Non-contract suppliers that furnish competitively bid items in a competitive bidding area (CBA) are not eligible for Medicare Part B payment for the competitively bid items for that CBA unless one or more of the exceptions listed below applies.
Physicians and Treating Practitioners
Physicians and treating practitioners (physician assistants, nurse practitioners, and clinical nurse specialists) do not need a competitive bidding contract to receive payment for medically necessary walkers, folding manual wheelchairs, or competitively bid off-the-shelf orthotics furnished to their own patients as part of their professional services. Furthermore, a physical or occupational therapist in private practice may furnish competitively bid off-the-shelf back and knee braces without submitting a bid and being awarded a contract, provided that the items are furnished only to the therapist’s own patients as part of the physical or occupational therapy service. Payment to physicians, treating practitioners, and therapists will be made based on the single payment amount (SPA) for the item for the CBA where the beneficiary resides.
Hospitals do not need a competitive bidding contract to receive payment for medically necessary walkers, folding manual wheelchairs, or competitively bid off-the-shelf orthotics furnished to their own patients during an admission or on the date of discharge. A hospital under this exception does not include a hospital-owned Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) supplier. Instead, a hospital is defined in accordance with section 1861(e) of the Social Security Act. Payments to hospitals will be made based on the SPA for the item for the CBA where the beneficiary resides. Hospital-owned DMEPOS suppliers must submit a bid and be awarded a contract to furnish competitively bid items to Medicare beneficiaries.
Primary Insurance Suppliers
Medicare may make a secondary payment for an item furnished by a non-contract supplier that the beneficiary is required to use under his or her primary insurance policy. This policy does not supersede any Medicare secondary payer payment laws, regulations, or policies. Payment will be calculated in accordance with Medicare secondary payer requirements.
Suppliers that are not awarded a contract for furnishing oxygen and oxygen equipment or rented durable medical equipment (DME) in a CBA can decide to be grandfathered suppliers for beneficiaries to whom they are furnishing these items at the time Round 2021 is implemented. For oxygen and oxygen equipment and rented DME, payment is based on the Round 2021 SPA for the item for the CBA where the beneficiary resides.
Any beneficiary in a CBA who is receiving oxygen and oxygen equipment or rented DME from a non-contract supplier that elects to be a grandfathered supplier at the time Round 2021 is implemented may elect to continue to receive the item from the grandfathered supplier or begin receiving the item from a Round 2021 contract supplier. A grandfathered supplier cannot turn a beneficiary away if he or she elects to continue receiving the item from the grandfathered supplier. For more information please refer to the Grandfathering for Contract Suppliers fact sheet.