[Code of Federal Regulations]
[Title 42, Volume 2]
[Revised as of October 1, 2002]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR414.210]

[Page 637-638]
 
                         TITLE 42--PUBLIC HEALTH
 
                             HUMAN SERVICES
 
PART 414--PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES--Table of Contents
 
  Subpart D--Payment for Durable Medical Equipment and Prosthetic and 
                            Orthotic Devices
 
Sec. 414.210  General payment rules.

    (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 Secs. 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 
Sec. 414.220.
    (ii) Items requiring frequent and substantial servicing, as 
specified in Sec. 414.222.
    (iii) Certain customized items, as specified in Sec. 414.224.
    (iv) Oxygen and oxygen equipment, as specified in Sec. 414.226.
    (v) Prosthetic and orthotic devices, as specified in Sec. 414.228.
    (vi) Other durable medical equipment (capped rental items), as 
specified in Sec. 414.229.
    (vii) Transcutaneous electrical nerve stimulators (TENS), as 
specified in Sec. 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 Sec. 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 Secs. 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 
Sec. 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 Sec. 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 Sec. 414.222(a);
    (ii) Capped rental items, as defined in Sec. 414.229(a), that are 
not purchased in accordance with Sec. 414.229(d); and
    (iii) Oxygen equipment, as defined in Sec. 414.226.
    (f) Replacement of equipment. Except as provided in Sec. 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

[[Page 638]]

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]