Or. Admin. Code § 291-124-0049

Current through Register Vol. 63, No. 9, September 1, 2024

Section 291-124-0049 - Durable Medical Equipment

(1) The following definitions apply in this rule:

(a) "Activities of Daily Living" (or "ADLs") means activities related to personal care (including, but not limited to, tasks such as eating, toileting, grooming, dressing, and bathing,) which are necessary to maintain or improve the AIC's health.

(b) "Durable Medical Equipment" (or "DME") means equipment that:

(A) Is furnished by a durable medical equipment, prosthetics, orthotics and supplies provider;

(B) Is primarily and customarily used to serve a medical purpose;

(C) Is generally not useful to a patient in the absence of a medical disability, illness, or injury;

(D) Can withstand repeated use;

(E) Can be reusable or removable;

(F) Is appropriate for use in any non-institutional setting in which normal life activities take place;

(G) May include prosthetic and orthotic devices, orthopedic footwear, a fitted wheelchair, or a power wheelchair that meets the criteria in this definition;

(H) Includes supplies and accessories that are necessary for the effective use of the associated durable medical equipment; and

(I) Excludes dental equipment or devices described in the Dental Treatment and Care rule, OAR 291-124-0042.

(c) "Orthopedic footwear" means shoes, shoe modifications, or shoe additions which are used to correct, accommodate or prevent a physical deformity or range of motion malfunction in a diseased or injured part of the ankle or foot; or to support a weak or deformed structure of the ankle or foot.

(d) "Medically Appropriate" means that health services, items, or medical supplies that are:

(A) Recommended by a licensed health provider practicing within the scope of their license;

(B) Safe, effective, and appropriate for the AIC based on standards of good health practice and generally recognized by the relevant scientific or professional community based on the best available evidence;

(C) Not solely for the convenience or preference of an AIC; and

(D) The most cost-effective of the alternative levels or types of health services, items, or medical supplies that can be safely and effectively provided to an AIC;

(e) "Prosthetic and orthotic devices" means devices that replace or augment all or part of an internal body organ, including ostomy bags and supplies directly related to ostomy care and replacement of such devices and supplies. Prosthetic and orthotic devices also include leg, arm, back, and neck braces, and artificial legs, arms, and eyes, including replacements if required because of a change in the client's physical condition. This term excludes devices or items described in the Dental Care and Treatment rule, OAR 291-124-0042.

(2) Health Services shall authorize and provide DME when clinically indicated because of a substantial functional deficit, when there is a demonstrable and substantial inability to perform activities of daily living (ADLs), or when provision of the DME may be necessary to provide access to one or more Department programs, services, or activities.

(a) When assessing whether the provision of DME is necessary to access Department programs, services, or activities, any such assessment shall consider the disability related accessibility and functional needs of the individual requesting the DME, and shall be based on documented assessments by persons trained in disability-related functional and accessibility needs of the AIC.

(b) Health Services may consider the following when determining whether to authorize DME:

(A) Urgency of need;

(B) Time left on sentence;

(C) Overall necessity;

(D) Morbidity;

(E) Mortality;

(F) Functional disability;

(G) Expected improvement;

(H) Alternatives;

(I) Risks and benefits;

(J) Ability to engage in ADL and access programs, services, and activities;

(K) Costs and benefits; and

(L) Security concerns.

(c) A recommendation to provide DME will be based upon the AIC's ability to function in the correctional environment with or without a proposed medical prosthesis, and as necessary to access programs, services, or activities.

(d) The Department shall pay for DME if it meets all the criteria in this rule, including all of the following conditions:

(A) The item is approved for marketing and registered or listed as a medical device by the Food and Drug Administration (FDA) and is otherwise generally considered to be safe and effective for the intended purpose;

(B) The item is reasonable and medically appropriate for the client;

(C) The item is primarily and customarily used to serve a medical purpose;

(D) The item is clinically indicated because of a substantial functional deficit, or because of a demonstrable and substantial inability to perform ADLs, or, because the Department has determined, after consultation between Health Services and the institution and statewide ADA coordinators, that the item is necessary or appropriate to provide to an otherwise qualified AIC to access Department programs, services, or activities;

(E) The item is generally not useful to an individual in the absence of medical disability, illness, or injury;

(F) The item is suitable for use in any non-institutional setting in which normal life activities take place;

(G) The item can withstand repeated use and can be reusable or removable;

(H) The item is the least costly, medically appropriate item that meets the medical needs of the client; and

(I) The item is not otherwise excluded under this rule.

(e) The Department may not pay for durable medical equipment when the item, or the use of the item:

(A) Is not primarily medical in nature;

(B) Is for personal comfort or convenience of the client or caregiver;

(C) Is a self-help device;

(D) Is not therapeutic or diagnostic in nature;

(E) Is not expected to significantly improve the basic health status of the AIC;

(F) Is inappropriate for client use in a non-institutional setting;

(G) Is for a purpose where the medical effectiveness is not supported by evidence- based clinical practice guidelines; or

(H) Presents a legitimate risk to the safety and security of Department facilities.

(f) Restriction or confiscation of a medical prosthesis for any non-emergent reason (other than a medical reason) should occur with prior consultation with Health Services and the institution or statewide ADA coordinators, and when appropriate, Behavioral Health Services. Any restriction or confiscation for any emergent reason should occur, when practicable, with prior consultation with Health Services and the institution or statewide ADA coordinators, and when appropriate, Behavioral Health Services. No DME shall be restricted or confiscated for any non-emergent reason without an individualized assessment of the AIC by the appropriate medical professional and a face-to-face discussion with the AIC to determine whether the AIC can access programs, services, and activities without the DME. This process shall be documented with the reasons why the DME was removed, and an explanation of the how the AIC will access programs, services, and activities without the DME.

(3) The frequency of monitoring of DMEs will be determined by Health Services. Monitoring shall include review for any alterations, natural wear, destruction, or disrepair.

(4) Health Services shall authorize and provide the repair or replacement of a DME provided under this rule, as clinically indicated and appropriate.

(5) Health Services may decline to authorize or pay for DME, or repair or replacement of DME provided under this rule, in the event an AIC misuses, alters, abuses, damages (ordinary wear and tear excepted,) or intentionally destroys any previously issued or approved DME. Health Services will consult with Behavioral Health Services and the institution or statewide ADA coordinators where appropriate prior to declining to pay for DME or repairs or replacement.

(6) The authorization and provision of DME under this rule is subject to clinical review as provided under OAR 291-124-0041.

Or. Admin. Code § 291-124-0049

DOC 17-2024, adopt filed 08/13/2024, effective 8/13/2024

Statutory/Other Authority: ORS 179.040, 423.020, 423.030 & 423.075

Statutes/Other Implemented: ORS 179.040, 423.020, 423.030 & 423.075