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New Medicare Durable Medical Equipment Procedures: What Do Benefits Counselors Need to Know?

In This Article:

• Introduction
• The First 10 Cities
• The Categories of Equipment and Supplies
• Affected Beneficiaries
• The New Way of Getting the Listed Medical Equipment and Supplies
• The Transition
• Repairs and Replacements
• Fail Safe if Your Clients Encounter Difficulties
• Resources

Introduction
Medicare is changing the way beneficiaries in some parts of the country get certain kinds of durable medical equipment, such as wheelchairs and oxygen, as well as other commonly used equipment and supplies. Medicare will pay for these types of medical equipment and supplies in a different way as well.  These changes go into effect in ten major urban areas, or metropolitan statistical areas (MSAs), on July 1, 2008.  Next year, 70 more regions will be phased in, with the rest of the country added later. 

In the first ten cities, beneficiaries who need certain commonly used medical equipment or supplies will be limited to specific contract suppliers to obtain certain types of Medicare-covered equipment and supplies. These suppliers have agreed to accept a low, competitively bid price from Medicare for providing certain medical equipment and supplies to Medicare customers.  They have also agreed to adhere to CMS-prescribed quality measures.

As a result of this change, some beneficiaries in these areas may need to switch to different suppliers in order to have Medicare continue to cover the equipment and supplies they need. When beneficiaries must switch to new suppliers, new orders will need to be written for needed equipment.  Current suppliers who are no longer able to provide equipment and supplies to Medicare beneficiaries must pick up their equipment and new suppliers must deliver equipment and supplies to beneficiaries.

This new initiative is commonly called the DMEPOS Competitive Bidding program. DMEPOS is an acronym that stands for “durable medical equipment, prosthetics, Orthotics and supplies”.  The new system is called “competitive bidding” because the suppliers with whom Medicare contracts in the selected MSAs have successfully bid to provide the designated equipment and supplies at a low cost.

If you have clients who live in or travel to the affected areas, you’ll need to know about these changes so you can answer your clients’ questions and assist them through the transition.

The First 10 Cities
The first 10 MSAs in which the new medical equipment and supplies initiative will launched are:

Charlotte – Gastonia – Concord, in North and South Carolina

Cincinnati - Middletown, in Ohio, Kentucky and Indiana

Cleveland – Elyria – Mentor, in Ohio

Dallas – Fort Worth – Arlington, in Texas

Kansas City, in Missouri and Kansas

Miami – Fort Lauderdale – Miami Beach, in Florida

Orlando – Kissimmee, in Florida

Pittsburgh, Pennsylvania

Riverside – San Bernardino – Ontario, in California

San Juan – Caguas – Guaynabo, in Puerto Rico

Within these urban areas, the initiative will be launched in specified zip codes that are within these cities’ limits, as well as in surrounding areas.  These areas were chosen to launch the initiative because of the high use of expensive medical equipment and supplies by Medicare beneficiaries within these areas.

This new medical equipment and supplies policy will be introduced in 2009 in 70 additional MSAs.

The Categories of Equipment and Supplies

The changes are not applicable to all medical equipment and supplies. Only certain types of medical equipment and supplies, called product categories by CMS, are included.  The included medical equipment and supplies are:

Oxygen equipment and supplies

            Standard power wheelchairs, scooters, and supplies

            Complex rehabilitative power wheelchairs and related accessories

Mail order diabetic supplies, but not diabetic supplies purchased at regular storefront pharmacies

Enteral nutrients, equipment and supplies, for people who need feeding through

Tubes

Continuous positive airway pressure (CPAP machines), respiratory assist devices and related supplies and accessories

Hospital beds and related accessories

Negative pressure wound therapy (NPWT) pumps and related supplies and accessories

Walkers and related accessories

Support surfaces (Group 2 mattress and overlays) only in the Miami area

Affected Beneficiaries
With few exceptions, any Medicare beneficiary residing in or traveling to one of the first 10 MSAs who needs the specific medical supplies or equipment listed above will be affected by the changes starting on July 1st.

The DMEPOS changes do not apply to Medicare beneficiaries who own their medical equipment and do not need new parts, supplies or accessories.  When beneficiaries who live in or travel to the 10 MSAs do need replacement of their equipment, or new supplies, they will have to deal with contracted suppliers. 

Medicare Advantage enrollees with medical equipment or supply needs are likewise not affected by the changes.  They will continue to get their equipment and supplies through their Medicare Advantage plan network suppliers.  If they disenroll from Medicare Advantage they would subsequently need to obtain their medical equipment and supplies through a contracted supplier.  Some physicians and other medical practitioners supply the patients in their practice with walkers and other medical equipment and they are allowed to continue to do so. 

The New Way of Getting the Listed Medical Equipment and Supplies 
In the affected areas, medical equipment and supplies had to bid for contracts if they wanted to continue to rent and sell the listed types of medical equipment and supplies to Medicare beneficiaries after July 1st.  In general, the suppliers who won a bid to get a contract with Medicare are the only ones that are allowed to rent or sell the listed medical equipment and supplies to Medicare beneficiaries. They are called DMEPOS contract suppliers and are listed here for each of the 10 MSAs:

Charlotte – Gastonia – Concord, in North and South Carolina

Cincinnati - Middletown, in Ohio, Kentucky and Indiana

Cleveland – Elyria – Mentor, in Ohio

Dallas – Fort Worth – Arlington, in Texas

Kansas City, in Missouri and Kansas

Miami – Fort Lauderdale – Miami Beach, in Florida

Orlando – Kissimmee, in Florida

Pittsburgh, Pennsylvania

Riverside – San Bernardino – Ontario, in California

San Juan – Caguas – Guaynabo, in Puerto Rico

Contract suppliers must accept the Medicare contract rate and will be reimbursed in a single payment from Medicare. Contract suppliers must offer the same quality of equipment and supplies to their Medicare customers as to their customers who are covered by commercial and other insurance.  They must either supply equipment as specified in the written prescription for the equipment or supplies, get the prescriber to rewrite the order, or refer the Medicare consumer to a contract supplier who can provide the equipment or suppliers in accordance with the specifications in the prescription.   

Current suppliers may continue to service their current Medicare clients only if they agree to certain conditions.  These suppliers are called grandfathered suppliers. They must accept the Medicare competitive rate in a single payment, just as the contracted suppliers must, and take assignment on all claims.  They cannot discriminate among their current Medicare customers; rather they must accept all of their current Medicare customers who elect to stay with them.  Their Medicare customers, on the other hand, may choose to stay with their grandfathered suppliers or switch to a contract supplier at any time. Grandfathered suppliers are not allowed to accept any new Medicare customers within the 10 MSAs after June 30, 2008.

The Transition
By the beginning of June 2008, CMS intends to send a general notice to all Medicare beneficiaries in the first 10 MSAs to tell them about the changes.  All non-contract suppliers must also mail notices to their Medicare clients in June.  Grandfathered suppliers’ notices must advise their Medicare customers that they can remain customers or they can switch to a contract supplier. Non contract-non-grandfathered suppliers’ notices must advise their customers that if they do not switch to a contracted supplier by July 1, 2008, Medicare will not pay for the listed equipment and supplies after July 1st.  Such suppliers must give Advance Beneficiary Notices (ABNs) to any Medicare beneficiary who fails to switch to a contracted supplier. 

Non-contract, non-grandfathered suppliers must pick up their equipment and supplies in the categories listed above before July 1, 2008.  Medicare beneficiaries who have switched to a contract supplier should expect to have the contract supplier deliver their equipment and supplies by July 1st.

Repairs and Replacements
Any supplier is allowed to repair equipment or to provide a part that is needed to make a repair in the listed product categories.  If the item must be completely replaced and cannot be repaired, the replacement item must be provided by contract suppliers.

Fail Safe if Your Clients Encounter Difficulties
If problems arise, CMS has advised beneficiaries call 1-800-MEDICARE. Moreover, each of the 10 MSAs has an Ombudsman who should be able to work on beneficiary problem resolution in conjunction with the CMS Regional Offices.

DMEPOS Competitive Bidding Ombudsman Program

The ombudsmen for the DMEPOS Competitive Bidding Program assist providers and beneficiaries by providing information and education and by facilitating the resolution of complaints and concerns. The ombudsmen’s role is to ensure that the program is operating in accordance with program policies and the intent of the law. There are eight ombudsmen who are located within the initial Competitive Bidding Areas (CBA).

You may contact an ombudsman:

• For general information about the DMEPOS Competitive Bidding Program;
• To obtain assistance in locating a supplier;
• For educational programs and activities;
• To report concerns about the program, a supplier or referral agent, the quality of services or items, and/or suspected fraud or abuse;
• For assistance with the competitive bidding technical process.

Charlotte-Gastonia-Concord, NC/SC

Makisha Pressley-Callaham is the DMEPOS Competitive Bidding Program ombudsman for the Charlotte-Gastonia-Concord, North Carolina/South Carolina, competitive bidding area. She has 11 years of Medicare experience, which includes seven years as a DMERC ombudsman for the state of NC. Makisha earned a Bachelor of Arts degree from the College of Charleston and a Master of Arts degreefrom Webster University. She is currently pursuing her Doctoral degree from Nova Southeastern University.

Telephone Number:704-795-6225

E-mail Address: Makisha.P.Callaham@PalmettoGBA.com

Cincinnati-Middletown, OH/KY/IN and Cleveland-Elyria-Mentor, OH

Vinsetta Montgomery is the DMEPOS Competitive Bidding Program ombudsman for the Cincinnati-Middletown, Ohio/Kentucky/Indiana, and Cleveland-Elyria-Mentor, Ohio, competitive bidding areas. She has more than 23 years experience with Medicare, which includes managing a beneficiary call center team. Vinsetta earned her Bachelor of Science degree and a Master of Business Administration (MBA) from Franklin University in Columbus, Ohio.

Telephone Number: 614-475-4235

E-mail Address:Vinsetta.Montgomery@PalmettoGBA.com

Dallas-Fort Worth-Arlington, TX

Elena Armstrong is the DMEPOS Competitive Bidding Program ombudsman for the Dallas-Fort Worth-Arlington, Texas, competitive bidding area. She is bilingual in English and Spanish. Elena has more than 20 years of experience with Medicare, which includes six years with the beneficiary outreach program conducting workshops and training sessions for various federal agencies and senior groups.

Telephone Number: 903-868-2705

E-mail Address:Elena.Armstrong@PalmettoGBA.com

Kansas City, MO/KS

Michal (Mike) Mitko is the DMEPOS Competitive Bidding Program ombudsman for the Kansas City, Missouri/Kansas, competitive bidding area. His previous experience includes manger of the customer service department for a DMEPOS supplier, as well as working for both non-profit organizations and business corporations. Mike earned his Bachelor of Science degree from the University of Missouri and is currently enrolled in Avila College’s MBA program.

Telephone Number: 913-441-1093

E-mail Address:Michal.Mitko@PalmettoGBA.com

Miami-Fort Lauderdale-Miami Beach, FL and Orlando-Kissimmee, FL

Letisha Davis is the DMEPOS Competitive Bidding Program ombudsman for the Miami-Fort Lauderdale-Miami Beach and Orlando-Kissimmee, Florida, competitive bidding areas. Letisha’s Medicare experience includes assisting both English and Spanish-speaking beneficiaries and providing training for Customer Service Representatives. She has a Bachelor of Arts degree and is working on her Master’s degree.

Telephone Number: 954-524-9809

E-mail Address:Letisha.Davis@PalmettoGBA.com

Pittsburgh, PA

Rahshaan Martin is the DMEPOS Competitive Bidding Program ombudsman for the Pittsburgh, Pennsylvania, competitive bidding area. Rahshaan has 13 years of experience in the health insurance industry, which includes five years with the Medicare program. Her Medicare experience includes implementing provider education activities and management of a beneficiary call center team. She has a Bachelor of Science degree from Coker College.

Telephone Number: 724-742-0167

E-mail Address:Rahshaan.Martin@PalmettoGBA.com

Riverside-San Bernardino-Ontario, CA

Rugina Tate is the DMEPOS Competitive Bidding Program ombudsman for the Riverside, California, competitive bidding area. Her experience includes 13 years facilitating educational programs for both non-profit and for-profit organizations. She has a Bachelor of Arts degree from California State University, Dominguez Hills, and a Master’s degree from National University.

Telephone Number: 323-295-5201

E-mail Address:Rugina.Tate@PalmettoGBA.com

San Juan-Caguas-Guaynabo, PR

Carmen Soto-Ortiz is the DMEPOS Competitive Bidding Program ombudsman for the San Juan-Caguas-Guaynabo, Puerto Rico, competitive bidding area. Carmen has 15 years of experience in the health insurance industry, which includes four years as the Puerto Rico DMERC ombudsman. She has a Bachelor of Arts degree from Brooklyn College in New York City.

Telephone Number: 787-261-2309

E-mail Address:Carmen.Soto-Ortiz@PalmettoGBA.com

Source: http://www.dmecompetitivebid.com/palmetto/CBIC.nsf/

Resources
CMS Basic Power Point presentation

CMS DMEPOS Competitive Bidding Page

Consumer Information on the Medicare Web site

CMS DMEPOS Contractor Website (CBIC) Website

 

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