Transitioning to Medicare Coverage for Durable Medical Equipment: What Beneficiaries Need to Know

As beneficiaries transition into Medicare Fee-for-Service (FFS) coverage, they may encounter various scenarios affecting their Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) that were previously covered by another payer. It's essential to understand that Medicare does not automatically extend coverage for items obtained prior to eligibility. This article outlines key scenarios beneficiaries should consider regarding their DMEPOS needs.

Renting an Item Previously Paid by Another Payer

When a beneficiary is renting a DMEPOS item under their previous insurance, it may be eligible for payment as a new initial rental under Medicare FFS, provided specific conditions are met.

  1. Requirements for Current Rental Item to Be Eligible as a New Initial Rental
    To qualify for Medicare coverage, the following must be satisfied:
    • Coverage and Documentation: The beneficiary must meet all Medicare's coverage, coding, and documentation requirements effective on the date of service (DOS) for the initial Medicare claim. It's important to refer to the applicable Local Coverage Determination (LCD) and Policy Article for the item.
    • Proof of Delivery (POD): A POD is mandatory for all items, even those in the beneficiary's possession that were provided by another insurer prior to Medicare eligibility. The POD must include:
      • 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
      • A supplier attestation confirming the item meets Medicare's standards, including reasonable useful lifetime (RUL) requirements.
    • Start Date for RUL and Continuous Use: The first day of the initial rental month for which Medicare FFS payments are made serves as the start date for the RUL and the period of continuous use.
  2. Choosing to Obtain a New Rental Item
    If a beneficiary opts to get a new rental item under Medicare FFS, they must fulfill the following:
    • Documentation Requirements: The beneficiary must meet all relevant Medicare coverage, coding, and documentation requirements on the DOS for the initial Medicare claim. This includes referencing the appropriate LCD and Policy Article.
    • Supplier Responsibilities: The supplier must submit the initial rental claim, ensuring that all billing and documentation requirements are satisfied.

Previous Payer Purchased Items Requiring Supplies or Accessories

For items previously purchased by another payer, suppliers must ensure that the beneficiary-owned equipment information is properly documented with Medicare FFS to avoid claim denials. The required information includes:

  • Beneficiary-Owned Item HCPCS Code: This should include the approximate month and year of purchase. For example: "Bene-owned E0601 pur Jan 2023 (approximate)."

Previous Payer Purchased Items Requiring Repairs

Repairs to items owned by beneficiaries are covered under Medicare when they are necessary to make the items serviceable. Suppliers should consult the Standard Documentation Requirements Policy Article A55426 to ensure compliance.

Last Updated Nov 06 , 2024