§ 51521. Durable Medical Equipment.

(a) Reimbursement for the rental or purchase of durable medical equipment, except wheelchairs, wheelchair accessories, and speech-generating devices and related accessories, shall be the lesser of:

(1) The amount billed pursuant to Section 51008.1, or

(2) An amount that does not exceed 80 percent of the lowest maximum allowance for California established by the federal Medicare Program for the same or similar item or service, or

(3) The guaranteed acquisition cost negotiated by means of the contracting process provided for pursuant to Welfare and Institutions Code Section 14105.3 plus a percentage markup to be established by the Department.

(b) Reimbursement for wheelchairs and wheelchair accessories, and speech-generating devices and related accessories shall be the lesser of:

(1) The amount billed pursuant to Section 51008.1, or

(2) An amount that does not exceed 100 percent of the lowest maximum allowance for California established by the federal Medicare Program for the same or similar item or service, or

(3) The guaranteed acquisition cost negotiated by means of the contracting process provided for pursuant to Welfare and Institutions Code Section 14105.3 plus a percentage markup to be established by the Department.

(c) Reimbursement for all durable medical equipment billed to the Medi-Cal Program utilizing codes with no specified maximum allowable rate shall be the lesser of:

(1) The amount billed pursuant to Section 51008.1, or

(2) The guaranteed acquisition cost negotiated by means of the contracting process provided for pursuant to Welfare and Institutions Code Section 14105.3 plus a percentage markup to be established by the Department, or

(3) The actual acquisition cost plus a markup to be established by the Department, or

(4) The manufacturer's suggested retail purchase price, on June 1, 2006, documented by a printed catalog or a hard copy of an electronic catalog page showing the price on that date, and reduced by a percentage discount not to exceed 20 percent, or not to exceed 15 percent for wheelchairs and wheelchair accessories if the provider employs or contracts with a qualified rehabilitation professional, as defined in paragraph (3) of subdivision (c) of Welfare and Institutions Code Section 14105.485, or

(5) A price established through targeted product-specific cost containment provisions developed with providers.

(d) Reimbursement for all durable medical equipment supplies and accessories billed to the Medi-Cal program shall be the lesser of:

(1) The amount billed pursuant to Section 51008.1, or

(2) The acquisition cost plus a 23 percent markup.

(e) In addition to other required information, billings for equipment reimbursed “By Report,” whether listed or unlisted, shall include or be accompanied by a description of the equipment indicating:

(1) The manufacturer's name and suggested retail price for the equipment.

(2) Description of and justification for any special features of the equipment such as custom modifications or special accessories.

(3) If an unlisted item, the reason a listed item cannot be used.

(f) Billings for wheelchairs, whether listed or unlisted, shall include or be accompanied by a description of the equipment indicating the manufacturer's name, model designation and suggested retail price.

(g) In addition to other required information, billings for repair and maintenance shall include or be accompanied by a written description of the service indicating:

(1) The reason or justification for repair and the services provided.

(2) The labor time involved (may be rounded to the nearest half hour for the total repair job) and the hourly charge for labor.

(3) The manufacturer's name and catalogue numbers of parts used.

(h) Maximum reimbursement rates established by the Department include payment for the following services. No additional reimbursement shall be allowed for these services except as provided below.

(1) Freight, delivery or transportation, except as necessary to cover the additional costs of required, atypical services not otherwise covered in the maximum reimbursement rates.

(2) Installation, setup or instruction in the use of equipment.

(3) Repair, maintenance or routine servicing of rental equipment.

(i) Purchased equipment shall be guaranteed for a period of at least six months from the date of purchase. Out-of-guarantee repairs shall be guaranteed for a period of at least three months from the date of such repair. No reimbursement shall be allowed for parts or labor during a guarantee period if the need for repair is due to a defect in materials or workmanship.

(j) Monthly rental rates shall apply to calendar month periods, or their equivalent.

HISTORY

1. Amendment filed 2-25-83 as an emergency; designated effective 3-1-83 (Register 83, No. 9). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 6-29-83. For prior history, see Register 81, No. 52).

2. Certificate of Compliance as to 2-25-83 order transmitted to OAL 6-27-83 and filed 7-28-83 (Register 83, No. 31).

3. Amendment filed 2-15-84 (approved by OAL with Certificate of Compliance filed 7-28-83; designated effective 8-27-83 (Register 84, No. 7).

4. Amendment of subsection (i) filed 8-1-84 as an emergency; effective upon filing (Register 84, No. 31). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 11-29-84.

5. Certificate of Compliance transmitted to OAL 11-27-84 and filed 12-27-84 (Register 84, No. 52).

6. Amendment of subsection (i) filed 8-1-85 as an emergency; effective upon filing (Register 85, No. 32). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 11-29-85.

7. Certificate of Compliance transmitted to OAL 11-20-85 and filed 12-27-85 (Register 85, No. 52).

8. Repealer and new section filed 9-25-92 as an emergency; operative 10-1-92 (Register 92, No. 40). A Certificate of Compliance must be transmitted to OAL 1-25-93 or emergency language will be repealed by operation of law on the following day.

9. Certificate of Compliance as to 9-25-92 order including amendment of subsections (i)(6) and (i)(7) transmitted to OAL 1-22-93 and filed 3-9-93 (Register 93, No. 11).

10. Amendment of subsection (i)(6) filed 9-29-93 as an emergency; operative 9-29-93 (Register 93, No. 40). A Certificate of Compliance must be transmitted to OAL 1-27-94 or emergency language will be repealed by operation of law on the following day.

11. Editorial correction amending subsection (i)(6) and History 10 (Register 93, No. 46).

12. Certificate of Compliance as to 9-29-93 order transmitted to OAL 10-29-93 and filed 11-8-93 (Register 93, No. 46).

13. Editorial correction of printing errors in subsections (i)(6) and (7) (Register 94, No. 7).

14. Amendment of subsections (i)(1), (5) and (8) filed 11-28-94 as an emergency; operative 11-28-94 (Register 94, No. 48). A Certificate of Compliance must be transmitted to OAL by 3-28-95 or emergency language will be repealed by operation of law on the following day.

15. Editorial correction of History 14 (Register 95, No. 18).

16. Certificate of Compliance as to 11-28-94 order transmitted to OAL 3-23-95 and filed 5-4-95 (Register 95, No. 18).

17. Editorial correction of subsection (i)(2) inserting inadvertently omitted text (Register 95, No. 29).

18. Amendment of subsection (i)(6) filed 8-2-95 as an emergency; operative 8-2-95 (Register 95, No. 31). A Certificate of Compliance must be transmitted to OAL by 11-30-95 or emergency language will be repealed by operation of law on the following day.

19. Certificate of Compliance as to 8-2-95 order including amendment of subsection (i)(6) transmitted to OAL 11-22-95 and filed 1-3-96 (Register 96, No. 1).

20. Editorial correction of subsections (i)(3) and (i)(7) (Register 96, No. 11).

21. Amendment of subsections (i)(3) [X2981 and X2982] and (i)(8) [E0600, E0747 and E0781-X2948] filed 7-29-96 as an emergency; operative 7-29-96 (Register 96, No. 31). A Certificate of Compliance must be transmitted to OAL by 11-26-96 or emergency language will be repealed by operation of law on the following day.

22. Certificate of Compliance as to 7-29-96 order transmitted to OAL 11-7-96 and filed 12-23-96 (Register 96, No. 52).

23. Amendment of subsection (i) filed 7-28-97 as an emergency; operative 7-28-97 (Register 97, No. 31). A Certificate of Compliance must be transmitted to OAL by 11-25-97 or emergency language will be repealed by operation of law on the following day.

24. Certificate of Compliance as to 7-28-97 order transmitted to OAL 11-19-97 and filed 1-6-98 (Register 98, No. 2)

25. Amendment of subsections (i)(1)-(7), new subsection (i)(8), subsection renumbering, and amendment of newly designated subsection (i)(9) filed 7-21-98 as an emergency; operative 7-27-98 (Register 98, No. 30). A Certificate of Compliance must be transmitted to OAL by 11-24-98 or emergency language will be repealed by operation of law on the following day.

26. Editorial correction of History 25 (Register 99, No. 2).

27. Certificate of Compliance as to 7-21-98 order, including further amendment of subsections (i)(3) and (i)(6)-(i)(9), transmitted to OAL 11-23-98 and filed 1-7-99 (Register 99, No. 2).

28. Amendment of subsections (i)(2)-(3) and (i)(6)-(7) filed 8-27-99 as an emergency; operative 8-30-99 (Register 99, No. 35). A Certificate of Compliance must be transmitted to OAL by 12-28-99 or emergency language will be repealed by operation of law on the following day.

29. Amendment of subsections (i)(2)-(3) and (i)(6)-(7) refiled 12-27-99 as an emergency, including further amendment of subsections (i)(3) and (i)(6)-(7); operative 12-28-99 (Register 99, No. 53). A Certificate of Compliance must be transmitted to OAL by 4-26-2000 or emergency language will be repealed by operation of law on the following day.

30. Amendment of subsections (i)(2)-(3) and (i)(6)-(7) refiled 4-24-2000 as an emergency; operative 4-26-2000 (Register 2000, No. 17). A Certificate of Compliance must be transmitted to OAL by 8-24-2000 or emergency language will be repealed by operation of law on the following day.

31. Amendment of subsections (i)(1)-(9) filed 6-5-2000 as an emergency; operative 6-5-2000 (Register 2000, No. 23). A Certificate of Compliance must be transmitted to OAL by 10-3-2000 or emergency language will be repealed by operation of law on the following day.

32. Certificate of Compliance as to 4-24-2000 order transmitted to OAL 5-24-2000 and filed 7-6-2000 (Register 2000, No. 27).

33. Amendment of subsections (i)(1)-(9) refiled 8-21-2000 as an emergency; operative 10-3-2000 (Register 2000, No. 34). A Certificate of Compliance must be transmitted to OAL by 1-31-2001 or emergency language will be repealed by operation of law on the following day.

34. Amendment of subsections (i)(1), (i)(6), (i)(8) and (i)(9) filed 10-31-2000 as an emergency; operative 10-31-2000 (Register 2000, No. 44). A Certificate of Compliance must be transmitted to OAL by 2-28-2001 or emergency language will be repealed by operation of law on the following day.

35. Certificate of Compliance as to 8-21-2000 order transmitted to OAL 1-3-2001 and filed 2-5-2001 (Register 2001, No. 6).

36. Certificate of Compliance as to 10-31-2000 order transmitted to OAL 2-22-2001 and filed 4-4-2001 (Register 2001, No. 14).

37. Amendment of subsection (i)(1) -- groups 1, 2, 4 and 6 filed 12-19-2001 as an emergency; operative 12-19-2001 (Register 2001, No. 51). A Certificate of Compliance must be transmitted to OAL by 4-18-2002 or emergency language will be repealed by operation of law on the following day.

38. Certificate of Compliance as to 12-19-2001 order transmitted to OAL 4-9-2002 and filed 4-30-2002 (Register 2002, No. 18).

39. Amendment of subsection (i), new subsection (j) and amendment of Note filed 7-16-2002; operative rates for services provided on or after 8-1-2000 pursuant to Stats. 2000, c. 52, Items 4260-101-0001 and 0890 (Register 2002, No. 29).

40. Certificate of Compliance as to 7-16-2002 order, including repealer of subsection (j), transmitted to OAL 11-12-2002 and filed 12-24-2002 (Register 2002, No. 52).

41. Amendment of subsection (a), repealer and new subsection (a)(1), new subsection (a)(2), subsection renumbering, amendment of newly designated subsection (a)(3) and amendment of Note filed 2-27-2003 as an emergency; operative 3-1-2003 (Register 2003, No. 9). Pursuant to statutes of 1999, chapter 146, section 78, a Certificate of Compliance must be transmitted to OAL by 8-28-2003 or emergency language will be repealed by operation of law on the following day.

42. Amendment of subsection (i) filed 4-4-2003 as an emergency; operative 4-4-2003 (Register 2003, No. 14). A Certificate of Compliance must be transmitted to OAL by 8-4-2003 or emergency language will be repealed by operation of law on the following day.

43. Editorial correction of History 41 (Register 2003, No. 20).

44. Amendment of subsection (a), repealer and new subsection (a)(1), new subsection (a)(2), subsection renumbering, amendment of newly designated subsection (a)(3) and amendment of Note refiled 8-28-2003 as an emergency; operative 8-28-2003 (Register 2003, No. 35). Pursuant to statutes of 1999, chapter 146, section 78, a Certificate of Compliance must be transmitted to OAL by 2-24-2004 or emergency language will be repealed by operation of law on the following day.

45. Certificate of Compliance as to 4-4-2003 order transmitted to OAL 7-28-2003 and filed 9-4-2003 (Register 2003, No. 36).

46. Order of 8-28-2003 repealed by operation of law (Register 2004, No. 9).

47. Amendment of subsection (a), repealer and new subsection (a)(1), new subsection (a)(2), subsection renumbering, amendment of newly designated subsection (a)(3) and amendment of Note filed 2-24-2004; operative 2-25-2004 (Register 2004, No. 9). Pursuant to section 14043.75(a) of the Welfare and Institutions Code, this filing is deemed an emergency and exempt from review by OAL. A Certificate of Compliance must be transmitted to OAL by 6-24-2004 or emergency language will be repealed by operation of law on the following day.

48. Certificate of Compliance as to 2-24-2004 order transmitted to OAL 3-12-2004 and filed 4-26-2004 (Register 2004, No. 18).

49. Amendment of section and Note filed 12-9-2008; operative 12-9-2008. Submitted to OAL for printing only (Register 2008, No. 50).

Note

Note: Authority cited: Section 20, Health and Safety Code; Sections 10725, 14043.75, 14105, 14105.2, 14105.48 and 14124.5, Welfare and Institutions Code; and Section 78, Chapter 146, Statutes of 1999. Reference: Sections 14103.7, 14105, 14105.2 and 14105.48, Welfare and Institutions Code; Statutes of 1984, Chapter 258, Items 4260-106-001 and 890; Statutes of 1985, Chapter 111, Items 4260-106-001 and 890; Statutes of 2000, Chapter 52, Items 4260-101-0001 and 0890; Statutes of 2003, Chapter 230 and Chapter 659, Items 4260-101-001 and 0890; and Statutes of 2006, Chapter 74, Items 4260-101-0001 and 0890.