A non-contract supplier is a supplier that isn’t awarded a contract by the Centers for Medicare & Medicaid Services (CMS) to provide items included in the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP). 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, as provided in 42 CFR § 414.404.
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 competitively bid insulin infusion pumps and 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 orthotics 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 after ensuring that a professional service has been provided to the beneficiary on the same date of service that the competitively bid item was furnished.
Hospitals
Hospitals do not need a competitive bidding contract to receive payment for competitively bid insulin infusion pumps and 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 (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 DMEPOS CBP Contract to furnish competitively bid items to Medicare beneficiaries.
Primary Insurance Suppliers
When Medicare is not the primary payer and makes a secondary payment for an item included under a DMEPOS CBP, the secondary payment can be made to a non-contract supplier if the beneficiary is required to use the supplier 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.
Grandfathered Suppliers
Suppliers that are not awarded a DMEPOS CBP Contract for furnishing rented class II continuous glucose monitors (CGMs) or insulin infusion pumps can decide to be grandfathered suppliers for beneficiaries to whom they are furnishing these items under a rental agreement at the time DMEPOS CBP Round 2028 is implemented. Payment to these grandfathered suppliers would be based on the monthly rental payment amounts established under the DMEPOS CBP, as provided in 42 CFR § 414.408(j)(2)(iii).
As provided in 42 CFR § 414.408(j)(4), at the time DMEPOS CBP Round 2028 is implemented, any beneficiary receiving a rented class II CGM or a rented insulin infusion pump which the beneficiary does not yet own from a non-contract supplier that elects to be a grandfathered supplier may elect to continue to receive the item from the grandfathered supplier or begin receiving the item from a Round 2028 contract supplier. A grandfathered supplier cannot turn a beneficiary away if he or she elects to continue receiving the item from the grandfathered supplier.