CMS Finalizes Rules Allowing Medicare Advantage Plans to Restrict DME Brands and Manufacturers

As part of the April 12, 2012 MA/Part D final rule, CMS is finalizing its proposal to allow MA plans to limit durable medical equipment (DME) coverage to specific "preferred" brands and manufacturers if certain conditions are met. These conditions include beneficiary access to all preferred brands, a transition period permitting enrollees to retain non-preferred DME brands for 90 days when changing plans, exceptions to plan limitations based on medical necessity, the ability to appeal denials based on brand or manufacturer, and plan disclosure to enrollees of DME limitations. CMS also acknowledges that certain categories of DME include items that are not interchangeable; the agency will determine annually which categories or subcategories of DME require full plan coverage without limitation by brand or manufacturer. In the final rule, CMS has clarified that the restrictive contracting provisions does not apply to orthotics and prosthetics.

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