- Pharmacy Fee Schedule Regulation
- Frequently Asked Questions about Pharmacy Fee Schedule and Pharmacy Benefit Manager (PBM)
- Frequently Asked Questions about Durable Medical Equipment (DME) Fee Schedule
Durable Medical Equipment Fee Schedule
The Workers' Compensation Board has adopted the NYS Medicaid durable medical equipment (DME) fee schedule. The most recent DME fee schedule is found in the Department of Health's eMedNY eMedNY website. This eMedNY site also provides periodic provider communications, announcements, manuals and fee schedules - What's New. Historic fee schedules and other information that is more than four months can be found in the Archives.
The NYS Medicaid durable medical equipment (DME) fee schedule will have these exceptions:
- According to Section 442.2(a) of the WC DME Fee Schedule (12 NYCRR part 442): For orthopedic footwear (DME codes from L3000 to L3649) or if the New York State Medicaid program has not established a fee payable for the specific item (DME items with a blank reimbursement value in the fee schedule), then the fee payable, shall be the lesser of:
- the acquisition cost (i.e. the line item cost from a manufacturer or wholesaler net of any rebates, discounts or other valuable considerations, mailing, shipping, handling, insurance costs or any sales tax) to the provider plus 50%; OR
- the usual and customary price charged to the general public.
- The following NYS Medicaid durable medical equipment (DME) fee schedule columns will not be applicable in the WC DME fee schedule:
- MAX UNITS: Maximum units allowed per month.
- PA: Prior approval.
- CHANGE: The CHANGE column indicating a change in the code since the last fee schedule was posted.
Note: The Medicaid provider manual for durable medical equipment and the policy guidance do not apply to workers' compensation except to the extent such documents contain the Medicaid durable medical equipment fee schedule. Application of the durable medical fee schedule is based on Workers' Compensation statute, rules and regulations in addition to the durable medical equipment fee schedule. Only the Board in the exercise of its adjudicatory function is authorized to determine entitlement to benefits based on the specific facts of a given claim and the application of the law to those facts. No-Fault cases may be subject to differing interpretations. For information regarding No-Fault Insurance, contact NYS Department of Financial Services at dfs.ny.gov.
Notice of Decision dated April 21, 2009, concerning request for fee schedule adjustment: In the Matter of Request by EMPI, 2009 NY Wrk Comp.