SECTION 317:40-5-104. Specialized medical supplies

(a)   Applicability. The rules in this section apply to specialized medical supplies provided through Home and Community Based Services (HCBS) Waivers operated by the Oklahoma Department of Human Services (OKDHS) Developmental Disabilities Services Division (DDSD).

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

(1)   Specialized medical supplies 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 Services (HCBS) funds are in addition to any supplies furnished by SoonerCare.

(2)   Specialized medical supplies meet the criteria for service necessity given in OAC 340:100-3-33.1.

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

(4)   Specialized medical supplies 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 as specialized medical supplies include:

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

(B)   nutritional supplements;

(C)   supplies for respirator or ventilator care;

(D)   decubitus care supplies;

(E)   supplies for catheterization; and

(F)   supplies needed for health conditions.

(6)   Items that cannot be purchased as specialized medical supplies include:

(A)   over the counter medications(s);

(B)   personal hygiene items;

(C)   medicine cups;

(D)   items that are not medically necessary; and

(E)   prescription medication(s).

(7)   Specialized medical supplies must be:

(A)   necessary to address a medical condition;

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

(C)   medical in nature; and

(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 specialized medical supplies include:

(1)   incontinence wipes, 300 wipes per month;

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

(3)   disposable underpads, 60 pads per month; and

(4)   incontinence briefs, 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 DDSD 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 Health Care Procedure Code exists, the case manager e-mails pertinent information regarding the member's medical supply need to the programs manager responsible for Specialized Medical Supplies. 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 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 specialized medical supplies exception does not exceed one plan of care year.

[Source: Reserved at 18 Ok Reg 1168, eff 5-11-01; Added at 23 Ok Reg 1396, eff 5-25-06; Amended at 27 Ok Reg 1509, eff 6-11-10]