Nursing homes are generally reimbursed by all-inclusive rates for EmblemHealth Medicaid members. Costs for most durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) are included in these all-inclusive rates paid to the facility. Payment will not be made for items provided by a facility or organization when the cost of these items is included in the rate, per Title 18 New York Codes, Rules and Regulations (NYCRR) §505.5(d)(1)(iii).
Generally, DMEPOS providers should not seek reimbursement for the costs of these items when the Medicaid member is a resident of a nursing home. There is an exception for custom-made DMEPOS. These items are defined as any durable medical equipment, orthopedic footwear, orthotics, or prosthetics fabricated solely for a particular Medicaid member and cannot be readily changed to conform to the needs of another Medicaid member.
Custom-made DMEPOS are not included in a nursing home’s rate and DMEPOS providers may seek reimbursement for these items. DMEPOS providers should confirm that a Medicaid member resides in a nursing home before submitting a claim for reimbursement. Providers should also ensure the items are not included in the rate of the facility before billing EmblemHealth.
JP 61060 6/23