Exceptional Durable Medical Equipment. The CHC-MCO must provide Exceptional DME to NF residents. The CHC- MCO must have a process to provide a separate payment for Exceptional DME, Ventilators, and related supplies. The CHC-MCO must also have a process for directly paying a DME vendor for Exceptional DME. The Department separately includes Exceptional DME from standard DME in developing the capitation rates. In the event of an Exceptional DME purchase, the equipment will belong to the Participant. The CHC-MCO will pay the DME vendor directly for Exceptional DME. The amount of the additional payment authorized is based upon the necessary, reasonable, and prudent cost of the Exceptional DME. A Ventilator Authorization allows exceptional payments under specific terms to a NF, in addition to the NF’s per diem rate, for NF services that are provided for the use of certain ventilator supplies. The amount of the additional payment authorized is based upon the necessary, reasonable, and prudent cost of the Ventilators and related supplies specified in the agreement with the NF. The CHC-MCO must provide, in accordance with then-existing Department policies and procedures, an Exceptional DME or Ventilator payment where the Exceptional DME or Ventilator is Medically Necessary, and it must be specially adapted for the Participant or designated by the Department. The Department will publish an annual list of Exceptional DME by notice in the Pennsylvania Bulletin.
Exceptional Durable Medical Equipment. The CHC-MCO must provide Exceptional DME, as defined in Exhibit EE Covered Services. The CHC-MCO must operate a grant process to provide grants for Exceptional DME and Ventilators. The Department separately includes Exceptional DME from standard DME in its rate calculation. In the event of an Exceptional DME purchase, the equipment will belong to the Participant. An Exceptional DME/Ventilator grant is an authorization permitting exceptional payments under specified terms to a NF, in addition to the NF’s case-mix per diem rate, for NF services that are provided to a specified resident and that involve the use of certain exceptional DME and ventilator supplies. The amount of the additional payment authorized by a grant is based upon the necessary, reasonable and prudent cost of the Exceptional DME/Ventilators and the related services and items specified in the grant. The CHC-MCO must provide an Exceptional DME/Ventilator grant where the Exceptional DME/Ventilator is Medically Necessary and it must be specially adapted for the Participant or is on the Exceptional List. The Department will publish the Exceptional DME List and annual notice in the PA Bulletin. The CHC-MCO must provide a Ventilator grant where the ventilator equipment and supplies must be used for the unique Participant. The CHC- MCO must certify the ventilator units in the NF. The Department will publish the Ventilator Supply List and annual notice in the PA Bulletin.
Exceptional Durable Medical Equipment. The CHC-MCO must provide Exceptional DME to NF residents, as listed in Exhibit A, Covered Services. The CHC-MCO must have a process to provide a separate payment for Exceptional DME, Ventilators, and related supplies. The CHC-MCO must also have a process for directly paying a DME vendor for Exceptional DME. The Department separately includes Exceptional DME from standard DME in developing the capitation rates. In the event of an Exceptional DME purchase, the equipment will belong to the Participant. The CHC-MCO will pay the DME vendor directly for Exceptional DME. The amount of the additional payment authorized is based upon the necessary, reasonable, and prudent cost of the Exceptional DME. A Ventilator Authorization allows exceptional payments under specific terms to a NF, in addition to the NF’s per diem rate, for NF services that are provided for the use of certain ventilator supplies. The amount of the additional payment authorized is based upon the necessary, reasonable, and prudent cost of the Ventilators and related supplies specified in the agreement with the NF. The CHC-MCO must provide, in accordance with then-existing Department policies and procedures, an Exceptional DME or Ventilator payment where the Exceptional DME or Ventilator is Medically Necessary, and it must be specially adapted for the Participant or designated by the Department. The Department will publish an annual list of Exceptional DME by notice in the Pennsylvania Bulletin, which shall be incorporated by reference and supersede the current list of Exceptional DME set forth in Exhibit A.
