R and S for an eligible patient who is covered by Medicare; or

(c) The outstanding deductible and patient contribution amount required by the insurer for an eligible patient who has insurance, other than Medicare, that provides coverage for the reimbursed service.

(2) The Department may not reimburse for:

(a) Completion of a form;

(b) A broken or missed appointment;

(c) A professional service rendered by mail or telephone; or

(d) A service rendered to the general public at no charge.

G. The Program shall reimburse for claims submitted pursuant to this regulation as set forth in Regulation .21 of this chapter.