1. Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS ) Assisting Medicare Beneficiaries Renee Richard CMS Boston Regional Office Edward McGuire, Liaison Palmetto GBA

2. Definition  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

3. 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

4. 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

5. Coverage 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

6. 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

7. 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 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

8. 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

9. 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

10. Competitive Bidding September 2015 National Training- DMEPOS 10

11. 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 11 National Training- DMEPOS

12. 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 12 National Training- DMEPOS

13. 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 13 National Training- DMEPOS

14. Round 2  Competitive Bidding Program expanded – Round 2 91 Metropolitan Statistical Areas (MSAs) Effective date July 1, 2013 – National Mail-Order Program September 2015 14 National Training- DMEPOS

15. 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

16. 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

17. 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 17 National Training- DMEPOS

18. September 2015 National Training- DMEPOS 18 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

19. 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 19 National Training- DMEPOS

20. Identifying Contract Suppliers  Visit the DMEPOS Supplier Locator tool – www.medicare.gov/supplier 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

21. 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 21 National Training- DMEPOS

22. 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 22 National Training- DMEPOS

23. 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

24. 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

25. Other Inquiries/Cases  Other inquiries/cases  Open Discussion for common or problematic inquiries September 2015 National Training- DMEPOS 25

26. Questions?  Visit www.medicare.gov/supplierwww.medicare.gov/supplier – DMEPOS Supplier Locator Tool  Visit www.medicare.gov websitewww.medicare.gov – 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 26 National Training- DMEPOS

27. Thank you Renee Richard, CMS 617-565-1256 Edward McGuire, Palmetto GBA 803-763-5774 September 2015 National Training- DMEPOS 27