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
December 2013 3Competitive Bidding Program
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
December 2013 4Competitive Bidding Program
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
December 2013 6Competitive Bidding Program
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
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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
December 2013 9Competitive Bidding Program
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
December 2013 Competitive Bidding Program 11
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
December 2013 12Competitive Bidding Program
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
December 2013 13Competitive Bidding Program
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
December 2013 14Competitive Bidding Program
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
December 2013 15Competitive Bidding Program
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.
December 2013 Competitive Bidding Program 16
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
December 2013 18Competitive Bidding Program
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
December 2013 Competitive Bidding Program 19
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.
December 2013 20Competitive Bidding Program
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
December 2013 21Competitive Bidding Program
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
December 2013 22Competitive Bidding Program
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
Stay InformedStay Informed
Visit www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSCompetitiveBid
December 2013 24Competitive Bidding Program