Overview for SHINE Counselors

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Overview for SHINE Counselors

• Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program

• National Mail Order Program for Diabetic Supplies


Part 1

Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

Competitive Bidding Program


What is the DMEPOS Competitive Bidding Program?

• Effective July 1, 2013 the competitive bidding program will change the amount Medicare pays for DMEPOS in an effort to save money and ensure a beneficiary obtains quality equipment, supplies and services.

• Medicare contracted suppliers will provide DMEPOS for 8 specific item categories. • A Medicare beneficiary living in a Competitive Bidding Area (CBA) must purchase

or rent competitive bid items from a Medicare Contract Supplier for coverage by Medicare.

• DMEPOS suppliers submitted bids to participate in this program. Contracts were awarded to suppliers who offered the most competitive prices and met Medicare's financial and eligibility standards.

• Medicare will pay Contract Suppliers a flat rate for each supply (Medicare approved amount).

• Medicare payments for DMEPOS will be reduced by approximately 45%, thus reducing costs for the beneficiary.


Who is Affected?• This affects a beneficiary who uses Original Medicare as

primary insurance coverage and lives in a CBA or obtains items while visiting a CBA.

• The CBA includes most counties in Massachusetts with the exception of Barnstable, Berkshire, Dukes and Nantucket counties.

• A beneficiary enrolled in a Medicare Advantage Plan is NOT affected and will continue to use suppliers designated by the plan.


What are the Competitive Bid Items?

• Oxygen, oxygen equipment and supplies• Enteral nutrients, equipment 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


Examples of Non-Competitive Bid Items

• Canes and Crutches• Prostheses• Ostomy Supplies• Commodes• Shower Chairs


Supplier InformationContract SuppliersMust•Provide competitive bid items•File claims with Medicare for payment of competitive bid items•Charge a beneficiary no more than the Medicare approved amount (accept assignment)

Non-Contract SuppliersMust•Provide the beneficiary with an Advance Beneficiary Notice (ABN)

Non-Contract Suppliers will NOT file claims with Medicare. If a beneficiary signs an ABN, the beneficiary will be responsible for the entire payment. If the ABN is not signed, the beneficiary is not responsible.


Who is a Contract Supplier?

• Check the DMEPOS Supplier Locator tool which offers a search by zip code.

www.medicare.gov/supplier• Call 1-800-MEDICARE (1-800-633-4227) TTY users (1-877-486-2048)


What does a beneficiary pay?

After a beneficiary pays the annual Part B deductible of $147:•Medicare pays 80% of Medicare approved amount •Beneficiary pays remaining 20% coinsurance

Contract Suppliers cannot bill more than these amounts! Any cases of overpayment or fraud should be reported to:•1-800-MEDICARE (1-800-633-4227)•Fraud Hotline of the HHS Office of Inspector General (1-800-447-8477)•SMP, Senior Medicare Patrol (1-800-892-0890)


Renting competitive bid equipment

If the current supplier becomes a Contract Supplier no action is required.

If the current supplier does NOT become a Contract Supplier:• Can choose to be a “grandfathered supplier” and is required to:

• Notify the beneficiary • Continue to provide coverage until the rental agreement ends• Coordinate with a Contract Supplier to ensure the beneficiary gets new

equipment without any lapse in coverage


Renting competitive bid equipment (continued)

• Can choose NOT to be a “grandfathered supplier” and is required to:• Take the equipment back after providing proper notification:

• 30 day written notice• Follow up contact 10 days and 2 days prior to picking item

• Coordinate the delivery of new equipment with a Contract Supplier to ensure no lapse in coverage

The beneficiary has the right to continue using a “grandfathered supplier” until the rental agreement ends OR can switch to a Contract Supplier .


Part 2

National Mail Order Program for Diabetic Testing Supplies


National Mail Order Program for Diabetic Testing Supplies

• New program effective July 1, 2013. A beneficiary who wishes to have diabetic supplies delivered to the home will need to use a Medicare National Mail-Order Contract Supplier.

• Local stores (pharmacies or storefront suppliers) that accept assignment will also provide diabetic testing supplies at the same low price, but cannot deliver them to a beneficiary’s home.

• A beneficiary enrolled in a Medicare Advantage Plan will continue to use the plan’s suppliers.

Example: A box of 100 Lancets

Current fee schedule: $11.72July 1st Medicare approved amount: $1.65

As of July 1st , If a beneficiary uses a local supplier or a retail pharmacy that accepts assignment:Medicare will pay 80% of the Medicare approved amount ($1.32) Beneficiary would be responsible for the 20% coinsurance ($0.33)


Diabetic Testing Supplies

• Blood sugar test strips• Lancet devices and lancets• Replacement Batteries for Glucose Monitors

(NOT Glucose Monitors)• Glucose control solutions for checking

accuracy of testing equipment and test strips

Items NOT affected:All diabetic supplies covered by Medicare Part D, i.e. syringes, needles, and inhaled insulin devices.


How it worksNational Mail-Order Contract Suppliers & Local Stores (pharmacies or storefront suppliers) that accept assignmentCannot charge more than the Medicare approved amount for diabetic supplies

Local Stores (pharmacies or storefront suppliers) that are non-participating suppliers (do NOT accept assignment)Can provide diabetic supplies to a beneficiary, but can charge more than the Medicare approved amount for an item. The claim is still sent to Medicare; however, Medicare will only pay 80% of the Medicare approved amount. The beneficiary would be responsible for the 20% coinsurance and any costs above the Medicare approved amount.

Example:Judy has only Original Medicare. On July 1st she purchases a box of 50 diabetic test strips from Paymore Pharmacy. Paymore is a non-participating provider so does not accept Medicare assignment and charges $40. Medicare paid 80% of Medicare approved amount $8.33 ($10.41 x .80) and Judy paid $31.67. Had Judy gone to a pharmacy that accepted Medicare assignment, she would have paid only $2.08 ($10.41 x .20) for her test strips.


To find a low cost Supplier

• Check the DMEPOS Supplier Locator tool which offers a search by zip code.

www.medicare.gov/supplier• Call 1-800-MEDICARE (1-800-633-4227) TTY users (1-877-486-2048)


Points to Remember and Next Steps

• For additional information on both programs consult www.medicare.gov/supplier, http://www.dmecompetitivebid.com or 1-800-MEDICARE.

• A beneficiary may need to change suppliers for Medicare coverage of DMEPOS competitive bid items and diabetic supplies.

• Medicare Advantage Plans are not affected. If a member has questions, contact the plan directly.

A beneficiary should:• See if the beneficiary's zip code is in a CBA• Check if the needed item is part of the competitive bidding program in the area• For competitive bid items, find the Contract Suppliers that can provide the needed

item in the CBA• For diabetic supplies, find the National Mail-Order Contract Suppliers and the local

stores (pharmacies or storefront suppliers) that accept assignment.

Overview for SHINE Counselors

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