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Durable Medical Equipment Reimbursement per the CARES Act – Update

Tuesday, December 22, 2020

In August, we informed you about the Centers for Medicare and Medicaid (CMS) revised durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) rates following the passage of the Coronavirus Aid, Relief, and Economic Security (CARES) Act. TRICARE implemented CMS’ fee schedule on May 18, 2020, with a directed effective date of March 6 for the rate changes. Health Net Federal Services, LLC (HNFS) recently became aware the revised CARES Act DMEPOS rates were made effective back to Jan. 1 instead of March 6 in our claims systems. As a result, we will adjust reimbursement for affected claims. Additionally, providers no longer need to submit claim review requests for claims that qualify for a rate adjustment per the CARES Act. We are automatically adjusting DMEPOS claims affected by CMS’ revised fee schedule and the effective date correction.

Where is TRICARE’s current DMEPOS fee schedule posted? The Defense Health Agency posts DMEPOS rates quarterly (January, April, July, and October) at https://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement. Per the TRICARE Reimbursement Manual (Chapter 1, Section 11, paragraph 4.15.1), contractors must replace existing pricing with the updated pricing information within 10 calendar days of publication on the internet.

Why was there a lag between CMS’ March 6, 2020 effective date and TRICARE’s May 18 implementation date? Providers can expect a delay from when CMS issues reimbursement changes and whether TRICARE follows suit.  

How is the maximum allowable amount, also referred to as the CHAMPUS Maximum Allowable Amount (CMAC), determined for DMEPOS? The CMAC is the maximum amount TRICARE will cover for nationally established fees for professional services. For DMEPOS, the CMAC is limited to the lower of the billed charge, the negotiated rate (network providers) or the DMEPOS fee schedule amount. Network providers must accept the CMAC for DMEPOS services they render to TRICARE beneficiaries. 

For up-to-date information on COVID-19, visit www.cdc.gov/COVID19. Find additional provider resources specific to TRICARE on our COVID-19 resources page.