Durable Medical Equipment, Prosthetics, Orthotics, and Supplies

• Contract Supplier Obligations
• Payment Policies
• - Grandfathered Suppliers
• - Repair and Replacement
• - Traveling Beneficiaries
• - Modifiers
• - Exemptions

Article III: Contract Period, Breach and Remedies, and Severability

• Breach of Contract
• - Any violation of the terms of the contract
• Remedies
• - Contract supplier notified prior to contract termination
• - Guidance provided on corrective action plans (CAP) and requests for reconsideration

Article IV B: Furnishing of a Particular Brand or Mode of Delivery

• Furnish what is prescribed by physician or treating practitioner OR
• Consult with physician to find another appropriate brand of item or mode of delivery OR
• Assist beneficiary in locating another contract supplier

Article IV C: Transition to Contract Supplier

• Must be coordinated among non-contract / current supplier, contract supplier and beneficiary
• New contract supplier should obtain supporting documentation from current supplier
• Pickup and delivery should occur on anniversary of delivery date of when item was first rented to beneficiary
• Non-contract or current supplier cannot pick up equipment before the end of the month for which that supplier is entitled payment

Article V: Change of Contract Supplier’s Ownership

• A contract supplier cannot sell or assign its competitive bidding contract to another person/entity. A contract that is sold will be terminated.
• CMS may award a new contract after a change of ownership (CHOW) if certain requirements are met

Article IX: Quarterly Reports

• Must disclose manufacturer, model name and model number of items and state how many were furnished during previous quarter.
• Information provided on Form C used to:
• - Monitor the program
• - Populate the Supplier Directory on Medicare website
• - Assist 1-800-MEDICARE customer service representatives to assist beneficiaries

Article IX: Quarterly Reports

• Reports due 10 calendar days after:
• - March 31
• - June 30
• - September 30
• - December 31

Article XI: Payment

• Must meet all claims processing requirements
• - Compliant standard electronic format
• - Applicable HCPCS codes and/or modifiers
• Must accept single payment amount (SPA) as payment in full
• Must accept assignment for bid items

Article XI: Payment

• SPA remains in effect for duration of contract period
• If HCPCS code changes, SPA based on how HCPCS code for item is changed

Article XI: Payment

• Single code divided into two or more codes for components of item: SPA for sum of new codes = SPA for original code
• Single code divided into two or more codes : SPA for each new code = SPA for original code

Article XI: Payment

• Multiple components of item merged into single code: SPA for new code = total of separate SPA
• Multiple codes for similar items merged into single code: item may be provided by any Medicare-enrolled supplier

• Applies to oxygen and rented durable medical equipment (DME) only
• Not applicable to enteral nutrition or mail-order diabetic supplies*
• Item must be under rental agreement at time program is implemented

• Must offer to grandfather all beneficiaries
• Must grandfather all items in the product category
• Beneficiaries may choose contract supplier or grandfathered supplier
• Applicable to beneficiaries transitioning from Medicare Advantage plans

• New contract supplier
• - Must accept beneficiary as customer
• - New rental period for 13 months of payment for capped rental
• - Remainder of rental months for inexpensive routinely purchased (IRP) items
• - Accept assignment; paid single payment amount
• - For capped rental DME, if break in need/service greater than 60 days – contract supplier must provide item

• New contract supplier
• - Paid at least 10 months of oxygen rental
• - Paid single payment amount
• - Break in need greater than 60 days PRIOR to 36 months – contract supplier must provide items
• - Must accept beneficiary as customer

• ALL suppliers
• - Must continue providing oxygen equipment and services for rest of reasonable useful lifetime
• - Cannot transfer obligation to continue furnishing oxygen to contract supplier or any other supplier
• - Paid for oxygen contents, if applicable, at single payment amount

• Beneficiary elects new oxygen equipment
• - Contract supplier
• - New 36-month rental period
• - Single payment amount
• Beneficiary elects to keep original oxygen equipment
• - Grandfathered supplier
• - Contents only

• Grandfathered suppliers: Written notice to CMS and beneficiaries – November 17, 2010
• Non-contract suppliers that do not become grandfathered suppliers: Initial written notice beneficiaries – November 17, 2010
• Notification instructions/tools on CBIC website, www.dmecompetitivebid.com

• KG – Identify product category for item
• - Standard power wheelchairs
• KK – Identify product category for item
• – Complex rehab power wheelchairs
• KL – Item delivered by mail order
• – Diabetic testing supplies

• KV – Item furnished by physician or other treating practitioner
• - Walkers
• J4 – Item furnished by hospital upon discharge
• – Walkers
• KT – Traveling beneficiary

• Physicians and Other Practitioners
• - No requirement to bid if bid item provided as part of professional services
• - Bid item limited to walkers
• Hospitals
• – No requirement to bid if item provided upon discharge as part of inpatient stay
• – Bid item limited to walkers
• – Hospital-owned DME suppliers not exempt from bidding

• Primary Insurance Supplier
• - May continue to receive secondary payment for an item
• - Paid in accordance with Medicare secondary payer requirements

• Competitive Bidding Implementation Contractor (CBIC) Customer Service Center: (877) 577-5331
• CMS Website:www.cms.gov/dmeposcompetitivebid
• Competitive Bidding Program (CBIC) Website:www.DMECompetitiveBid.com
• NSC Website:www.PalmettoGBA.com/NSC