42 C.F.R. § 414.210 General payment rules.
Title 42 - Public Health
(a) General rule. For items furnished on or after January 1, 1989, except as provided in paragraphs (c) and (d) of this section, Medicare pays for durable medical equipment, prosthetics and orthotics, including a separate payment for maintenance and servicing of the items as described in paragraph (e) of this section, on the basis of 80 percent of the lesser of— (1) The actual charge for the item; (2) The fee schedule amount for the item, as determined in accordance with the provisions of §§414.220 through 414.232. (b) Payment classification. (1) The carrier determines fee schedules for the following classes of equipment and devices: (i) Inexpensive or routinely purchased items, as specified in §414.220. (ii) Items requiring frequent and substantial servicing, as specified in §414.222. (iii) Certain customized items, as specified in §414.224. (iv) Oxygen and oxygen equipment, as specified in §414.226. (v) Prosthetic and orthotic devices, as specified in §414.228. (vi) Other durable medical equipment (capped rental items), as specified in §414.229. (vii) Transcutaneous electrical nerve stimulators (TENS), as specified in §414.232. (2) CMS designates the items in each class of equipment or device through its program instructions. (c) Exception for certain HHAs. Public HHAs and HHAs that furnish services or items free-of-charge or at nominal prices to a significant number of low-income patients, as defined in §413.13(a) of this chapter, are paid on the basis of 80 percent of the fee schedule amount determined in accordance with the provision of §§414.220 through 414.230. (d) Prohibition on special limits. For items furnished on or after January 1, 1989 and before January 1, 1991, neither CMS nor a carrier may establish a special reasonable charge for items covered under this subpart on the basis of inherent reasonableness as described in §405.502(g) of this chapter. (e) Maintenance and servicing—(1) General rule. Except as provided in paragraph (e)(2) of this section, the carrier pays the reasonable and necessary charges for maintenance and servicing of purchased equipment. Reasonable and necessary charges are those made for parts and labor not otherwise covered under a manufacturer's or supplier's warranty. Payment is made, as needed, in a lump sum based on the carrier's consideration of the item. Payment is not made for maintenance and servicing of a rented item other than the maintenance and servicing fee for other durable medical equipment, as described in §414.229(e). (2) Exception. For items purchased on or after June 1, 1989, no payment is made under the provisions of paragraph (e)(1) of this section for the maintenance and servicing of: (i) Items requiring frequent and substantial servicing, as defined in §414.222(a); (ii) Capped rental items, as defined in §414.229(a), that are not purchased in accordance with §414.229(d); and (iii) Oxygen equipment, as defined in §414.226. (f) Replacement of equipment. Except as provided in §414.229(g), if a purchased item of DME or a prosthetic or orthotic device paid for under this subpart has been in continuous use by the patient for the equipment's reasonable useful lifetime or if the carrier determines that the item is lost or irreparably damaged, the patient may elect to obtain a new piece of equipment. (1) The reasonable useful lifetime of DME or prosthetic and orthotic devices is determined through program instructions. In the absence of program instructions, carriers may determine the reasonable useful lifetime of equipment but in no case can it be less than 5 years. Computation is based on when the equipment is delivered to the beneficiary, not the age of the equipment. (2) If the beneficiary elects to obtain replacement equipment, payment is made on a purchase basis. [57 FR 57689, Dec. 7, 1992]
Title 42: Public Health
PART 414—PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES
Subpart D—Payment for Durable Medical Equipment and Prosthetic and Orthotic Devices
§ 414.210 General payment rules.
