Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Assisting Medicare Beneficiaries Renee Richard CMS Boston Regional Office Edward McGuire, Liaison Palmetto GBA Definition Durable medical equipment (DME) is furnished to a beneficiary for use in the patients home, covered under the Part B program, whether furnished on a rental basis or purchased. Definition: DME is equipment that: (1) can withstand repeated use, (2) is primarily and customarily used to serve a medical purpose, (3)
generally is not useful to a person in the absence of illness or injury, and (4) is appropriate for use in the home. September 2015 National Training- DMEPOS 2 Major Categories of DMEPOS DME equipment used in the home which can withstand repeated use, is primarily and customarily used to serve a medical purpose and is generally not useful in the absence of an illness or injury; Prosthetic Devices devices that replace all or part of an internal body organ, including ostomy, tracheostomy and urological supplies, parenteral and enteral nutrients, equipment and supplies (PEN), intraocular lenses (IOLs), and one pair of conventional
eyeglasses or contact lenses after each cataract surgery; Prosthetics artificial legs, arms, and eyes; Orthotics rigid or semi-rigid leg, arm, back, and neck braces; Surgical Dressings Therapeutic Shoes and Inserts September 2015 National Training- DMEPOS 3 Non-covered DME Other devices and equipment used for environmental control or to enhance the environmental setting in which a bene resides are not considered covered DME. These include items such as room heaters, air
conditioners, humidifiers, dehumidifiers, elevators, posture chairs, physical fitness equipment, self-help devices and training equipment. September 2015 National Training- DMEPOS 4 Coverage Criteria Medicare requires a physicians prescription for DMEPOS items. A supplier must have an order signed and dated by the benes doctor before dispensing any DMEPOS item to a bene. September 2015
National Training- DMEPOS 5 Face-to-Face Exam Requirements Effective July 01, 2013 As a condition for payment, Section 6407 of the Affordable Care Act (ACA) requires a physician to document that the physician, PA, NP or CNS has had a face-to-face encounter examination with a beneficiary in the six (6) months prior to the written order for certain items of DME This includes encounters conducted via CMS approved telehealth services PMD bases are not affected by these changes
September 2015 National Training- DMEPOS 6 Replacement - Basic Payment Rules Defined Substitute an item for another that is broken, inefficient, lost or no longer working or yielding what is expected Replacement of DME may occur in cases of loss, irreparable damage, or a change in patients condition Loss/stolen Irreparable Damage Specific accident or a natural disaster Equipment may be replaced in cases of loss or irreparable damage
New order/CMN required Patients condition changes to necessitate a different type of equipment September 2015 National Training- DMEPOS 7 Replacement - Basic Payment Rules Replacement of DME may occur in cases of irreparable wear after the reasonable useful lifetime has expire Irreparable Wear Deterioration sustained from day-to-day usage over time Replacement due to irreparable wear takes into consideration the reasonable useful lifetime of the
equipment New order/CMN required Note: Replacement due to wear and tear before the reasonable useful lifetime is not covered September 2015 National Training- DMEPOS 8 Replacement - Basic Payment Rules Useful Lifetime Determined through program instructions In absence of instructions, contractors may determine the reasonable useful lifetime of equipment In no case can it be less than five years
Computation is based on when the equipment was delivered Replacement due to wear is not covered during the reasonable useful lifetime September 2015 National Training- DMEPOS 9 Competitive Bidding September 2015 National Training- DMEPOS
10 Competitive Bidding A Better Way to Pay Program will help people with Medicare Save money Get quality equipment, supplies and services Program strengthens protections against Medicare fraud September 2015 National Training- DMEPOS 11 How the Program Works
DMEPOS suppliers submit bids Suppliers must submit a bid to be awarded a contract Medicare uses bids to determine payments Contracts will be awarded to sell/rent DMEPOS Contract suppliers will be those who Offer the most competitive price Meet eligibility, quality, and financial standards Are accredited by an independent organization September 2015 National Training- DMEPOS 12
How the Program Works Only contract suppliers will be able to Provide competitively bid DMEPOS items File claims with Medicare for payment of competitively bid items and services Contract supplier charge cannot exceed Single payment amount based on bids received for an item Medicare fee schedule allowed amount September 2015 National Training- DMEPOS 13
Round 2 Competitive Bidding Program expanded Round 2 91 Metropolitan Statistical Areas (MSAs) Effective date July 1, 2013 National Mail-Order Program September 2015 National Training- DMEPOS 14 Products Included in Round 2* Products Included in Round 2 Oxygen, oxygen equipment, and supplies
Enteral nutrients, equipment, and supplies Continuous Positive Airway Pressure (CPAP) devices and Respiratory Assist Devices (RADs), and related supplies and accessories Hospital beds and related accessories Walkers and related accessories Support surfaces (Group 2 mattresses and overlays) Standard (power and manual) wheelchairs, scooters, and related accessories Negative pressure wound therapy pumps and related supplies and accessories *Changes from Round 1 to Round 2 in Bold Italics September 2015 National Training- DMEPOS 15
National Mail Order Program for Diabetic Testing Supplies Targeted to go into effect at the same time as Round 2 Includes all parts of the United States: The 50 States The District of Columbia Puerto Rico The US Virgin Islands Guam American Samoa September 2015 National Training- DMEPOS 16
Who is Affected? Beneficiaries who have Original Medicare and Permanently reside in a ZIP Code in a CBA Obtain competitive bid items while visiting a CBA To find out if a ZIP Code is in a Competitive Bidding Area (CBA) Call 1-800-MEDICARE (1-800-633-4227) TTY users call 1-877-486-2048 Medicare Advantage enrollees can use suppliers designated by their plan September 2015 National Training- DMEPOS
17 Region I: Round 2 MSAs Connecticut Bridgeport-Stamford-Norwalk, CT Hartford-West Hartford-East Hartford, CT New Haven-Milford, CT Maine: None Massachusetts Boston-Cambridge-Quincy, MA-NH
Providence-New Bedford-Fall River, RI-MA Springfield, MA Worcester, MA New Hampshire Boston-Cambridge-Quincy, MA-NH Rhode Island Providence-New Bedford-Fall River, RI-MA Vermont: None September 2015 National Training- DMEPOS
18 Using Contract Suppliers Must almost always use contract supplier if Items and services are included in Competitive Bidding Program where a beneficiary lives in a CBA Traveling to or visiting a CBA Doctors, treating practitioners, and hospitals can supply certain items (ex: walkers or folding manual wheelchairs) Nursing Facility can only supply directly if it becomes a contract supplier September 2015 National Training- DMEPOS
19 Identifying Contract Suppliers Visit the DMEPOS Supplier Locator tool www.medicare.gov/supplier Call 1-800-MEDICARE (1-800-633-4227) TTY users call 1-877-486-2048 September 2015 National Training- DMEPOS 20 Non-contract Supplier
If in CBA, a non-contract supplier may not furnish bid items If non-contract supplier used, supplier must issue Advance Beneficiary Notice (ABN) Says Medicare will not pay By signing, beneficiary agrees to pay entire amount If no ABN signed, beneficiary not responsible for payment September 2015 National Training- DMEPOS 21 Specific Brands Doctor must prescribe in writing
Medical record must reflect need Contract supplier must Furnish the specific brand or form as prescribed OR Work with doctor or treating practitioner to find suitable alternative OR Help locate another contract supplier that can furnish the specific brand or form as prescribed September 2015 National Training- DMEPOS 22 Equipment Repair & Replacement For owned medical equipment Any Medicare-enrolled supplier can make
necessary repairs For replacement must use contract supplier For warranty repairs, follow the warranty rules For rented equipment Repairs are included in rental payment the supplier must fix at no charge September 2015 National Training- DMEPOS 23 Hot Topics Repairs to Power Mobility Devices: many suppliers unwilling to do repairs because the PMDs were
purchased from now out of business suppliers. Bankruptcy Closed Benes are paying out of pocket for equipment from non-enrolled suppliers. Eye glasses (post cataract surgery)(Now in the Medicare handbook) September 2015 National Training- DMEPOS 24 Other Inquiries/Cases Other inquiries/cases Open Discussion for common or problematic
inquiries September 2015 National Training- DMEPOS 25 Questions? Visit www.medicare.gov/supplier DMEPOS Supplier Locator Tool Visit www.medicare.gov website Consumer information Call 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048
Beneficiarys physician or supplier Medicares local information resources (SHIPs, ACL, etc) September 2015 National Training- DMEPOS 26 Thank you Renee Richard, CMS 617-565-1256 Edward McGuire, Palmetto GBA 803-763-5774 September 2015
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