The Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program What You Need to Know

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

Competitive Bidding Program

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

Competitive Bidding Program

What You Need to Know

Competitive Bidding– A Better Way to Pay Competitive Bidding– A Better Way to Pay

Program started in January 2011 for certain DMEPOS in nine areas of the country (Round 1)

Program helps people with Medicare− Save money− Get quality equipment, supplies and services

Program strengthens protections against Medicare fraud

December 2013 2Competitive Bidding Program

How the Program WorksHow the Program Works

DMEPOS suppliers submit bids– Suppliers must submit a bid to be considered for

contract award Payment amounts based on bids Contracts are awarded to winning suppliers to

sell/rent DMEPOS Contract suppliers must

– Meet eligibility, quality, and financial standards– Be accredited by an independent organization


How the Program WorksHow the Program Works

In most cases, only contract suppliers can– 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


Round 1 Rebid Round 1 Rebid

Round 1 Rebid resulted in savings of 35% below fee schedule

Savings for first two years over $400 million

December 20135Competitive Bidding Program

Round 1 RecompeteRound 1 Recompete

Current competitive bidding program supplier contracts in Round 1 areas end December 31, 2013 (national mail-order program remains in effect)

Round 1 Recompete contracts go into effect on January 1, 2014 in same nine areas

Round 1 Recompete projected to result in savings of 37% compared to fee schedule


Round 1 Rebid Products 1/1/11-12/31/13

Round 1 Rebid Products 1/1/11-12/31/13

Products Included in Round 1 Rebid

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) (in Miami area only)

Standard power wheelchairs, scooters, and related accessories

Complex rehabilitative power wheelchairs and related accessories (Group 2)

Note: Round 1 mail-order diabetic supply contracts ended on December, 31 2012

December 2013 Competitive Bidding Program 5

*

Round 1 Recompete Products 1/1/14-12/31/16

Round 1 Recompete Products 1/1/14-12/31/16

Products Included in Round 1 RecompeteRespiratory Equipment and Related Supplies and Accessoriesincludes oxygen, oxygen equipment and supplies; continuous positive airway pressure (CPAP) devices and respiratory assist devices (RADs) and related supplies and accessories; and standard nebulizers

Standard Mobility Equipment and Related Accessoriesincludes walkers, standard power and manual wheelchairs, scooters, and related accessoriesGeneral Home Equipmentincludes hospital beds and related accessories, group 1 and 2 support surfaces, transcutaneous electrical nerve stimulation (TENS) devices, commode chairs, patient lifts, and seat liftsEnteral Nutrients, Equipment and Supplies

Negative Pressure Wound Therapy Pumps and Related Supplies and Accessories

External Infusion Pumps and Supplies


Who will be Affected? Who will be Affected?

Round 1 areas:– Charlotte-Gastonia-Rock Hill (North Carolina and South Carolina) – Cincinnati-Middletown (Ohio, Kentucky and Indiana) – Cleveland-Elyria-Mentor (Ohio) – Dallas-Fort Worth-Arlington (Texas) – Kansas City (Missouri and Kansas) – Miami-Fort Lauderdale-Pompano Beach (Florida) – Orlando-Kissimmee-Sanford (Florida) – Pittsburgh (Pennsylvania) – Riverside-San Bernardino-Ontario (California)

Medicare Advantage enrollees use suppliers designated by their plan


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– Traveling to or visiting a CBA

Doctors, treating practitioners, and hospitals can supply certain items (ex: walkers, folding manual wheelchairs and external infusion pumps) without being contract suppliers

Nursing Facility can supply directly to its own residents only if it becomes a contract supplier

December 2013 10 Competitive Bidding Program

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


http://www.medicare.gov/supplier

Stay With Current Supplier Stay With Current Supplier

Can stay with current supplier that doesn’t have a new contract if (ALL of the following):– Supplier elects to become “grandfathered” – Beneficiary permanently resides in a CBA– Renting certain equipment or oxygen when program

starts in CBA If current supplier did NOT win a new contract

AND elects NOT to become “grandfathered”– Must generally use a supplier that has a new contract


Grandfathering Grandfathering

Non-contract supplier Issues written notice saying if it is willing to continue

renting equipment Works with contract supplier to get new equipment to

beneficiary if beneficiary switches to contract supplierBeneficiary May continue getting services from grandfathered

supplier until rental period ends OR May switch to a new contract supplier


Have Other Insurance?Have Other Insurance?

Medicare may make payment to a non-contract supplier if required by primary policy

Non-contract supplier must – Be accredited– Have valid Medicare billing number– Be eligible to receive secondary payments


Non-contract SupplierNon-contract Supplier

A non-contract supplier generally may not furnish competitively bid items in a CBA

If non-contract supplier used and no exception applies, beneficiary not responsible for payment unless supplier issues Advance Beneficiary Notice (ABN)– Says Medicare will not pay– By signing ABN, beneficiary agrees to pay entire

amount


Changing Suppliers ScenarioChanging Suppliers Scenario

Obtaining DMEPOS items from a new contract supplier

Mildred’s permanent residence is in Miami, FL which is a Round 1 CBA. She is currently renting her Continuous Positive Airway Pressure (CPAP) device from ABC company, which has a Round 1 Rebid contract but not a Round 1 Recompete contract. Mildred receives a notice from ABC company informing her that they won’t be a contract supplier after December 31, 2013 and that they also won’t be a grandfathered supplier starting January 1, 2014. Mildred must transition to a Round 1 Recompete contract supplier for Medicare to help pay.


Traveling BeneficiariesTraveling Beneficiaries

To CBA: Must generally use contract supplier for that

CBA If non-contract supplier used and no exception

applies, beneficiary not responsible for payment unless supplier issues Advance Beneficiary Notice (ABN)

To non-CBA: Can use any Medicare-enrolled supplierDecember 2013 17Competitive Bidding Program

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 and obtain a revised prescription OR

– Help locate another contract supplier that can furnish the specific brand or form as prescribed


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


Deductible and CoinsuranceDeductible and Coinsurance

After beneficiaries pay their annual Part B deductible– Medicare pays 80% of the Medicare-approved amount for

equipment, supplies and services– Beneficiaries are responsible for a 20% coinsurance

Contract suppliers cannot bill for more than these amounts

For suspected overpayment or fraud call – 1-800-MEDICARE (1-800-633-4227)

• TTY users call 1-877-486-2048

– Fraud Hotline of the HHS Office of Inspector General at 1-800-447-8477.


Points to RememberPoints to Remember

Program does NOT affect which physicians or hospitals beneficiaries use

Generally must use contract supplier for Medicare to help pay

May be able to stay with current supplier if renting from supplier who has new contract or elects to become “grandfathered”

If in Medicare Advantage plan, beneficiary should check with the plan


What Beneficiaries Need To DoWhat Beneficiaries Need To Do

Beneficiaries who live in or will visit a CBA and need medical items included in the program, should

– Find out if the ZIP Code where they live or visit is included in a CBA

– Find out if the items they need are included in the Medicare Competitive Bidding Program in that area

– Find out which suppliers are contract suppliers for their items for the Medicare Competitive Bidding Program

Visit www.medicare.gov/supplier or Call 1-800-MEDICARE (1-800-633-4227) to find this

information– TTY users call 1-877-486-2048


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)December 2013 23Competitive Bidding Program

http://www.medicare.gov/suppliers

http://www.medicare.gov/

Stay InformedStay Informed

Visit www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSCompetitiveBid


http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSCompetitiveBid

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSCompetitiveBid

Documents

The Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program What You Need to Know