Medicare info

[darthlucy]

I was looking for something on the Medicare web site today, and came across some information that may be useful to those of you who have their cpap through Medicare. This is taken from the Federal Register, Vol. 71, No. 18 (January 27, 2006) and references 42 CFR Part 414. (CR = capped rental).

Key points:
- Your DME must give you the option of purchasing your capped rental xpap.
- Your DME must maintain and replace at no charge or repair Medicare-covered items it has rented to beneficiaries
- Your DME can bill Medicare twice a year for service and maintenance of rented equipment whether or not such equipment is serviced, so USE THAT SERVICE!
- Medicare will pay for maintenace, repair, or replacement of patient-owned equipment.


"Payment for an item in the CR category is made on a monthly rental basis.
During the 10th rental month, the supplier is required to offer the
beneficiary the option to take over ownership of the item. If the beneficiary
chooses this option, Medicare rental payments end after the 13th month of
use and the title for the equipment transfers from the supplier to the
beneficiary. After the title for the equipment has transferred to the
beneficiary, Medicare will make payments for any necessary
maintenance and servicing of the patient-owned equipment. If the
beneficiary chooses to continue renting the equipment, Medicare rental
payments end after the 15th month of use, the supplier continues to own the equipment, and the supplier must continue to supply the item to the
beneficiary until the medical necessity ends or Medicare coverage ceases.
Beginning 6 months after the 15th month of use, the supplier may bill and
receive a semiannual maintenance and servicing payment in an amount not to exceed 10 percent of the purchase price for the equipment as determined in accordance with the statute and § 414.229(c). These maintenance and
servicing payments are made regardless of whether maintenance and servicing were actually performed on the equipment during the 6-month period. Total Medicare payments made through the 13th and 15th months of rental equal 105 and 120 percent, respectively, of the statutory purchase price of the equipment. Suppliers of DME must meet the standards specified in regulations at § 424.57. These standards specify that the supplier ‘‘must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicare-covered items it has rented to beneficiaries.’’ This requirement applies to items in both the
FSS and CR payment categories. Therefore, for rental items in either
category, the supplier is responsible for ensuring that the equipment is in good working order. In the case of an item for which the beneficiary has selected the purchase option, the patient arranges for the servicing and repair of the patient-owned equipment. Medicare payments
are made as needed for maintenance and servicing of patient-owned
equipment in the CR category."

[Slinky]

Oh gawd!! Tell me I read this wrong. PLEASE!!! My stinkin' CPAP DME provider can bill and receive from Medicare payments for servicing my CPAP even after the capped rental and I own the CPAP??? I'm STUCK going to THAT DME provider for service for it?

I don't want that sheister making ONE PENNY off the rental/sale of my CPAP once I've completed the capped rental!!!!! IF that IS the case, I'm gonna bounce my CPAP off the Z bridge unto the xway below every 6 months so they've GOT to give me a new one!!!! Make them EARN every penny they milk from Medicare.

Nah! I HAVE to have misunderstood this. Its late, I'm tired, I can't read, my comprehension is shot.

[darthlucy]

I think you might be slightly misreading, Slinky. The way I read this, if one were to continue renting the unit, then the DME could charge Medicare for service/maintenance even if none was done. Yes, that part stinks that they can bill for services not rendered, but the good news I see here is that renters can insist that their DME service/repair/replace a machine if it's a rental, since the DME (a) is required to do this per Medicare, and (b) they are getting paid to do it. "The supplier is responsible for ensuring that the equipment is in good working order."

At the very end of this text, it says that if the patient owns the equipment, "the patient arranges for the servicing and repair of the patient-owed equipment. Medicare payments are made as needed for maintenance and servicing of patient-owned equipment." It does not say that you have to go to the same DME from whom you got the equipment. Just that Medicare will pay for the services needed.

Hope this helps.

[Slinky]

Whew!! Thank you!! I'm not feeling well tonight and I've got some pain meds in me.

I've been counting the days until this sheister DME quits making a penny off of me or my Medicare benefits!

I've had my CPAP since 09 Oct 06. And haven't heard a word from the sheisters since ending the 2 week loaner autoPAP in Jan 07 (which has been fine w/me except, heaven forbid! they received any money for maintenance of my CPAP that they haven't done or earned!).

During the 10th rental month, the supplier is required to offer the
beneficiary the option to take over ownership of the item.

August is almost over, August is my CPAP's 10th month, I can't wait to get my letter!!! 09 Nov 07 this Elite should be MINE and I should be totally FREE of this sheister DME!

[Slinky]

Calling Medicare Claims and Billing is almost as much fun and as time consuming as searching their many websites for this information!!!! I just spent a good 45 minutes to an hour "on hold" before I FINALLy was patched thru to a most pleasant Sue Kelly who found an answer to my question:

I started CPAP therapy on 09 Oct 2006. WHEN does the capped rental end and "I" OWN the CPAP?

1] There is NO MORE continuous rental option, there is ONLY the capped rental option.
2] The period of the capped rental is 13 months.
3] There is an actual title to the CPAP that is to be given to you.
4] The DME supplier can NOT routinely receive payment for servicing the CPAP. They can only receive payment for servicing a CPAP if the service is necessary and requested by the patient.
5] This change went into effect 01 Jan 2006.

I was looking for something on the Medicare web site today, and came across some information that may be useful to those of you who have their cpap through Medicare. This is taken from the Federal Register, Vol. 71, No. 18 (January 27, 2006) and references 42 CFR Part 414. (CR = capped rental). ...

... "Payment for an item in the CR category is made on a monthly rental basis. During the 10th rental month, the supplier is required to offer the
beneficiary the option to take over ownership of the item. If the beneficiary
chooses this option, Medicare rental payments end after the 13th month of
use and the title for the equipment transfers from the supplier to the
beneficiary. After the title for the equipment has transferred to the
beneficiary, Medicare will make payments for any necessary
maintenance and servicing of the patient-owned equipment. If the
beneficiary chooses to continue renting the equipment, ...

... Beginning 6 months after the 15th month of use, the supplier may bill and receive a semiannual maintenance and servicing payment in an amount not to exceed 10 percent of the purchase price for the equipment as determined in accordance with the statute and § 414.229(c). These maintenance and servicing payments are made regardless of whether maintenance and servicing were actually performed on the equipment during the 6-month period. Total Medicare payments made through the 13th and 15th months of rental equal 105 and 120 percent, respectively, of the statutory purchase price of the equipment. ...

... In the case of an item for which the beneficiary has selected the purchase option, the patient arranges for the servicing and repair of the patient-owned equipment. Medicare payments are made as needed for maintenance and servicing of patient-owned equipment in the CR category."

I had called my sheister DME's dumb as a rock, not always truthful, RT to ask about when I would receive the letter offering the option of outright purchase or continuing rental of my CPAP. She said I wouldn't receive one, that it was now just an automatic 15 month capped rental. I don't care about any letter BUT I do want to be shed of this DME ASAP and I've had my heart set on and been counting the days to that 13th month and taking title to my Resmed buddy. That's what spurred my call to Medicare.

Medicare says on 10 Oct 2007 my Resmed S8 Elite is MINE and MINE ALONE courtesy of Medicare. And Medicare won't be paying one more penny's rental for it regardless if "dumb as a rock" tries billing for it another 2 months or not. Ain't a gonna happen. I just hope Medicare's Sue Kelly is as smart about the regulations as she is pleasant!!!

[Slinky]

By the way, DarthLucy, I did ask Ms Kelly if she would give me the page, article, identifying number, whatever so that I could point my DME supplier directly to the "citation" and she couldn't give that to me. She said there was no identifier that she could find. That shook my faith a bit.

Besides as I was being advised of all this visions of driving up to my DME's and slamming down the "citation" under their nose as I demanded title to my CPAP on 10 Oct 07 were flowing thru my head! *sigh*

It sounded as she searched that "DME" and "capped rental" were the keywords.

[darthlucy]

Wow, sorry you're getting such a run around! I had hoped this was helpful info, but apparently it just confused matters. Sorry about that! It seems kind of odd, though, that what I posted was dated January 2006 and the Medicare lady said that the policy she cited was effective January 2006. Grrrrr.

[echo]

The kind lady at Medicare was right, because your equipment was rented on or after January 1, 2006........ and your DME is wrong (she is citing the rules for equipment rented out prior to Jan 1 2006).

There are also changes to the way that the DME can bill Medicare for services after the 13th month (reasonable and necessary only), for equipment rented after Jan 1 2006.

Read on.....

From what I can determine, section 414.229 was changed in November 2006 (but retroactively effecitve to January 1, 2006) in order to align with the Deficit Reduction Act (DRA) of 2005 enacted by Congress on February 8, 2006, (Pub. L. 109-171)

5101 of the DRA refers to the DMEs and Capped rental equipment.

The following document discusses the changes that were made to section 414.229 and others, based on the DRA.

http://a257.g.akamaitech.net/7/257/2422 ... 6-9068.htm
.. search for
"D. Changes in Payment for Oxygen and Oxygen Equipment and Other Durable
Medical Equipment (Capped Rental Items)"
"G. Payment for Oxygen, Oxygen Equipment and Capped Rental DME Items"
and "J. Payment for Maintenance and Servicing of Oxygen and Oxygen Equipment
and Capped Rental Items"

I now come to understand that the 15 month / 13 month discussion goes to whether the eqipment was rented before or after January 1, 2006!

- Equipment rented Before Jan 1 2006, capped at 15 and 13 months:

In accordance with the rules set forth in section 1834(a)(7) of the
Act and Sec. 414.229 of our regulations, before the enactment of the
DRA, suppliers of capped rental items (that is, other DME not described
in paragraphs (2) through (6) of section 1834(a) of the Act) were paid
on a rental or purchase option basis. Payment for most items in the
capped rental category was made on a monthly rental basis, with rental
payments being capped at 15 months or 13 months, depending on whether
the beneficiary chose to continue renting the item or to take over
ownership of the item through the ``purchase option.''

- On or after Jan 1 2006, Ownership automatically after 13 months:

Effective for items for which the first rental month occurs on or
after January 1, 2006, section 5101(a) of the DRA of 2005 amended
section 1834(a)(7) of the Act, limiting to 13 months the total number
of continuous months for which Medicare will pay for DME in this
category. After a 13-month period of continuous use during which rental
payments are made, the statute requires that the supplier transfer
title to the equipment to the beneficiary. Beneficiaries may still
elect to obtain power-driven wheelchairs on a lump-sum purchase
agreement basis. In all cases, payment for reasonable and necessary
maintenance and servicing of beneficiary-owned equipment will be made
for parts and labor not covered by the supplier's or manufacturer's
warranty.

.... and if I go back an re-read section 414.229 , it does actually state that :
(2) For items other than power-driven wheelchairs furnished on or after January 1, 2006, payment is made in accordance with the rules set forth in paragraph (f) of this section.

- and paragraph (f) only talks about automatically transfer of title on the 13th month:
(2) The supplier must transfer title to the item to the beneficiary on the first day that begins after the 13th continuous month in which payments are made under paragraph (f)(1) of this section.

and some more gobblydygook about how they cannot bill medicare twice a year, only for reasonable and necessary charges...

So in conclusion, i guess you don't need to do anything, just sit back, relax, and wait for November 1 to roll around..... (and not worry that the DME is screwing Medicare either!!!)

Citation for article 414.229:
http://ecfr.gpoaccess.gov/cgi/t/text/te ... .1.1.4.1.9

------------------------------------------

There was also some clarification or further ammendments that you can get replacement equipment w/o re-renting if it's lost/stolen/damaged and out of warranty).

AND you can get a new item (free of charge to you and Medicare) if the total accumulated costs of repairing the item exceed 60% of the replacement cost. Interesting to know!! (so that means if they repaired it 3 times over its lifetime and that totals to more than 60% of the cost of a new machine, then they have to replace if free of charge) - even if you already own it!! (Well, it depends on if it's still within the 'reasonable lifetime' of the equipment)

[Slinky]

Thank you, Echo. I called my 02 DME supplier's insurance billing office and ask them if they could clarify and THEY knew Medicare had changed to the 13 month capped rental for those getting their equipment after 01 Jan 06.

She said there is no title per se for these xPAPs but that they do send a lettter to their patients notifying them that the xPAP is now theirs free and clear when the 13 month capped rental is up.

[echo]

Cool Glad you found SOMEONE who knew what they were talking about!

[Kattitude]

Hope it's ok to ask this on this thread... I've been trying to encourage both of my parents to get a sleep study. My mom's Dr. diagnosed her with fibromyalgia and gave her a hand full of perscriptions. She told him she wanted a sleep study but he said he wanted her to try the perscriptions first. She handed them back to him and told her she would not take them. Does someone with medicare have to have a primary care Dr.'s referral to get a sleep study or can they go direct to a sleep Dr.? Thanks in advance for any info!

"Kattitude"

[Slinky]

Medicare does not require a referral, but the individual sleep doctor or sleep lab may do so.

[Ody]

My Oncologist had a blood oxygen test done first. He said a blood oxygen level of 89% or lower was required in order to get Medicare to pay for a sleep study.

[stan106]

Hope it's ok to ask this on this thread... I've been trying to encourage both of my parents to get a sleep study. My mom's Dr. diagnosed her with fibromyalgia and gave her a hand full of perscriptions. She told him she wanted a sleep study but he said he wanted her to try the perscriptions first. She handed them back to him and told her she would not take them. Does someone with medicare have to have a primary care Dr.'s referral to get a sleep study or can they go direct to a sleep Dr.? Thanks in advance for any info!

"Kattitude"

Hi, i think you need some kind of referral first before going to a sleep doctor to let the sleep doctor know that you have been diagnosed with such a syndrome. Hope this helps.

[Slinky]

My Oncologist had a blood oxygen test done first. He said a blood oxygen level of 89% or lower was required in order to get Medicare to pay for a sleep study.

That is NOT true.