Library: Policy

317:40-5-104. Medical supplies, equipment, and appliances

Revised 9-1-21

(a) Applicability. This section applies to medical supplies, equipment, and appliances provided through home and community-based waiver services (HCBS) operated by the Oklahoma Department of Human Services (OKDHS) Developmental Disabilities Services (DDS).

(b) General information. Medical supplies, equipment, and appliances include supplies specified in the plan of care that enable the member to increase his or her ability to perform activities of daily living. Medical supplies, equipment, and appliances include the purchase of additional supplies not available through SoonerCare.

(1) Medical supplies, equipment, and appliances are included in the member's plan, when prescribed by a physician with a SoonerCare contract, and arrangements for this service must be made through the member's case manager. Items reimbursed with HCBS funds are in addition to supplies furnished by SoonerCare.

(2) Medical supplies, equipment, and appliances meet the criteria for service necessity, per Oklahoma Administrative Code (OAC) 340:100-3-33.1.

(3) All items must meet applicable standards of manufacture, design, and installation.

(4) Medical supplies, equipment, and appliance providers must hold a current SoonerCare Durable Medical Equipment (DME) and/or Medical Supplies Provider Agreement with the Oklahoma Health Care Authority, and be registered to do business in Oklahoma or in the state in which they are domiciled. Providers must enter into the agreement giving assurance of ability to provide products and services and agree to the audit and inspection of all records concerning goods and services provided.

(5) Specialized medical supplies, equipment, and appliances include:

(A) Incontinence supplies, per subsection (b) of this Section;

(B) Nutritional supplements; and

(6) Items that cannot be purchased as medical supplies, equipment, and appliances include:

(A) Over-the-counter medications(s);

(B) Personal hygiene items;

(D) Items that are not medically necessary;

(E) Prescription medication(s); and

(F) Incontinence wipes not used in conjunction with incontinence briefs or incontinence underwear/pull-ons.

(7) Medical supplies, equipment, and appliances must be:

(A) Necessary to address a medical condition;

(B) Of direct medical or remedial benefit to the member;

(D) Consistent with accepted health care practice standards and guidelines for the prevention, diagnosis, or treatment of symptoms of illness, disease, or disability.

(c) Limited coverage. Items available in limited quantities through medical supplies, equipment, and appliances include:

(1) Incontinence wipes, three-hundred (300) wipes per month;

(2) Thirty-six hundred (3,600) individual non-sterile gloves, per plan year;

(3) Sixty (60) disposable underpads per month;

(4) One-hundred eighty (180) disposable incontinence briefs per month (Adult disposable incontinence briefs are purchased only in accordance with the implementation of elimination guidelines developed by the team);

(5) One-hundred fifty (150) disposable incontinence underwear/pull-ons per month (Adult disposable incontinence underwear/pull-ons are purchased only in accordance with the implementation of elimination guidelines developed by the team);

(6) Any combination of disposable incontinence briefs and disposable incontinence underwear/pull-ons that do not exceed one-hundred fifty (150) per month; and

(7) One-hundred fifty (150) disposable liner/shield/guard/pads per month.

(d) Exceptions. Exceptions to the requirements of this section:

(1) When a member's Team determines that the member needs medical supplies that:

(A) Are not available through SoonerCare and a healthcare common procedure code does not exist, the case manager emails pertinent information regarding the member's medical supply need to the Specialized Medical Supplies programs manager. The email includes all pertinent information that supports the need for the supply including; but not limited to, quantity and purpose; or

(B) Exceed the limits stated in subsection(c) of this Section, the case manager documents the need in the individual plan for review and approval, per OAC 340:100-33.

(2) Approval or denial of exception requests is made on a case-by-case basis and does not override the general applicability of this section.

(3) Approval of a medical supplies, equipment, and appliances exception does not exceed one (1) plan of care year.

(b) General information.Medical supplies, equipment, and appliances include supplies specified in the plan of care that enable the member to increase his or her ability to perform activities of daily living. Medical supplies, equipment, and appliances include the purchase of ancillary supplies not available through SoonerCare.

(1) Medical supplies, equipment, and appliances must be included in the member's plan and arrangements for this service must be made through the member's case manager. Items reimbursed with home and community-based waiver services (HCBS) funds are in addition to any supplies furnished by SoonerCare.

(2) Medical supplies, equipment, and appliances meet the criteria for service necessity given in Oklahoma Administrative Code (OAC) 340:100-3-33.1.

(3) All items meet applicable standards of manufacture, design, and installation.

(4) Medical supplies, equipment, and appliance providers must hold a current SoonerCare Durable Medical Equipment (DME) and/or Medical Supplies Provider Agreement with the Oklahoma Health Care Authority, and be registered to do business in Oklahoma or the state in which they are domiciled. Providers must enter into the agreement giving assurance of ability to provide products and services and agree to the audit and inspection of all records concerning goods and services provided.

(5) Items that can be purchased asmedical supplies, equipment, and appliances include:

(A) Incontinence supplies, as described in subsection (b) of this Section;

(B) Nutritional supplements;

(D) Decubitus care supplies;

(E) Supplies for catheterization; and

(F) Supplies needed for health conditions.

(6) Items that cannot be purchased as medical supplies, equipment, and appliances include:

(A) Over-the-counter medications(s);

(B) Personal hygiene items;

(D) Items that are not medically necessary; and

(E) Prescription medication(s).

(7) Medical supplies, equipment, and appliances must be:

(A) Necessary to address a medical condition;

(B) Of direct medical or remedial benefit to the member;

(D) Consistent with accepted health care practice standards and guidelines for the prevention, diagnosis, or treatment of symptoms of illness, disease, or disability.

(c) Limited coverage.Items available in limited quantities through medical supplies, equipment, and appliances include:

(1) Incontinence wipes, three-hundred (300) wipes per month;

(2) Non-sterile gloves, as approved by the Team;

(3) Disposable underpads, sixty (60) pads per month; and

(4) Incontinence briefs, one-hundred and eighty (180) briefs per month.

(A) Adult briefs are purchased only in accordance with the implementation of elimination guidelines developed by the team.

(B) Exceptions to the requirement for implementation of elimination guidelines may be approved by the DDS nurse when the member has a medical condition that precludes implementation of elimination guidelines, such as atonic bladder, neurogenic bladder, or following a surgical procedure.

(d) Exceptions.Exceptions to the requirements of this Section are explained in this subsection.

(1) When a member's team determines that the member needs medical supplies that:

(A) Are not available through SoonerCare and for which no healthcare common procedure code exists, the case manager e-mails pertinent information regarding the member's medical supply need to the programs manager responsible for medical supplies, equipment, and appliances. The e-mail includes all pertinent information that supports the need for the supply, including but not limited to, quantity and purpose; or

(B) Exceed the limits stated in subsection(c) of this Section, the case manager documents the need in the individual plan for review and approval per OAC 340:100-33.

(2) Approval or denial of exception requests is made on a case-by-case basis and does not override the general applicability of this Section.

(3) Approval of a medical supplies, equipment, and appliances exception does not exceed one (1) plan of care year.