In most cases, if you have Original Medicare, Medicare will only help pay for these items and supplies if they're provided by contract suppliers.
However, there are a few exceptions, like if you use a "grandfathered" supplier or if you get items and supplies from doctors or hospitals.
If your current supplier doesn’t get a new contract, you may still be able to stay with that supplier if they decide to participate in the program as a “grandfathered” supplier. Suppliers that don’t get Medicare contracts can decide to become "grandfathered" suppliers. This means a supplier may continue to rent equipment to you if you were renting the equipment when the program started. This rule applies to oxygen, oxygen equipment, and certain rented equipment. You may continue using the “grandfathered” supplier until the rental period for your equipment ends.
If you start renting additional equipment from a “grandfathered” supplier after the program starts, Medicare won’t pay for the new equipment.
If you’re renting equipment that’s eligible for grandfathering, your supplier will let you know in writing 30 business days before the program begins whether it will or won’t become a “grandfathered” supplier.
What happens if my supplier decides not to become a grandfathered supplier?
You need to decide whether to continue to rent from your current supplier and pay all the costs, or switch to a Medicare contract supplier.
A supplier that doesn’t have a new contract and decides not to become a grandfathered supplier is required to notify you and pick up the item from your home after the program starts. Your supplier must notify you these 3 ways before it can pick up the item:
- The supplier must send you a letter at least 30 business days before the program starts telling you that it will no longer provide rental items to you after a certain date. This letter will tell you the date that a Medicare contract supplier must start to provide you with the rented item.
- The supplier must call you 10 days before picking up the item to make arrangements for pick up at an agreed upon time.
- The supplier must call you again 2 business days before picking up the item.
A supplier that isn’t grandfathered can't pick up a medically necessary item before the end of the last rental month for which the supplier is eligible to get a rental payment, even if the end of the last rental month occurs on or after January 1, 2014.
If you change to a Medicare contract supplier, your old supplier should work with the contract supplier so there isn’t a break in service. Keep the pickup slip or other documentation from the supplier that shows you no longer have the item.
Equipment & supplies from doctors or hospitals
Medicare will help pay for a walker, folding manual wheelchair, or external infusion pump that your doctor or treating health care practitioner (including a physician assistant, clinical nurse specialist, or nurse practitioner) gives you, even if he or she isn't a Medicare contract supplier, as long as the walker is supplied in the office during a visit for medical care.
If you're admitted to a hospital and need a walker, folding manual wheelchair, or external infusion pump, Medicare will also help pay for it if the hospital gives it to you while you're admitted or on the day you're discharged from the hospital even if the hospital isn't a contract supplier.
If you need a particular brand or mode of delivery of an item or service in order to avoid an adverse medical outcome, your doctor must prescribe the specific brand or mode of delivery in writing. Your doctor must also document in your medical record why this specific brand or mode of delivery is needed in order to avoid an adverse medical outcome. In these situations, a Medicare contract supplier is required to do one of these:
- Give you the exact brand or mode of delivery of the item or service your doctor authorizes for you.
- Help you find another contract supplier that offers that brand or mode of delivery.
- Work with your doctor to find an appropriate alternative brand or mode of delivery and get a revised written prescription.
If you own
If you own medical equipment that's included in the program, you can use any Medicare-approved supplier (even a non-contract supplier) for repairs or replacement parts needed to repair your equipment. Before your equipment is serviced, make sure the supplier is enrolled in Medicare so Medicare can help pay. A “Medicare-approved” supplier means any supplier that can submit claims to Medicare.
Medicare doesn’t pay for repairs that are covered under a manufacturer’s or supplier’s warranty. If you need warranty repairs, follow the warranty rules.
If you rent
If you’re renting medical equipment, repair costs are included in the rental payments. The supplier renting you the equipment must fix it at no additional charge to you.
Accessories for equipment like CPAP tubing and masks are replacement items. Medicare will only pay if a contract supplier provides these items.
Suppliers that don’t get Medicare contracts can decide to become "grandfathered" suppliers. This means a supplier may continue to rent equipment to you if you were renting the equipment when the program started. A “grandfathered” supplier can provide replacement accessories for use with the equipment for as long as you rent the equipment.
Blood glucose test strips and lancets are also replacement items and in all cases must be provided by a mail-order contract supplier if you get them delivered to your home and don't pick them up in person at a local store.
If you have Medicare and Medicaid and live in a competitive bidding area, you'll have to get supplies and equipment from a Medicare contract supplier. Medicaid will pay the cost sharing amounts (deductible and coinsurance) for those services.
If you’re a Qualified Medicare Beneficiary (QMB) Plus, Specified Low-Income Medicare Beneficiary (SLMB) Program Plus, or other Full Benefit Dual Eligible (FBDE) beneficiary, you'll still be able to get supplies and equipment that Medicare doesn’t cover, but your state Medicaid program does, from any Medicaid-participating provider.
You may need to use specific suppliers for some types of diabetic testing supplies. Find a list of suppliers for your area.
All Medicare contract suppliers have to meet special Competitive Bidding Program requirements, federal quality standards, and state licensure requirements. They also have to be in good standing with Medicare, and be accredited by an Independent Accreditation Organization.
Medicare contract suppliers must:
- Accept assignment for all contract items. This means they can’t charge you more than the Medicare-approved amount.
- Offer the same brands of equipment to Medicare and non-Medicare customers.
- Make competitively bid items and supplies available throughout the entire competitive bidding area.
- Only provide equipment that meets all applicable Food and Drug Administration regulations, effectiveness, and safety standards.
- Maintain equipment according to manufacturer’s guidelines.
- Provide all equipment using educated professionals who meet applicable licensure requirements.
- Make available a competent professional to provide or arrange for necessary repairs or replacement of existing equipment.
- Provide safe operating equipment
- Provide equipment that's consistent with the doctor’s prescription.
- Provide appropriate instructions and training on the safe use and maintenance of the equipment.
- Be aware of changes in your medical needs and work together with your doctor.
If you use respiratory equipment:
- A professional will come to your home, if necessary, to provide additional equipment or to troubleshoot issues with existing equipment.
- Your contract supplier will provide access to respiratory services 24 hours a day, 7 days a week.
Your Medicare contract supplier may work with other suppliers (subcontractors) to provide you with certain services, like delivering or installing equipment. Your Medicare contract supplier (not the subcontractor) should work with you directly when making arrangements for services. Subcontractors shouldn’t market to you directly.
If you have questions about the subcontractor, talk to your Medicare contract supplier.
The same marketing rules and regulations for Original Medicare apply to the Competitive Bidding Program. For example, suppliers can’t misuse symbols, emblems, or names in reference to Social Security or Medicare.
In addition, Medicare has specific standards for marketing to people with Medicare. Suppliers can’t make uninvited contact with you by phone about supplying a Medicare-covered item unless one of these situations applies:
- You've given written permission to the supplier to contact you about a Medicare-covered item that you need to rent or buy.
- The supplier is coordinating delivery of the item.
- The supplier is contacting you about providing a Medicare-covered item other than a covered item you already have, and the supplier has provided at least one covered item to you during the previous 15-month period.