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Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
Assisting Medicare Beneficiaries
Renee RichardCMS Boston Regional OfficeEdward McGuire, LiaisonPalmetto GBA
DefinitionDefinition
Durable medical equipment (DME) is furnished to a beneficiary for use in the patient’s 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 DMEPOSMajor 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 DMENon-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 CriteriaCoverage Criteria
Medicare requires a physician’s prescription for DMEPOS items. A supplier must have an order signed and dated by the bene’s doctor before dispensing any DMEPOS item to a bene.
September 2015 National Training- DMEPOS 5
Face-to-Face Exam RequirementsFace-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 RulesReplacement - 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 patient’s 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
Patient’s condition changes to necessitate a different type of equipment
September 2015 National Training- DMEPOS 7
Replacement - Basic Payment RulesReplacement - 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 RulesReplacement - 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– A Better Way to Pay 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 11National Training- DMEPOS
How the Program WorksHow 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 12National Training- DMEPOS
How the Program WorksHow 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 13National Training- DMEPOS
Round 2Round 2
Competitive Bidding Program expanded– Round 2
• 91 Metropolitan Statistical Areas (MSAs)• Effective date July 1, 2013
– National Mail-Order Program
September 2015 14National Training- DMEPOS
Products Included in Round 2*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
September 2015 National Training- DMEPOS 15
*Changes from Round 1 to Round 2 in Bold Italics
National Mail Order Program for Diabetic Testing Supplies
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? 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 17National Training- DMEPOS
September 2015 National Training- DMEPOS 18
Region I: Round 2 MSAsConnecticut
• 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
Using Contract SuppliersUsing 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 19 National Training- DMEPOS
Identifying Contract SuppliersIdentifying 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 SupplierNon-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 21National Training- DMEPOS
Specific BrandsSpecific 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 22National Training- DMEPOS
Equipment Repair & ReplacementEquipment 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 TopicsHot 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/CasesOther Inquiries/Cases
Other inquiries/cases
Open Discussion for common or problematic inquiries
September 2015 National Training- DMEPOS 25
Questions?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
Beneficiary’s physician or supplier Medicare’s local information resources
(SHIPs, ACL, etc)September 2015 26National Training- DMEPOS