The New DMEPOS Competitive Bidding Program What You Need to Know Medicare-covered Durable Medical Equipment, Prosthetics, Orthotics and Supplies

What is DMEPOS? DMEPOS stands for Durable Medical Equipment Prosthetics Orthotics Supplies Equipment and supplies covered under Medicare Part B

Change in Payment for DMEPOS Congress changed The way Medicare pays How much is paid Who can furnish these items Called “Competitive Bidding Program” Begins July 1, initial competitive bidding areas (CBAs) Applies if residing in or visiting a CBA

Competitive Bidding Program Bidding process will set Medicare payment lower than previous amounts Program will help people with Medicare Save money Get quality equipment, supplies and services Program will limit Medicare fraud and abuse

Program Evolution Builds on success of demonstrations April 2007: 10 initial areas announced July 2008: Program begins in 10 MSAs Average savings of 26% January 2008: 70 additional areas announced In 2009: Program begins in 70 additional areas

Who will be Affected? Beneficiaries who Have Original Medicare (not apply if have Medicare Advantage) Permanently reside in a ZIP Code in a CBA Obtain items while visiting a CBA To find out if ZIP Code is in a CBA Call MEDICARE Visit

Initial CBAs California – Riverside, San Bernardino, Ontario Florida - Miami, Fort Lauderdale, Miami Beach Florida - Orlando, Kissimmee Missouri and Kansas - Kansas City North and South Carolina - Charlotte, Gastonia, Concord Ohio - Cleveland, Elyria, Mentor Ohio, Kentucky, and Indiana - Cincinnati, Middletown Pennsylvania - Pittsburgh Texas - Dallas-Fort Worth, Arlington Puerto Rico-- San Juan, Caguas, Guaynabo

How New Program Works DMEPOS suppliers submit bids Suppliers in a CBA 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 best price Meet eligibility, quality, and financial standards Accredited by an independent organization

How New Program Works Only contract suppliers will be able to Provide certain DMEPOS items File claims with Medicare for payment Contract supplier charge cannot exceed Single payment amount based on bids received for an item Medicare fee schedule allowed amount

Products Included in the Program 1.Oxygen supplies and equipment 2.Standard power wheelchairs, scooters 3.Complex rehabilitative power wheelchairs 4.Mail-order diabetic supplies 5.Enteral nutrients, equipment, and supplies 6.Hospital beds and related accessories 7.Continuous Positive Airway Pressure (CPAP) devices and Respiratory Assist devices (RADs)

Products Included in the Program 8.Negative pressure wound therapy devices 9.Walkers and related accessories 10.Support surfaces (Miami only) To check for specific included products Call MEDICARE Visit

Using Contract Suppliers Must use contract supplier if Item included in Competitive Bidding Program where a beneficiary lives Traveling to or visiting a CBA Treating practitioner can supply certain items (ex: walkers) Nursing Facility can only supply directly if it becomes a contract supplier

Identifying Contract Suppliers Call MEDICARE ( ) TTY users call Visit DMEPOS Supplier Locator Tool

Non-contract Supplier If in CBA, a non-contract supplier may not furnish bid items If non-contract supplier used, supplier will issue Advance Beneficiary Notice (ABN) ABN says Medicare will not pay By signing, beneficiary agreeing to pay If not sign ABN, beneficiary not responsible for payment

Scenario 1 Obtaining an item from a non-contract supplier Betty lives in Cincinnati, OH (which is in a Competitive Bidding Area) and is diagnosed with sleep apnea. Her doctor prescribes a Continuous Positive Airway Pressure (CPAP) device. If Betty wants to buy the item from a non-contract supplier, the supplier must have her sign an Advance Beneficiary Notice (ABN). The ABN says Medicare probably won’t pay for the item. By signing this notice, Betty agrees to pay for the CPAP device. If Betty purchases the CPAP device from a non-contract supplier, and she wasn’t informed in writing of the Competitive Bidding Program rules before receiving the item, she is not responsible for payment.

Temporary Visits To CBA: Must use contract supplier If non-contract supplier used, supplier will issue Advance Beneficiary Notice (ABN) If not sign ABN, beneficiary not responsible for payment To non-CBA: Can use any Medicare-enrolled supplier

Scenario 2 Obtaining DMEPOS items while traveling Mildred’s permanent residence is in Rhode Island (which is not a Competitive Bidding Area), but she travels to Miami, FL. While she’s in Miami, her doctor prescribes a walker. Since Miami is in the Competitive Bidding Area, Mildred must receive the walker from a contract supplier. If Mildred wants to buy the walker from a non- contract supplier, the supplier must have her sign an Advance Beneficiary Notice (ABN). The ABN says Medicare probably won’t pay for the item. By signing this notice, Mildred agrees to pay for the walker. If Mildred travels to Jacksonville, FL, which is not a Competitive Bidding Area, she may purchase a walker from any Medicare- enrolled supplier of durable medical equipment, prosthetics, orthotics and supplies.

Specific Brands Doctor must prescribe in writing Medical record must reflect need If specific brand not available Supplier will work with practitioner to find suitable alternative OR Help locate another contract supplier who can meet the need

Stay With Current Supplier Can stay with current non-contract supplier if all of the following Supplier elects to be “grandfathered” Beneficiary permanently resides in a CBA Renting the equipment before July 2008 If current non-contract supplier elects not to be “grandfathered” Must switch to a contract supplier

“Grandfathered” Supplier Supplier Notifies beneficiary confirming desire to continue services Beneficiary May continue getting services until rental period ends OR Must switch to a contract supplier

Scenario 3 Grandfathering Process for Rented Items George lives in Kansas City, MO (which is in a Competitive Bidding Area) and has been renting oxygen and oxygen supplies from his supplier. His supplier was not awarded a contract with Medicare under the new Competitive Bidding Program. George’s supplier decides to become a “grandfathered” supplier which means the supplier can continue to furnish the oxygen items and receive the Medicare payment amounts under the new Competitive Bidding Program. George may continue receiving his oxygen items from the grandfathered supplier until his contract ends.

If Not “Grandfathered” Supplier Supplier Should confirm desire to discontinue services Picks up equipment Beneficiary Must switch to contract supplier Retains documentation of pick-up If not hear from supplier, check with supplier or Medicare

Equipment Repair & Replacement For owned medical equipment Any Medicare-enrolled supplier can make necessary repairs or get replacement parts For complete replacement must use contract supplier Owned medical equipment includes Items purchased by beneficiary Items for which beneficiary took the purchase option within the rental period

Scenario 4 Repair and Replacement Elaine has a wheelchair and lives in Dallas, TX (which is in a Competitive Bidding Area). The wheel on her chair breaks and she needs to have it repaired. She may have her wheelchair repaired by either a contract supplier or by any Medicare-enrolled, non-contract supplier. If Elaine’s wheelchair needs a replacement part, she may have the replacement part installed by either a contract supplier or any Medicare-enrolled, non-contract supplier. If it is determined that Elaine’s wheelchair cannot be repaired and she needs a new wheelchair, she must receive it from a contract supplier in the Competitive Bidding Area.

Deductible and Coinsurance Annual deductible and 20% coinsurance remain in effect Contract suppliers cannot bill for more than these amounts For suspected overpayment or fraud call MEDICARE Fraud Hotline of the HHS Office of the Inspector General at

Have Other Insurance? Medicare may make payment to a non- contract supplier if required by policy Non-contract supplier must Meet Medicare enrollment standards Be eligible to receive secondary payments

Points to Remember Program does NOT affect which physician or hospital you use May need to change DMEPOS supplier to continue your Medicare coverage May be able to stay with current supplier if renting from supplier who elects to be “grandfathered” If in MA plan, program is not applicable

What You Need To Do If you live in or will visit a CBA and need medical items included in the program Find out if the ZIP Code where you live or visit is included in a CBA Find out which suppliers are included in the Medicare Competitive Bidding Program in that area Visit or call MEDICARE to find this informationwww.medicare.gov

Questions? MEDICARE ( ), TTY users should call website Supplier Locator Tool Consumer fact sheets Your physician or supplier Medicare’s local information resources (SHIPs, AoA, etc)

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