Beneficiaries Entering Medicare - JA DME

When a beneficiary becomes eligible for Medicare Fee-for-Service (FFS), several scenarios can impact Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) that were previously covered by another payer. Medicare does not automatically continue coverage for any item obtained from another payer when a beneficiary transitions to Medicare FFS coverage. Here are the main scenarios to consider:

Renting Item Currently, Paid Previously by Prior Payer

If the beneficiary was renting a DMEPOS item under their previous insurance, that item may be eligible for payment with FFS as a new initial rental, when certain requirements are met, or the beneficiary may choose to obtain a different piece of equipment to begin a new rental period with FFS.

1. Requirements For Current Rental Item to Be Eligible as a New Initial Rental
   1. For Medicare FFS to provide payment, the beneficiary must meet all Medicare coverage, coding, and documentation requirements for the DMEPOS items in effect on the date of service (DOS) of the initial Medicare claim. Refer to the applicable Local Coverage Determination (LCD) and Policy Article for the item. This information must be available upon request
   2. A proof of delivery (POD) is required for all items, even those in the beneficiary's possession provided by another insurer prior to Medicare eligibility.
      1. To meet POD requirements for beneficiaries recently eligible for Medicare FFS, with items provided by another insurer prior to FFS eligibility, the supplier record must document:
         1. A statement, signed and dated by the beneficiary (or beneficiary's designee), that the supplier has examined the item (date of DME item examination = date of service), meets the POD requirements; and
         2. A supplier attestation that the item meets Medicare requirements, including reasonable useful lifetime (RUL) requirements for item
   3. For the purposes of reasonable useful lifetime and calculation of continuous use, the first day of the first rental month in which Medicare FFS payments are made for the item (i.e., DOS) serves as the start date of the RUL and period of continuous use. In these cases, the POD documentation serves as evidence that the beneficiary is already in possession of the item.

   Refer to Capped Rental Item or other DMEPOS Payment Category Item

2. Requirements When Beneficiary Chooses to Obtain a New Rental Item to Begin a New Rental Period with Medicare FFS.
   1. The beneficiary must meet all Medicare coverage, coding, and documentation requirements for the DMEPOS items provided for the date of service (DOS) of the initial Medicare claim. Refer to the applicable Local Coverage Determination (LCD) and Policy Article for the item, including the Standard Documentation Requirements Policy Article. This information must be available upon request.
   2. Supplier will bill initial rental claim with all billing and documentation requirements met.

   Refer to Capped Rental Item or other DMEPOS Payment Category Item

3. Previous Payer Purchased Item That Requires Supplies or Accessories
   1. Suppliers must ensure that the beneficiary-owned equipment information is on file with Medicare Fee-for-Service (FFS) to avoid denials.
      1. The information required is:
         1. Beneficiary owned item HCPCS; approximate purchased month and year
            1. Good example: Bene-owned E0601 pur Jan 2023 (approximate)

   Refer to Beneficiary-Owned Equipment When Billing for Accessories and Supplies

4. Previous Payer Purchased Item That Requires Repairs
   1. Per the Standard Documentation Requirements Policy Article A55426 - Repairs to items that a beneficiary owns are covered when necessary to make the items serviceable.

   Refer to Repairs