Date: November 13, 2019
To: Enrolled Durable Medicaid Equipment and Supplies Providers and Hospitals
Re: Rate Increases for Custom Orthotic and Prosthetic Devices Effective November 1, 2019
This notice informs providers of rate increases for custom orthotics and prosthetics. These rates apply to items for participants covered under the Department’s fee-for-service program as well as those covered under a managed care plan.
Effective with dates of service beginning November 1, 2019, the Department’s maximum allowable rates for custom orthotic and prosthetic devices will be calculated based on the Medicare rate in effect on July 1, 2019, minus six percent (6%). The Department’s maximum allowable rates for new items added to the fee schedule after November 1, 2019 will be calculated based on the Medicare rate for the year the procedure code is first established on the Department’s fee schedule, minus six percent (6%). All orthotic and prosthetic device services are subject to the 2.7% SMART Act rate reduction.
Actual payment for covered items is based on the lesser of the provider’s charge or the maximum allowable rate established by the Department.