KRS 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 M edicaid 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 healthc are 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 f or

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 twen ty 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 Com mon 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 e nsure 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.