New York State Medicaid DME Services Fee Schedule

The New York State (NYS) Medicaid program provides a comprehensive fee schedule for Durable Medical Equipment (DME) services. The schedule establishes the maximum amount that Medicaid will reimburse providers for each covered item or service. Understanding the fee schedule helps suppliers, clinicians, and patients navigate billing, ensure compliance, and anticipate costs.

What Is DME?

Durable Medical Equipment (DME) includes devices that:

• Are medically necessary and prescribed by a licensed practitioner.
• Can withstand repeated use.
• Are primarily used for a medical purpose rather than for general comfort.
• Are not consumable in a single episode of care.

Common examples include wheelchairs, hospital beds, oxygen equipment, prosthetics, and home infusion pumps.

Key Features of the NYS Medicaid DME Fee Schedule

How to Locate Specific Rates

The fee schedule is organized by HCPCS (Healthcare Common Procedure Coding System) codes. Providers can find rates by:

1. Visiting the NYSDOH DME webpage.
2. Downloading the latest FY2024 DME Fee Schedule PDF.
3. Using the searchable online table on the Medicaid Provider Portal.

Sample Fee Schedule Excerpts

Billing Guidelines

To receive reimbursement, providers must:

• Submit a claim using the correct HCPCS code and accompanying documentation (physician order, patient assessment, and written justification).
• Verify patient eligibility for the specific DME item.
• Obtain prior authorization when required (e.g., oxygen therapy, prosthetics).
• Apply any applicable quantity limits (e.g., one wheelchair per 24month period).
• Include the National Provider Identifier (NPI) and NYS Medicaid provider number on every claim.

Common Questions

1. What if a provider charges more than the fee schedule amount?

Medicaid will only reimburse up to the listed fee. Any amount billed above the schedule is considered patient responsibility and may be subject to collection or waiver, depending on the providers policy.

2. Are there any exemptions?

Some specialty items, such as customfabricated orthotics, may be reimbursed at a negotiated rate outside the standard schedule. These are typically handled through a separate contract with the state.

3. How are price updates communicated?

The NYSDOH publishes updates in the Provider Manual and sends email alerts to registered providers. It is the providers responsibility to stay current.

4. Can a patient appeal a denial?

Yes. Patients and providers may submit a written appeal to the Medicaid Office of Claims and Recovery within 30days of the denial notice, providing supporting documentation.

Impact on Patients

The fee schedule directly influences outofpocket costs. When the Medicaid fee exceeds the suppliers cost, patients typically face no charge. However, if a suppliers price is higher, the patient may be asked to cover the difference, unless a waiver is granted.

Resources

• NYSDOH Medicaid Home
• DME Services Overview
• CMS Medicare DME Manual (for reference)
• Provider Help Desk: 18005412831

Staying informed about the NYS Medicaid DME Services Fee Schedule helps ensure timely, accurate reimbursement and uninterrupted access to essential medical equipment for New Yorkers who rely on Medicaid benefits.