HR4475-119

What This Bill Does

The Medicare Orthotics and Prosthetics Patient-Centered Care Act adds patient-protection rules to Medicare payment for orthotic and prosthetic care. Medicare may not pay for covered orthotics or prosthetics furnished by drop shipment on or after the first day of the first year after enactment if the beneficiary has not received training or education from a qualified practitioner on fitting, adjustment, care, and use. The drop-shipment ban applies to orthotics and prosthetics identified by HCPCS codes not paid under competitive acquisition, excluding supplies. The bill also amends competitive-acquisition rules so physical therapists, occupational therapists, orthotists, and prosthetists are included alongside physicians for certain item determinations. It expands replacement language to cover custom-fitted orthotics and custom-fabricated orthotics, not only prosthetic devices. HHS must issue final implementing regulations within one year.

Who Benefits and How

Medicare beneficiaries receiving orthotics benefit from training before direct shipment of covered devices. Medicare beneficiaries receiving prosthetics benefit from stronger payment rules against untrained drop shipment. Orthotists and prosthetists benefit from recognition in Medicare item-determination rules. Physical therapists and occupational therapists benefit from being added to the Medicare competitive-acquisition exception language.

Who Bears the Burden and How

Drop-shipment suppliers lose Medicare payment for covered orthotic or prosthetic items sent without qualified-practitioner training. The Centers for Medicare and Medicaid Services must update payment systems and HCPCS enforcement rules. The Secretary of Health and Human Services must issue final regulations within one year. Durable medical equipment contractors must screen claims for drop-shipment and training compliance.

Key Provisions

• Prohibits Medicare payment for certain orthotic and prosthetic items furnished by drop shipment without beneficiary training from a qualified practitioner.
• Defines drop shipment as direct shipment to an individual who has not received fitting, adjustment, care, and use education.
• Adds physical therapists, occupational therapists, orthotists, and prosthetists to certain competitive-acquisition item rules.
• Extends replacement provisions to custom-fitted orthotics and custom-fabricated orthotics.
• Requires HHS final regulations within one year after enactment.