Top Mobile Menu Bottom Mobile Menu

Search For:

Prosthetic Devices

Download PDF
June 08, 2022, 03:28 EDT

Chapter 4: Covered Services, Limitations, and Payment (PD)

Updated: 4/2/2012

General Information (PD)

The provision of medically necessary artificial arms, legs,  their  necessary supportive  devices, and breast prostheses to Medicaid-eligible members in the Commonwealth of Virginia requires service authorization prior to rendering service.

SERVICE AUTHORIZATION

Effective April 1, 2012, Service Authorization (Srv Auth) is required through DMAS’ Service Authorization contractor. Refer to Chapter V of this manual for further information regarding service authorization, timely submittal of requests and service specific details.

Coverage and Limitations (PD)

  1. Prosthetic services shall mean the replacement of  missing arms, legs, eyes, and breasts and  the provision of an internal (implant) body part. Nothing in this regulation shall be construed to refer to orthotic services or devices or organ transplantation services. (12VAC30-50-210)

 

  1. Artificial arms and legs, and their necessary supportive attachments, implants, and breasts are provided when prescribed by a physician or other licensed practitioner of the healing arts within the scope of their professional license as defined by state law. This service, when provided by an authorized vendor, must be medically necessary, and service authorized  for  the minimum applicable component necessary for the activities of daily living (ADLs).

 

  1. Eye prostheses are provided when eyeballs are missing regardless of the age of the member   or the cause of the loss of the eyeball. Eye prostheses are provided regardless of the function  of the eye. Service authorization is not required, but post-payment review is conducted.

 

To obtain the required service authorization for coverage, the prosthetist will ask the prescribing practitioner to complete a DMAS Certificate of Need form (DMAS-4001). The prosthetist will then submit the Certificate of Need, a copy of the physician’s prescription, and a completed Service Authorization Request form (DMAS-363) to DMAS’ Service Authorization contractor. Refer to Chapter V titled “Service Authorization Information”. The Appendix D includes an “Exhibits” section for the necessary forms.

Non-Covered Services

The following devices are not covered for adults:

    • Orthotic Devices - Spinal
    • Orthotic Devices - Cervical
    • Orthotic Devices - Thoracic
    • Orthotic Devices - Sacral
    • Orthopedic Footwear
    • Orthopedic Footwear Modifications
    • Shoe Modifications
    • Trusses
    • Penile Prostheses

Payment for Services (PD)

General Information

The payment criteria  established for prosthetic devices are designed to enlist  the participation of a sufficient number of suppliers so that Medicaid-eligible persons receive prostheses at least to   the extent that they are available to the general population.

Participation as a prosthetic provider is limited to those who accept the amount paid by the Virginia Medicaid Program as payment in full.

Payment for services will not exceed the amount indicated to be paid in accordance with the  policy and methods described in the State Plan for Medical Assistance, and payment will not be made in excess of the upper limits described in 42 CFR § 447.304(a).

 

Federal requirements prohibit Medicaid from paying prosthetic device providers more than Medicare would allow for the same service.

Payment Methodology

Payment for prostheses is the lowest of Medicaid’s fee schedule, the actual charge, or the Medicare allowance.

For Medicare crossover claims, the payment will be the deductible and co-insurance amounts computed by Medicare based on the Medicare-allowed charge, as reported on the Explanation of Medicare Benefits (EOMB) received from the Medicare carrier.

Cost Sharing

There are no Medicaid deductible or co-insurance amounts imposed for any prosthetic device provided to Medicaid members. As previously mentioned, Medicaid will pay the deductible and co-insurance amounts imposed on Medicaid members who are also Medicare beneficiaries and whose claims the Medicare carrier processes initially.

Medicare Catastrophic Coverage Act of 1988 (Podiatry)

[Effective Date: January 1989]

The Medicare Catastrophic Act of l988 and other legislation require State Medicaid Programs to expand the coverage of services to certain low income Medicare beneficiaries, known as Qualified Medicare Beneficiaries (QMBs).

QMB Coverage Only

Recipients in this group are eligible only for Medicaid coverage of Medicare premiums and of deductible and coinsurance on allowed charges for all Medicare-covered services. They will receive Medicaid cards with the message "QUALIFIED MEDICARE BENEFICIARY-QMB-MEDICAID PAYMENT LIMITED TO MEDICARE

COINSURANCE AND DEDUCTIBLE." Medicaid does not make payment for any recipient of this group for pharmacy, non-emergency transportation, medical supplies, or  any service not covered by Medicare.

 

QMB Extended Coverage

Recipients in this group will be eligible for Medicaid coverage of Medicare premiums and  of deductible and coinsurance on allowed charges for all Medicare-covered services plus coverage of all other Medicaid-covered services listed in Chapter I of this manual. This group will receive Medicaid cards with the message "QUALIFIED MEDICARE BENEFICIARY-QMB EXTENDED." These recipients are responsible for copay for pharmacy services, health department clinic visits, and vision services.

All Others

Recipients without either of these messages on their Medicaid cards will be eligible for  those covered services listed in Chapter I of this manual.