DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
 
CMCS Informational Bulletin 
 
DATE:   January 4, 2019 
 
FROM:  Mary C. Mayhew, Deputy Administrator and Director 
Center for Medicaid and CHIP Services 
 
Demetrios L. Kouzoukas, Principal Deputy Administrator and Director 
Center for Medicare 
 
Tim Engelhardt, Director 
    Medicare-Medicaid Coordination Office  
 
SUBJECT:   Strategies to Support Dually Eligible Individuals Access to Durable Medical 
Equipment, Prosthetics, Orthotics, and Supplies  
 
The purpose of this Informational Bulletin is to provide another strategy for states to better 
support timely access to durable medical equipment, prosthetics, orthotics, and supplies 
(DMEPOS) for people dually eligible for Medicaid and Medicare. Both Medicare and Medicaid 
cover DMEPOS, which can be essential to dually eligible individuals mobility, health status, 
independence in the community, and overall quality of life. This Informational Bulletin provides 
an additional strategy to those included in the Informational Bulletin released in January 2017 in 
which we described several strategies to increase access to DMEPOS for dually eligible 
individuals.1  
 
Background 
 
Medicare and Medicaid differ in their coverage of DMEPOS: 
  Medicare limits coverage to DME that can withstand repeated use, is primarily and 
customarily used to serve a medical purpose, generally is not useful in the absence of 
illness or injury, is appropriate for use in the home, and effective with respect to items 
classified as DME after January 1, 2012, has an expected life of at least 3 years. 
Additionally, there are items that Medicare does not cover because they are explicitly 
excluded by statute or they do not meet Medicares medical necessity requirements.  
  Medicaid provides coverage for DMEPOS under two separate benefit categories:  (1) 
Durable Medical Equipment and Supplies, which are called medical supplies, equipment 
and appliances in Medicaid, are covered under the mandatory home health benefit; (2) 
prosthetics are covered separately under the optional prosthetics benefit.  Medicaid has a 
broader definition of medical supplies, equipment and appliances and may cover 
DMEPOS that Medicare does not, including certain specialized equipment that promotes 
independent living outside the home.    
                                                           
1 https://www.medicaid.gov/federal-policy-guidance/downloads/cib011317.pdf   Medicare is primary payer for DMEPOS covered by both programs: 
  Medicaid pays secondary to most other legally liable payers, including Medicare. Section 
1902(a)(25) of the Social Security Act requires each state, under its State Medicaid Plan, 
to take all reasonable measures to ensure that other payers pay to the limit of their legal 
liability before any Medicaid payment is available. However, this does not mean that 
states must always obtain a Medicare denial before covering a DMEPOS item, such as 
situations in which a DMEPOS item is not covered by Medicare.  For those DMEPOS 
items not expressly excluded by Medicare, state Medicaid agencies should follow CMS 
Coordination of Benefits Third Party Liability claims processing cost avoidance 
requirements.2 
  Medicare generally only processes claims after the equipment is delivered. If a state 
requires a Medicare denial for an item before covering a DMEPOS item, it can lead to 
potential access issues for dually eligible individuals. When suppliers lack assurance 
regarding how Medicare or Medicaid will cover DMEPOS at the time it is furnished and 
dually eligible individuals (the majority of whom have incomes under 100 percent of the 
federal poverty level) generally cannot afford to pay out-of-pocket up front  the 
suppliers may be reluctant to furnish needed DMEPOS. 
 
Denials Not Required for DMEPOS that Medicare Does Not Cover 
 
In the January 2017 Informational Bulletin, we explained that states can use non-affirmed 
Medicare prior authorization requests as evidence of Medicare non-coverage and do not need to 
go on to seek an actual claim denial for the item. We are building on that guidance by clarifying 
a second strategy states may adopt to better wrap around Medicare DMEPOS coverage for dually 
eligible individuals. Specifically, in this Informational Bulletin, we are providing guidance that 
states need not obtain a Medicare denial for DMEPOS that Medicare routinely denies as non-
covered under the Medicare DME benefit (e.g., incontinence supplies). Below are some specific 
procedures states may adopt and resources that are available.   
 
Medicare Non-Covered Lists 
Medicaid agencies commonly cover DME that Medicare does not. States may consider creating a 
list of DME items that are not covered by Medicare to expedite Medicaid coverage and payment 
for dually eligible individuals. States can develop such a Medicare Non-Covered Items list and 
use it to immediately process claims for an item they know that Medicare will not cover; they 
would not need to require proof of Medicare denial. This approach, thoughtfully implemented, 
allows states to minimize burden by removing the step of having to obtain a Medicare denial of a 
DME claim while still fulfilling their statutory requirement to remain the payer of last resort. It 
also streamlines the administrative process and promotes timely beneficiary access to needed 
items and repairs. States that develop a Medicare Non-Covered Items list should also 
encourage their Medicaid managed care organizations to adopt the same list if they are 
responsible for covering DME for dually eligible individuals. 
 
Creating a Medicare Non-Covered List of DME  
                                                           
2 See 42 CFR 433.139(b)(1).  The DME Medicare Administrative Contractors post up-to-date lists of items that they will 
currently deny as non-covered. We encourage states to utilize these lists as the basis for their 
Medicare Non-Covered Items lists.   
Medicare has four jurisdictions for MACs.  Please use the bullets below to identify the 
jurisdiction in which your state is located, and then use the link for MAC list posted for that 
jurisdiction.   
  For Jurisdiction A (CT, DE, MA, ME, MD, NH, NJ, NY, PA, RI, VT, Washington D.C.) 
and Jurisdiction D (AK, Am. Samoa, AZ, CA, Guam, HI, ID, IA, KS, MO, MT, NE, NV, 
ND, N. Mariana Is., OR, SD, UT, WA, WY)  
https://med.noridianmedicare.com/web/jddme/topics/noncovered-items 
  For Jurisdiction B (IL, IN, KY, MI, MN, OH, WI) and Jurisdiction C (AL, AR, CO, FL, 
GA, LA, MS, NM, NC, OK, PR, SC, TN, TX, USVI, VA, WV)   
https://cgsmedicare.com/jc/pubs/news/2016/1216/cope1605.html  
Please see Appendix 1 for additional resources to help states keep these lists updated. These 
include resources on updates on items that are not covered under the Medicare DMEPOS benefit 
with reasons for denial as well as instructions on how to sign up for listservs to be notified when 
these non-covered lists are updated. 
 
 
 
More Information 
For more information please contact Sharon Donovan (Sharon.Donovan1@cms.hhs.gov) in the 
Medicare-Medicaid Coordination Office or Cathy Sturgill (Cathy.Sturgill@cms.hhs.gov) in the 
Center for Medicaid and CHIP Services. 
    APPENDIX 1 
 
Getting Updates via Listservs  
Medicare revises its policies from time to time, so we recommend that state Medicaid Agencies 
keep abreast of coverage issues by subscribing to the DME MAC listservs. To receive ongoing 
policy updates and keep your list up-to-date, identify the jurisdiction in which your state is 
located (see section above called Creating a Medicare Non-Covered List of DME), and then 
sign up for the appropriate DME MAC listserv: 
DME MAC Listserv for Jurisdictions A and D 
https://naslists.noridian.com/list/subscribe.html?mContainer=2&mOwner=G3039
2x2n39372t36 
DME MAC Listserv for Jurisdictions B and C: 
https://cgsmedicare.com/medicare_dynamic/ls/001.asp 
 
Additional Resources  
The resources below discuss in more detail some of the DMEPOS that Medicare covers and 
some of the items that are not covered. States may use these resources to obtain additional 
context for Medicare policy. 
  CMS Internet Only Manual Publication 100-3, Medicare National Coverage 
Determinations Manual, Chapter 1, Part 4, Section 280.1 
(https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf) provides a list of some 
items that are covered, and some items that are not covered, with the reason for denial. It 
should be noted that Section 280.1 does not address all items of DMEPOS that may be 
covered under the Medicare program; in the absence of a National Coverage 
Determination (NCD), coverage determinations may be made by Medicare claims 
contractors and are subject to appeal in the claims review process.  
  Items and Services That Are Not Covered Under the Medicare Program 
(https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNProducts/Downloads/Items-and-Services-Not-Covered-Under-Medicare-
Booklet-ICN906765.pdf)