Georgia Medicare Durable Medical Equipment Benefit

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By Brevy Care Team · Last verified May 13, 2026

Section 1861(n) of the Social Security Act, codified at 42 U.S.C. 1395x(n), establishes durable medical equipment as a Medicare Part B benefit covering iron lungs, oxygen tents, hospital beds, wheelchairs, blood glucose monitors and testing strips, and other equipment that meets the regulatory five-part test: durable enough to withstand repeated use, used to serve a medical purpose, generally not useful in the absence of illness or injury, appropriate for use in the home, and with a minimum life expectancy of three years. Section 1834(a) establishes the DME payment methodology including the DMEPOS fee schedule, the five payment categories (inexpensive or routinely purchased, frequently serviced, capped rental, oxygen, customized), and the face-to-face physician examination requirement for power mobility devices.

For Georgia Medicare beneficiaries recovering from a hip replacement at Piedmont Atlanta Hospital, managing severe chronic obstructive pulmonary disease in Savannah, transitioning to a power wheelchair due to Parkinson disease in Macon, beginning continuous positive airway pressure therapy after a sleep study at Augusta University Health, or fitting a prosthesis after a below-knee amputation in Athens, the DME benefit determines what equipment Medicare will pay for, which suppliers are eligible to bill Medicare, what cost-sharing the beneficiary owes, what documentation the physician must complete, and what to do when claims deny.

This guide explains every component of the Medicare DME benefit as it applies in Georgia: the statutory framework under Sections 1861(n) and 1834(a), the regulatory implementation at 42 CFR 410.38, 42 CFR Part 414, and 42 CFR 424.57, the DMEPOS Competitive Bidding Program created by the Medicare Modernization Act of 2003, the 30 DMEPOS supplier standards including the $50,000 surety bond and the accreditation requirement, the five DME payment categories, the power mobility device face-to-face encounter and prior authorization requirements, the oxygen 36-month rental cap under Section 1834(a)(5), the CPAP 12-week trial and compliance requirements (four hours per night on 70 percent of nights), the prior authorization Master List, the role of DME MAC Jurisdiction C (CGS Administrators) which processes Georgia Part B DME claims, and the Georgia DMEPOS supplier landscape from Lincare to Apria to AdaptHealth. Six worked examples illustrate real Georgia scenarios from a hospital bed rental in Atlanta to a power wheelchair acquisition in Macon, and a 25-question accordion FAQ addresses the most common beneficiary questions. :::

Federal Statutory and Regulatory Authority for the Medicare DME Benefit

The Medicare durable medical equipment benefit rests on a layered framework of statutory and regulatory authority. Understanding the framework is essential because DME coverage disputes, supplier enrollment questions, prior authorization denials, and competitive bidding access issues are resolved by reference to specific provisions of the Social Security Act and Title 42 of the Code of Federal Regulations.

Section 1861(n) of the Social Security Act, codified at 42 U.S.C. 1395x(n), is the foundational definitional provision. Section 1861(n) defines "durable medical equipment" to include "iron lungs, oxygen tents, hospital beds, and wheelchairs (which may include a power-operated vehicle that may be appropriately used as a wheelchair, but only where the use of such a vehicle is determined to be necessary on the basis of the individual's medical and physical condition and the vehicle meets such safety requirements as the Secretary may prescribe) used in the patient's home (including an institution used as his home other than an institution that meets the requirements of subsection (e)(1) or (j)(1) of this section), whether furnished on a rental basis or purchased, and includes blood-testing strips and blood glucose monitors for individuals with diabetes."

The CMS Medicare Benefit Policy Manual (Pub. 100-02), Chapter 15, operationalizes the Section 1861(n) definition through the five-part DME test: an item is DME if it (1) can withstand repeated use, (2) is primarily and customarily used to serve a medical purpose, (3) generally is not useful to a person in the absence of an illness or injury, (4) is appropriate for use in the home, and (5) has a minimum expected life of at least three years.

Section 1861(s)(6) of the Social Security Act establishes DME as one of the categories of "medical and other health services" covered under Part B. Section 1861(s)(8) establishes prosthetic devices that replace all or part of an internal body organ. Section 1861(s)(9) establishes leg, arm, back, and neck braces, and artificial legs, arms, and eyes. Together these provisions define the universe of DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) under Part B.

Section 1834(a) of the Social Security Act, codified at 42 U.S.C. 1395m(a), establishes the DME payment methodology. Section 1834(a)(1) authorizes the DMEPOS fee schedule that pays a predetermined allowed amount per HCPCS code, replacing the older reasonable charge methodology. Section 1834(a)(7) defines the payment categories: inexpensive or routinely purchased items, items requiring frequent and substantial servicing, customized items, oxygen and oxygen equipment, and capped rental items.

Section 1834(a)(5) establishes the oxygen 36-month rental cap, under which monthly rental payments are made for 36 months, followed by 24 additional months of supplier-provided maintenance and contents at no rental payment.

Section 1834(a)(1)(E)(iv) requires a face-to-face encounter between the beneficiary and the prescribing physician (or other authorized practitioner) within six months prior to the written order for power mobility devices. This face-to-face requirement was added by the Medicare Modernization Act of 2003 (Public Law 108-173) to address widespread fraud and improper utilization of power wheelchairs and scooters.

Section 1834(h) of the Social Security Act establishes the payment methodology for prosthetics and orthotics, separate from the DME fee schedule under Section 1834(a). Prosthetic limbs, custom-made orthoses, and similar items are paid under Section 1834(h).

Section 1847 of the Social Security Act, codified at 42 U.S.C. 1395w-3, is the Competitive Acquisition Program statute, known operationally as the DMEPOS Competitive Bidding Program. Section 1847 was added by Section 302 of the Medicare Modernization Act of 2003 to create a competitive bidding mechanism for DMEPOS payment in designated Competitive Bidding Areas. CMS solicits bids from suppliers, awards contracts to qualifying suppliers, and pays single payment amounts (SPAs) for DMEPOS items in those areas.

Section 1862(a)(1)(A) of the Social Security Act is the foundational "reasonable and necessary" standard that governs all DME coverage decisions. Even when an item meets the Section 1861(n) definitional test, Medicare will not pay unless the item is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

42 CFR 410.38 is the principal coverage regulation for DME. It defines coverage requirements for various DME categories, including hospital beds, wheelchairs, oxygen, CPAP, and other items.

42 CFR Part 414, Subpart D implements the DMEPOS payment methodology, including the fee schedule calculation, the payment categories, and the rural and frontier area adjustments.

42 CFR Part 414, Subpart F implements the DMEPOS Competitive Bidding Program: Competitive Bidding Areas, single payment amounts, contract supplier requirements, and grandfathered supplier rules.

42 CFR 424.57 is the supplier standards regulation. It contains 30 separate standards that DMEPOS suppliers must meet to obtain and maintain Medicare billing privileges, including:

• Standard 1: comply with applicable Federal and State licensure and regulatory requirements.
• Standard 2: maintain a physical facility on an appropriate site.
• Standard 3: maintain minimum hours of operation.
• Standard 7: have a written complaint resolution process.
• Standard 8: maintain a $50,000 surety bond per practice location.
• Standard 22: be accredited by a CMS-approved Accreditation Organization.
• Standard 26: meet the DMEPOS Quality Standards.
• Standard 30: maintain comprehensive liability insurance of at least $300,000.

42 CFR 424.518 establishes the categorical risk levels for supplier screening. DMEPOS suppliers are designated as high-risk under the regulation, requiring fingerprint-based criminal background checks, unannounced site visits, and other enhanced screening procedures.

Statutory history: DME was a Part B benefit from Medicare's inception in 1965. The Omnibus Budget Reconciliation Act of 1987 (Public Law 100-203) established the DMEPOS fee schedule replacing the reasonable charge methodology. The Balanced Budget Act of 1997 (Public Law 105-33) authorized DME competitive bidding demonstration projects. The Medicare Modernization Act of 2003 (Public Law 108-173) established the DMEPOS Competitive Bidding Program under Section 1847, the face-to-face requirement for power mobility devices, and the DMEPOS supplier accreditation requirement. The Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275) delayed Round 1 of competitive bidding and refined quality standards. The Affordable Care Act of 2010 (Public Law 111-148), in Section 6405 and Section 6411, extended face-to-face requirements and Recovery Audit Contractor authority. The 21st Century Cures Act of 2016 (Public Law 114-255) expanded the DMEPOS prior authorization program.

::: callout Key Takeaways: Medicare DME Benefit in Georgia

1. Section 1861(n) SSA defines DME and Section 1834(a) establishes payment. Items must meet the five-part test (durable, medical purpose, not useful absent illness, appropriate for home use, three-year life) and the Section 1862(a)(1)(A) reasonable-and-necessary standard.
2. Five payment categories under Section 1834(a)(7): inexpensive or routinely purchased, frequently and substantially serviced, capped rental, oxygen and oxygen equipment, and customized items. Each has distinct payment rules and beneficiary cost-sharing implications.
3. Oxygen 36-month rental cap: Section 1834(a)(5) requires monthly rental payments for 36 months, followed by 24 months of supplier-provided maintenance and contents at no rental payment. Recertification at months 12 and 24.
4. Power mobility devices require a face-to-face physician examination within six months before the written order, a seven-element written order, and prior authorization for 31 PMD HCPCS codes under the national prior authorization program effective September 1, 2018.
5. CPAP coverage requires a documented sleep study, a 12-week initial trial, and compliance documentation of at least four hours per night on 70 percent of nights over a 30-consecutive-day period, followed by a face-to-face evaluation between Day 31 and Day 91.
6. DMEPOS Competitive Bidding Program (Section 1847) creates Competitive Bidding Areas in which beneficiaries must use contracted suppliers to receive Medicare payment. Atlanta-Sandy Springs-Roswell and Augusta-Richmond County (cross-state) are Georgia CBAs.
7. DMEPOS supplier standards (42 CFR 424.57): 30 standards including accreditation, $50,000 surety bond per location, physical facility, complaint resolution, and quality standards compliance.
8. DME MAC Jurisdiction C (CGS Administrators) processes all Georgia Part B DME claims and conducts redetermination appeals at 1-866-270-4909.
9. Part B cost-sharing: After the Part B deductible ($257 in 2026), the beneficiary owes 20 percent coinsurance on the Medicare-allowed amount. Most standardized Medigap plans cover this coinsurance. :::

The Five DME Payment Categories Under Section 1834(a)(7)

Section 1834(a)(7) of the Social Security Act establishes five distinct payment categories for DME, and understanding which category applies to a particular item is essential for predicting cost, ownership, and beneficiary financial responsibility.

Category 1: Inexpensive or routinely purchased items

These are items with a fee schedule purchase price of $150 or less, or items that are typically purchased rather than rented (such as canes, crutches, walkers, certain commodes, and some other low-cost items). The beneficiary may elect either purchase or capped rental (up to 13 months). For most inexpensive items, purchase is the more economical option for both the beneficiary and Medicare.

Examples (HCPCS codes):

• E0100 cane, single
• E0143 standard walker, folding
• E0163 commode chair, mobile
• E0250 hospital bed semi-electric (some configurations)

Category 2: Items requiring frequent and substantial servicing

These are items for which monthly maintenance and servicing are essential and continuous, requiring continuous monthly rental rather than purchase. Title to the equipment never transfers to the beneficiary. The supplier retains responsibility for all maintenance, servicing, and replacement of components.

Examples:

• E0465 / E0466 / E0467 ventilators (invasive, non-invasive, multi-function)
• E0731 form-fitting conductive garment
• E1399 continuous infusion pumps
• Continuous Passive Motion (CPM) devices in certain circumstances

Monthly rental continues as long as medical necessity persists. There is no 13-month cap and no transfer of title.

Category 3: Oxygen and oxygen equipment (Section 1834(a)(5))

Oxygen is its own specific payment category with unique rules:

• Months 1 through 36: Monthly rental payment that covers the oxygen equipment, contents, and supplier maintenance.
• Months 37 through 60: The supplier must continue providing oxygen and equipment maintenance for 24 additional months at no rental payment (the supplier is paid for contents and maintenance only if liquid or high-flow oxygen criteria apply).
• Months 61 and beyond: If the patient continues to require oxygen, a new 36-month rental period may begin under specified conditions, but this is rare and requires demonstration that a new period of medical need has arisen.

Recertification of medical necessity is required at month 12 and month 24, with physician documentation that the underlying clinical criteria (Group I or Group II oxygen criteria per CMS National Coverage Determination 240.2) continue to be met.

Category 4: Capped rental items

This is the largest DME category by volume and includes hospital beds, manual and many power wheelchairs, CPAP machines, and most other major DME items. The rules:

• Months 1 through 3: Monthly rental payment at 10 percent of the fee schedule allowable amount.
• Months 4 through 13: Monthly rental payment at 7.5 percent of the fee schedule allowable amount.
• End of month 13: Title transfers to the beneficiary. The supplier remains responsible for maintenance and servicing for an additional five years (or the remaining useful life of the equipment).

The beneficiary may purchase the item outright at any time during the rental period at the difference between fee schedule purchase amount and rental amounts already paid.

Examples (HCPCS codes):

• E0260 hospital bed semi-electric (most configurations)
• E0265 hospital bed total electric
• E0601 CPAP device
• E0470 / E0471 bilevel positive airway pressure (RAD)
• K0001 / K0002 standard manual wheelchairs
• K0823 power wheelchair Group 2 (selected configurations)

Category 5: Customized items

These are items made to order for a specific patient and not amenable to rental. They are paid on a purchase basis with individual consideration pricing. Examples include complex rehab technology power wheelchairs with extensive custom seating modifications.

Power Mobility Devices: Face-to-Face Examination and Prior Authorization

Power mobility devices (PMDs) - including power wheelchairs and power-operated vehicles (scooters) - have the most stringent coverage requirements of any DME category. This reflects the history of widespread fraud and improper utilization in the early 2000s that prompted Congress to enact specific safeguards in the Medicare Modernization Act of 2003.

Face-to-face physician examination (Section 1834(a)(1)(E)(iv))

Under Section 1834(a)(1)(E)(iv) and 42 CFR 410.38(c), a face-to-face encounter is required between the beneficiary and the prescribing physician (or treating practitioner: physician assistant, nurse practitioner, or clinical nurse specialist) within six months prior to the written order for a PMD. The encounter must include an examination of the patient, an assessment of the patient's ability to safely use mobility-related activities of daily living, and a determination that a PMD is medically necessary.

The medical record documentation of the face-to-face encounter must include:

• The patient's history relevant to mobility (diagnoses, prior mobility devices, fall history)
• Findings on physical examination relevant to mobility (strength, range of motion, sensation, balance, gait, posture)
• Functional assessment of mobility-related activities of daily living
• Other diagnostic findings (imaging, prior physical therapy notes)
• An assessment of whether the patient could be made functionally independent with a less expensive mobility option (cane, walker, manual wheelchair)
• A determination that the patient meets coverage criteria for the specific PMD prescribed

Seven-element written order

After the face-to-face encounter and before the supplier delivers the PMD, the prescribing physician must complete a written order containing seven specific elements:

1. Beneficiary's name
2. Description of the item (specific HCPCS or detailed product description)
3. Date of the face-to-face examination
4. Pertinent diagnoses or conditions
5. Length of need
6. Physician's signature
7. Date of the physician's signature

The seven-element order must be in the supplier's records before delivery; oral orders or post-delivery orders are not acceptable.

Prior authorization for PMDs

The DMEPOS Prior Authorization Program for power mobility devices began as a demonstration in seven states in 2012 and was made permanent nationally effective September 1, 2018, covering 31 PMD HCPCS codes. The program has been expanded over time to additional DMEPOS items including pressure-reducing support surfaces, lower limb prosthetics, and others.

Under the prior authorization program:

• The supplier (not the beneficiary or physician) submits a prior authorization request to the DME MAC, with the medical record documentation and face-to-face encounter note.
• The DME MAC reviews the request and issues either an affirmation decision (the item meets coverage criteria) or a non-affirmation decision (the item does not meet criteria).
• Initial decisions are generally issued within 10 business days. Expedited review is available when delay would jeopardize the patient's health, with a decision within two business days.
• An affirmation is valid for six months. If the item is not delivered within six months, a new prior authorization is required.
• Beneficiaries cannot be billed if a non-affirmation was issued and the supplier nonetheless furnished the item without subsequent affirmation.

The Oxygen Benefit and 36-Month Rental Cap

Oxygen is one of the most heavily used Medicare DME benefits, particularly in Georgia where chronic obstructive pulmonary disease is highly prevalent among older adults. Coverage rules are governed by CMS National Coverage Determination 240.2 and the statutory 36-month rental cap under Section 1834(a)(5).

Coverage criteria

To qualify for Medicare-covered home oxygen, a beneficiary must have severe lung disease (such as COPD, interstitial lung disease, or pulmonary hypertension) or hypoxia-related symptoms, supported by arterial blood gas (ABG) or pulse oximetry documentation:

Group I (most common):

• PaO2 of 55 mmHg or less on arterial blood gas, or
• Oxygen saturation (SpO2) of 88 percent or less on pulse oximetry
• Measured at rest, during exercise, or during sleep

Group II (less common):

• PaO2 of 56 to 59 mmHg, or SpO2 of 89 percent, with documentation of dependent edema suggesting congestive heart failure, pulmonary hypertension, cor pulmonale, or erythrocythemia (hematocrit greater than 56 percent)

Group III: PaO2 of 60 mmHg or greater or SpO2 of 90 percent or greater is generally not covered, with very narrow specific exceptions.

The ABG or oximetry must be obtained within 30 days prior to the initial certification of medical necessity, in a chronic stable state, and not during an acute illness (such as a hospital admission for pneumonia exacerbation). The treating physician must complete a written order specifying the prescribed flow rate, frequency of use, and duration of use.

The 36-month rental cap

Under Section 1834(a)(5), the Medicare oxygen benefit operates on a 36-month rental cap with a 24-month maintenance period:

• Months 1 through 36: The supplier furnishes oxygen and equipment and bills Medicare a monthly rental fee. The beneficiary pays 20 percent coinsurance after the Part B deductible. The supplier is responsible for all equipment maintenance, repair, and replacement, plus delivery of contents (concentrated oxygen, or liquid or gas oxygen as applicable).
• Months 37 through 60: The supplier must continue providing the oxygen equipment, maintenance, repair, and replacement at no rental payment. The supplier is paid only for the cost of contents (liquid or gas oxygen) and a one-time maintenance and servicing fee at month 37. The beneficiary pays 20 percent of the maintenance fee.
• Months 61 and beyond: If the patient continues to require oxygen and a new period of medical need has been established (rare, but possible), a new 36-month rental cap begins.

Recertification

The treating physician must recertify medical necessity at month 12 and month 24 of the rental period. Recertification requires updated ABG or oximetry, documentation that the underlying condition continues to meet Group I or Group II criteria, and a written statement of continued medical necessity. If recertification is not completed, the supplier cannot bill Medicare for subsequent months.

Portable oxygen

Many oxygen beneficiaries require portable oxygen for use outside the home. The portable benefit is added to the stationary oxygen benefit through specific HCPCS codes and modifiers, with additional monthly payment to the supplier. Portable options include liquid oxygen (high cost, high portability), small concentrators with portable cylinders, and portable concentrators.

CPAP, BiPAP, and Ventilators

Continuous positive airway pressure (CPAP) is the standard treatment for obstructive sleep apnea (OSA) and is covered under DME with specific coverage and compliance requirements per CMS National Coverage Determination 240.4.

CPAP coverage criteria

CPAP is covered when:

1. The patient has a clinical diagnosis of OSA documented by a Medicare-covered sleep study (in-laboratory polysomnography or home sleep apnea test) demonstrating an apnea-hypopnea index (AHI) of 15 or more events per hour, OR an AHI of 5 to 14 events per hour with documented symptoms such as excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease, or history of stroke.
2. The treating physician orders CPAP after evaluating the sleep study results.

12-week trial period and compliance requirement

CPAP coverage is initially authorized for a 12-week trial period. Continued coverage beyond 12 weeks requires documentation that:

1. The patient is using the CPAP at least four hours per night on 70 percent of nights over a 30-consecutive-day period during the trial.
2. A face-to-face evaluation between Day 31 and Day 91 of the trial documents subjective benefit (improvement in sleep apnea symptoms) and adherence to therapy.

Most CPAP devices furnished under Medicare contain a modem that transmits adherence data directly to the supplier and, with patient consent, to the prescribing physician. Suppliers monitor adherence and, if a patient fails to meet the compliance threshold during the trial, Medicare will not continue coverage after the trial period ends.

BiPAP and RAD

Bilevel Positive Airway Pressure (BiPAP) is a Respiratory Assist Device (RAD) covered under more stringent criteria than CPAP:

• For OSA, the patient must have documented CPAP failure (intolerance or ineffective treatment) before BiPAP is covered.
• For restrictive thoracic disorders, severe COPD, or central sleep apnea, specific clinical criteria apply.

Ventilators

Mechanical ventilators (HCPCS E0465 invasive, E0466 non-invasive, E0467 multi-function) are paid as items requiring frequent and substantial servicing (Category 2) under continuous monthly rental with no transfer of title. Coverage requires documented respiratory failure (chronic), neuromuscular disease, severe restrictive thoracic disease, or other specified conditions. Ventilator suppliers must provide respiratory therapist services as part of their setup and ongoing service obligation.

The DMEPOS Competitive Bidding Program

The DMEPOS Competitive Bidding Program (CBP) was created by Section 302 of the Medicare Modernization Act of 2003 (Public Law 108-173), codified at Section 1847 of the Social Security Act. The program restructures DMEPOS pricing and supplier access in designated Competitive Bidding Areas (CBAs).

How the program works

CMS solicits bids from DMEPOS suppliers who wish to furnish specified products within a designated CBA. Each supplier submits a bid for each product category, indicating the price at which the supplier is willing to furnish the product. CMS calculates a single payment amount (SPA) by analyzing the bids (typically setting the SPA at the median of qualifying bids) and awards contracts to suppliers who submitted bids at or below the SPA.

Once contracts are awarded, beneficiaries in the CBA must obtain covered DMEPOS items from a contracted supplier to receive Medicare payment, with limited exceptions:

• Grandfathered suppliers: Some non-contracted suppliers who were furnishing equipment to beneficiaries before the CBA contract took effect may continue billing Medicare for the duration of the rental period for those grandfathered patients.
• Mail-order CGM and certain national mail-order products: Subject to separate national mail-order CBA programs.

Round history

• Round 1: Began January 1, 2011 in nine CBAs nationwide (none in Georgia). Round 1 was preceded by Round 1 Rebid (effective January 1, 2011 after MIPPA-mandated rebid).
• Round 2: Expanded to 91 additional CBAs effective July 1, 2013, including Atlanta-Sandy Springs-Marietta MSA.
• National Mail-Order Program for Diabetic Testing Supplies: Effective July 1, 2013, requiring beneficiaries who order test strips by mail to use national mail-order contract suppliers.
• Round 2 Recompete: Effective July 1, 2016.
• Round 2021: Limited to off-the-shelf back braces and knee braces only, effective January 1, 2021 through December 31, 2023.
• Subsequent rounds: Most DMEPOS categories were temporarily paused from competitive bidding in 2024 through 2026 pending program restructuring; fee schedule rates currently apply in former CBAs for non-CBP categories.

Georgia CBAs

The Atlanta-Sandy Springs-Roswell metropolitan statistical area is a Georgia CBA covering metropolitan Atlanta including Fulton, DeKalb, Gwinnett, Cobb, Clayton, Fayette, Forsyth, Henry, Cherokee, Douglas, Rockdale, and surrounding counties. The Augusta-Richmond County MSA is a cross-state CBA (Georgia and South Carolina) covering metropolitan Augusta. Rural Georgia counties outside these MSAs are not in CBAs and are paid under the standard DMEPOS fee schedule.

DMEPOS Supplier Standards and Accreditation

To bill Medicare for DMEPOS, a supplier must enroll in Medicare through the National Supplier Clearinghouse (operated by Palmetto GBA), obtain a Provider Transaction Access Number (PTAN), and meet the 30 supplier standards under 42 CFR 424.57.

Key standards

Standard 1: Operate the business in compliance with all applicable Federal and State licensure and regulatory requirements, including pharmacy licensure if dispensing prescription items.

Standard 2: Maintain a physical facility on an appropriate site (not a personal residence, P.O. box, or commercial mail receiving agency). The facility must be at least 200 square feet, accessible to beneficiaries during posted hours, and appropriately stocked with inventory.

Standard 3: Maintain a posted schedule of operating hours, including at least 30 hours per week of operation accessible to the public, including some evening or weekend hours.

Standard 7: Maintain a written complaint resolution process and respond to beneficiary complaints in writing within 14 calendar days.

Standard 8: Maintain a surety bond of at least $50,000 per practice location, made payable to CMS. The bond protects against improper Medicare payments and serves as a barrier to entry for marginal suppliers.

Standard 22: Be accredited by a CMS-approved Accreditation Organization (AO). Approved AOs include the Accreditation Commission for Health Care (ACHC), The Compliance Team, the Healthcare Quality Association on Accreditation (HQAA), the National Association of Boards of Pharmacy (NABP), and others. Limited exemptions exist for certain professional categories (pharmacists, occupational therapists) but most DMEPOS suppliers must be accredited.

Standard 26: Meet the DMEPOS Quality Standards, a separate set of approximately 90 standards covering business practices, product safety, beneficiary services, intake and assessment, delivery and setup, training and instruction, and respiratory therapy services where applicable.

Standard 30: Maintain comprehensive liability insurance of at least $300,000.

Supplier screening

Under 42 CFR 424.518, DMEPOS suppliers are designated as "high-risk" providers subject to enhanced screening procedures including:

• Fingerprint-based criminal background checks for owners (5 percent or greater ownership interest), authorized officials, and managing employees.
• Unannounced site visits by the National Supplier Clearinghouse to verify continued operation and standards compliance.
• Triennial revalidation of enrollment information.

Prior Authorization for Other DMEPOS Items

Beyond power mobility devices, the prior authorization program has been progressively extended:

• Pressure-reducing support surfaces (Group 2 mattresses, HCPCS E0277 and E0193): Required effective July 22, 2019.
• Lower limb prosthetics (5 HCPCS codes): Required effective September 1, 2020.
• Cervical fusion devices (multi-level): Required for certain procedures.
• Other items added periodically: CMS publishes the current Required Prior Authorization List on its website.

The "Master List of DMEPOS Items Frequently Subject to Unnecessary Utilization" is a broader list of items potentially subject to prior authorization. The "Required Prior Authorization List" is the subset for which PA is currently mandated.

DME MAC Jurisdiction C and Georgia Claim Processing

All Part B DME claims for Georgia beneficiaries are processed by DME MAC Jurisdiction C, operated by CGS Administrators. DME MAC Jurisdiction C covers Georgia, Alabama, Arkansas, Colorado, Florida, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, and West Virginia.

DME MAC functions:

• Claims processing and payment
• Coverage determinations
• Prior authorization review
• Initial appeals (redetermination, the first level of the Medicare five-level appeals process)
• Coding and billing education for suppliers

CGS Administrators contact information:

• Toll-free 1-866-270-4909
• PO Box 20007, Nashville, TN 37202
• Website: cgsmedicare.com/jc

The National Supplier Clearinghouse (operated by Palmetto GBA, separate from CGS as the DME MAC) is the entity that enrolls all DMEPOS suppliers nationally and issues PTANs. NSC is reached at 1-866-238-9652.

Worked Examples: Georgia Medicare DME Beneficiary Scenarios

Example 1: Margaret, 78, Atlanta, hospital bed and walker post-discharge from Piedmont Atlanta Hospital

Margaret is recovering from a left hip arthroplasty at Piedmont Atlanta Hospital. The discharge planner identifies that she needs a hospital bed (semi-electric, head and foot elevation) for the first eight weeks while she recovers, and a standard folding walker for ambulation.

The physician orders a hospital bed (E0260) and a standard walker (E0143). The discharge planner refers Margaret to Lincare Atlanta, a Medicare-contracted DMEPOS supplier serving the Atlanta CBA.

Walker: Inexpensive or routinely purchased item (Category 1). Margaret elects to purchase the walker outright. Medicare-allowed amount is approximately $60. After her Part B deductible, Medicare pays 80 percent and Margaret owes 20 percent. Her Medigap Plan G covers the coinsurance.

Hospital bed: Capped rental (Category 4). Months 1 through 3: rental at 10 percent of fee schedule. Months 4 through 13: rental at 7.5 percent. After month 13, title transfers to Margaret with Lincare providing five additional years of maintenance and servicing. Total Medicare rental payments approximately equal the fee schedule purchase amount. Margaret's 20 percent coinsurance covered by Medigap Plan G.

Example 2: Robert, 82, Savannah, oxygen 36-month rental at Apria Healthcare

Robert has severe COPD with a documented PaO2 of 53 mmHg on arterial blood gas obtained at his Memorial Health pulmonary clinic visit (Group I criteria). His pulmonologist orders home oxygen at 2 liters per minute by nasal cannula continuous, with portable oxygen for ambulation.

Apria Healthcare Savannah is the contracted supplier. Apria delivers a stationary oxygen concentrator and small portable cylinders. Robert's monthly Medicare payment to Apria is approximately $80 to $100 (varies by HCPCS code and modifier) plus a portable add-on. Robert pays 20 percent coinsurance; his Medigap Plan G covers.

Months 1 through 36: Monthly rental.

Months 12 and 24: Robert's pulmonologist recertifies continued medical necessity with updated documentation.

Months 37 through 60: Apria continues providing oxygen and maintenance at no rental payment.

Total Medicare cost over the full 60-month benefit: approximately $3,500 to $4,000 in rental payments, much less than the cumulative cost would have been under the pre-1834(a)(5) rental structure.

Example 3: Linda, 75, Macon, power wheelchair with face-to-face examination and prior authorization at Atrium Health Navicent

Linda has Parkinson disease with progressive mobility limitation. She can no longer ambulate distances within her home, cannot effectively use a cane or walker, and her family is concerned about falls.

Linda's primary care physician at Atrium Health Navicent Macon refers her to a physical medicine and rehabilitation specialist for a face-to-face mobility examination. The specialist conducts a detailed exam, documents the findings (gait abnormalities, balance impairment, fall history, prior unsuccessful trials of walker and manual wheelchair), assesses mobility-related activities of daily living, and determines that a Group 2 power wheelchair is medically necessary. The specialist completes the seven-element written order.

AdaptHealth Macon, a CMS-accredited DMEPOS supplier, receives the order and the medical record documentation. AdaptHealth submits a prior authorization request to DME MAC Jurisdiction C (CGS Administrators). Within 10 business days, CGS issues an affirmation. AdaptHealth then delivers a Group 2 power wheelchair (K0823) customized for Linda's needs.

The wheelchair is a capped rental item. Months 1 through 13 are paid by Medicare; Linda owes 20 percent coinsurance (covered by Medigap Plan G). At month 13, title transfers to Linda; AdaptHealth provides five years of maintenance.

Example 4: Charles, 80, Augusta, CPAP trial and compliance documentation at AdaptHealth Augusta

Charles has loud snoring, witnessed apneas, and excessive daytime sleepiness. His Augusta University Health sleep medicine physician orders a polysomnogram, which documents moderate-to-severe OSA with an apnea-hypopnea index of 28.

The sleep physician orders a CPAP device (E0601) with a heated humidifier and prescription pressure setting. AdaptHealth Augusta delivers the CPAP equipped with a modem for adherence monitoring.

During the 12-week trial period, Charles uses the CPAP an average of six hours per night on 25 of 30 consecutive nights (83 percent compliance), well above the four-hour-per-night-on-70-percent-of-nights threshold. At Day 60, Charles returns for a face-to-face evaluation with his sleep physician, who documents subjective improvement in daytime sleepiness, snoring, and morning headaches, and reviews the adherence data.

Continued CPAP coverage is authorized. The CPAP is a capped rental item. Months 1 through 13 are paid by Medicare; Charles owes 20 percent coinsurance (covered by Medigap Plan G). At month 13, title transfers to Charles. Supplies (mask, tubing, filters, water chamber) are replaced on Medicare-allowed schedules.

Example 5: Patricia, 73, Columbus, therapeutic continuous glucose monitor and diabetic supplies through US Med (mail-order)

Patricia has Type 2 diabetes mellitus on intensive insulin therapy: 24 units of basal insulin at bedtime plus rapid-acting insulin at meals (basal-bolus regimen, four injections daily). She has had multiple episodes of severe hypoglycemia.

Patricia's endocrinologist at Piedmont Columbus orders a therapeutic continuous glucose monitor (CGM) - either Dexcom G7 or Abbott FreeStyle Libre 3 - to provide continuous glucose readings and alarms for hypoglycemia.

US Med, a Medicare-enrolled mail-order DMEPOS supplier with national distribution from its Florida headquarters, is selected. US Med ships the CGM receiver/transmitter (HCPCS K0554) initially, then monthly supply boxes (HCPCS K0553 supply allowance) with sensors and replacement transmitters as needed.

Patricia pays 20 percent coinsurance after Part B deductible; her Medigap Plan G covers. Test strips for confirmatory finger-stick testing are also covered as DME under the Section 1861(n) blood glucose monitor provision.

Example 6: Henry, 85, Athens, below-knee prosthesis through Hanger Clinic following amputation at Piedmont Athens Regional

Henry has long-standing Type 2 diabetes mellitus and develops a non-healing right foot ulcer that progresses to osteomyelitis. After multiple interventions, his vascular surgeon at Piedmont Athens Regional performs a below-knee amputation. Henry completes acute rehabilitation and is fitted with an immediate post-operative prosthesis.

Two months after surgery, Henry is ready for his definitive prosthesis. The Piedmont prosthetist refers him to Hanger Clinic, a national prosthetic and orthotic provider with offices in Athens, Augusta, Atlanta, and elsewhere in Georgia. Hanger Clinic conducts a comprehensive evaluation, takes measurements and casting, and fabricates a custom-made below-knee prosthesis.

The prosthesis is covered under Section 1861(s)(9) (artificial legs) and paid under Section 1834(h) prosthetics fee schedule. Total Medicare-allowed amount is approximately $7,000 to $12,000 depending on the K-level (functional classification) and prosthetic components selected. Henry pays 20 percent coinsurance after Part B deductible; his Medigap Plan G covers.

Fourteen Common Mistakes Georgia Medicare DME Beneficiaries Should Avoid

1. Using a non-contracted supplier in a Competitive Bidding Area. In the Atlanta or Augusta CBAs, beneficiaries must use a contracted supplier to receive Medicare payment. Verify supplier status before signing for delivery.

2. Missing the face-to-face requirement timing for power mobility devices. The face-to-face encounter must be within six months prior to the written order, and the order must contain seven specific elements.

3. Not documenting medical necessity beyond the physician order. The medical record must support the coverage criteria. A bare order without supporting documentation will result in denials and post-payment recoveries.

4. Renting oxygen past the 36-month cap without understanding the transition. Months 37 through 60 are no-rental-payment maintenance and contents months. The supplier remains responsible for the equipment.

5. Not completing the CPAP 12-week trial compliance documentation. Four hours per night on 70 percent of nights, plus a face-to-face evaluation between Day 31 and Day 91. Failing this means loss of continued CPAP coverage.

6. Treating capped rental as a permanent rental. Title transfers at month 13 in nearly all capped rental categories. The beneficiary owns the equipment thereafter; the supplier remains responsible for maintenance for five additional years.

7. Ignoring prior authorization requirements. PA is required for 31 PMD codes plus growing list of other DMEPOS items. Items furnished without affirmation may be denied.

8. Not understanding that Medicare Advantage plans may have different DME networks and prior authorization. Each MA plan publishes its DME network and authorization rules.

9. Failing to coordinate DME with home health benefit. Certain DME items furnished concurrent with a home health certification may be considered part of the home health bundled payment rather than separately billable DME.

10. Choosing a non-accredited supplier. Claims from non-accredited suppliers will deny. Verify accreditation status.

11. Confusing prosthetic devices, orthotics, and DME payment categories. Prosthetic limbs are paid under Section 1834(h), not Section 1834(a) DME fee schedule.

12. Not appealing initial denials. The five-level Medicare appeals process is available for denied DME claims. The first level is redetermination by the DME MAC (CGS Administrators for Georgia).

13. Failing to verify supplier Medicare enrollment. Use medicare.gov/care-compare or call 1-800-MEDICARE to verify supplier enrollment before service.

14. Allowing a supplier to bill for items not ordered or not delivered. Review every Medicare Summary Notice. Report fraud to 1-800-HHS-TIPS.

::: accordion

Frequently Asked Questions About the Georgia Medicare DME Benefit

1. What is durable medical equipment under Medicare? Durable medical equipment under Section 1861(n) of the Social Security Act includes hospital beds, wheelchairs, oxygen tents, blood glucose monitors, and other equipment that meets the regulatory five-part test: durable, used for a medical purpose, not useful absent illness or injury, appropriate for home use, and with a minimum life expectancy of three years.

2. Is DME covered under Medicare Part A or Part B? DME is a Part B benefit under Section 1861(s)(6). Part A may include equipment furnished during a covered hospital or skilled nursing facility stay as part of the bundled facility payment, but home DME is exclusively Part B.

3. How much does DME cost a Medicare beneficiary? After the annual Part B deductible ($257 in 2026), the beneficiary owes 20 percent coinsurance on the Medicare-allowed amount. Most standardized Medigap plans cover the 20 percent coinsurance. Beneficiaries with QMB Medicare Savings Program enrollment cannot be billed for cost-sharing by participating providers under Section 1902(n)(3)(B).

4. What are the five DME payment categories? Section 1834(a)(7) establishes: (1) inexpensive or routinely purchased items, (2) items requiring frequent and substantial servicing, (3) oxygen and oxygen equipment, (4) capped rental items, and (5) customized items. Each category has distinct payment rules.

5. What is the DMEPOS Competitive Bidding Program? The Competitive Bidding Program under Section 1847 (added by MMA 2003) creates Competitive Bidding Areas in which suppliers compete via bids and contracts are awarded to qualifying lowest bidders. Beneficiaries in CBAs must use contracted suppliers. The Atlanta-Sandy Springs-Roswell MSA and Augusta-Richmond County MSA are Georgia CBAs.

6. What is DME MAC Jurisdiction C and why does it matter for Georgia? DME MAC Jurisdiction C, operated by CGS Administrators, processes all Part B DME claims for Georgia beneficiaries, conducts prior authorization review, and decides initial appeals. CGS Administrators is reached at 1-866-270-4909.

7. Do I need a doctor's order for every piece of DME? Yes. All DME requires a physician (or other authorized practitioner) order. For power mobility devices and certain other items, a face-to-face examination and a seven-element written order are required.

8. What is the face-to-face requirement for power wheelchairs? Under Section 1834(a)(1)(E)(iv), a face-to-face encounter between the beneficiary and the prescribing physician (or treating practitioner) must occur within six months prior to the written order. The encounter must include examination, mobility assessment, and determination of medical necessity, all documented in the medical record.

9. What is prior authorization and which DME items require it? Prior authorization requires the supplier to obtain DME MAC affirmation before furnishing certain DMEPOS items. Currently 31 power mobility device HCPCS codes, certain pressure-reducing support surfaces, certain lower limb prosthetics, and other items on the Required Prior Authorization List require PA.

10. How does oxygen coverage work? Oxygen is its own payment category under Section 1834(a)(5). Months 1 through 36 are monthly rental payments. Months 37 through 60 are no-rental maintenance and contents months (supplier continues providing equipment and oxygen). The treating physician must recertify medical necessity at month 12 and month 24. Coverage criteria include PaO2 of 55 mmHg or less or SpO2 of 88 percent or less (Group I).

11. How does CPAP coverage and compliance work? After a sleep study documenting OSA, CPAP is authorized for a 12-week trial. Continued coverage requires compliance documentation: at least four hours per night on 70 percent of nights over a 30-consecutive-day period, plus a face-to-face evaluation between Day 31 and Day 91. The CPAP machine transmits adherence data to the supplier and physician.

12. What is the difference between a CPAP and a BiPAP? CPAP provides a single continuous pressure throughout the breathing cycle. BiPAP (a Respiratory Assist Device, or RAD) provides two pressures: higher on inspiration, lower on expiration. BiPAP for OSA requires documented CPAP failure. BiPAP has separate coverage criteria for restrictive thoracic disorders, severe COPD, and central sleep apnea.

13. What are the DMEPOS supplier standards? The 30 supplier standards at 42 CFR 424.57 include accreditation by a CMS-approved Accreditation Organization, a $50,000 surety bond per location, a physical facility, minimum operating hours, a complaint resolution process, compliance with the DMEPOS Quality Standards, and comprehensive liability insurance of at least $300,000.

14. How do I find a Medicare-enrolled DMEPOS supplier in Georgia? Use the Medicare.gov supplier directory at medicare.gov/medical-equipment-suppliers or call 1-800-MEDICARE. Verify the supplier's enrollment, accreditation, and (in CBAs) contract status before service.

15. What if my DME claim is denied? The Medicare appeals process has five levels: redetermination by the DME MAC (CGS for Georgia), reconsideration by a Qualified Independent Contractor, an Administrative Law Judge hearing, the Medicare Appeals Council, and federal district court review. Most DME appeals are resolved at the redetermination or reconsideration level.

16. Can Medicare Advantage plans cover DME differently than Original Medicare? Yes. Medicare Advantage plans must cover the same statutorily defined DME benefit but may use different networks, different prior authorization processes, and different cost-sharing structures (typically copayments per item rather than coinsurance). Always verify with your MA plan before obtaining DME.

17. Are prosthetic limbs DME? Prosthetic limbs are covered under Section 1861(s)(9) (artificial legs, arms, eyes) and paid under the Section 1834(h) prosthetics and orthotics fee schedule, separate from the DME fee schedule. The benefit covers both initial fitting and subsequent replacement.

18. Are diabetic supplies DME? Yes. Section 1861(n) explicitly includes blood glucose testing strips and blood glucose monitors as DME for individuals with diabetes. Therapeutic continuous glucose monitors are also covered under the DME benefit, with specific eligibility criteria.

19. What is a capped rental and when does title transfer? Capped rental is the largest DME payment category (Category 4). Monthly rental payments are made for 13 months. At the end of month 13, title to the equipment transfers to the beneficiary. The supplier remains responsible for maintenance and servicing for an additional five years.

20. Can I purchase a DME item outright rather than rent? For inexpensive or routinely purchased items (Category 1), yes, you may elect to purchase. For capped rental items, you may purchase outright at any time during the rental period, with appropriate accounting credit for rental payments already made. For items requiring frequent and substantial servicing, purchase is not available.

21. Do I need to use a Medicare-enrolled supplier? Yes. Medicare will only pay for DME furnished by a Medicare-enrolled supplier with current accreditation, surety bond, and (in CBAs) contract status. Verify supplier enrollment at medicare.gov before service.

22. What if I am dual-eligible (Medicare and Medicaid) in Georgia? Medicare is the primary payer for DME. Georgia Medicaid is secondary and may cover the 20 percent Medicare coinsurance for QMB beneficiaries. Some additional DME items not covered by Medicare may be covered by Georgia Medicaid under the EPSDT (children) or adult durable medical equipment benefit. Contact DCH Member Services at 1-866-211-0950.

23. Can I rent versus buy a wheelchair? Manual wheelchairs and most basic power wheelchairs are capped rental items: Medicare rents for 13 months, then title transfers to the beneficiary. Complex power wheelchairs with extensive customization are customized items, purchased only (no rental).

24. What is the role of the National Supplier Clearinghouse? The National Supplier Clearinghouse (NSC), operated by Palmetto GBA, is the Medicare contractor responsible for enrolling all DMEPOS suppliers nationally, issuing Provider Transaction Access Numbers (PTANs), conducting site visits, and revalidating supplier enrollment every three years. The NSC is reached at 1-866-238-9652. NSC is distinct from the DME MAC (CGS for Georgia), which processes claims.

25. How can a Georgia Medicare beneficiary report DME fraud? DME fraud may be reported to: (1) the HHS Office of Inspector General hotline at 1-800-HHS-TIPS (1-800-447-8477) or oig.hhs.gov; (2) 1-800-MEDICARE; (3) the Senior Medicare Patrol Program through GeorgiaCares at 1-866-552-4464; (4) the Georgia Attorney General's Medicaid Fraud Control Unit at 404-656-3300. :::

::: cta Georgia Medicare DME Benefit: Where to Get Help

If you or a family member needs help obtaining durable medical equipment, understanding coverage, or appealing a denial in Georgia, the following resources can help. Brevy compiles these contacts as a service to Georgia families and updates them regularly at brevy.com.

• 1-800-MEDICARE (1-800-633-4227): Medicare general information, claims questions, plan choices.
• DME MAC Jurisdiction C (CGS Administrators) at 1-866-270-4909: Part B DME claims, prior authorization, redetermination appeals for Georgia.
• National Supplier Clearinghouse (Palmetto GBA) at 1-866-238-9652: supplier enrollment verification.
• GeorgiaCares (Georgia SHIP) at 1-866-552-4464: free, unbiased Medicare counseling from State Health Insurance Assistance Program counselors statewide.
• KEPRO (Beneficiary and Family Centered Care Quality Improvement Organization for Georgia) at 1-844-455-8708: quality of care complaints.
• Georgia Department of Community Health (DCH) Medicaid Member Services at 1-866-211-0950: Medicaid coordination, dual-eligible questions, QMB billing protections.
• Social Security Administration at 1-800-772-1213: Medicare enrollment, Part A entitlement.
• Medicare Rights Center at 1-800-333-4114: independent counseling on Medicare coverage and appeals.
• Center for Medicare Advocacy at 1-860-456-7790: legal advocacy on Medicare DME coverage and appeals.
• Atlanta Legal Aid Society Senior Citizens Law Project at 404-377-0701: free legal assistance for Medicare beneficiaries 60 and over in metropolitan Atlanta.
• Georgia Legal Services Program at 1-800-498-9469: free legal assistance for Medicare beneficiaries outside metropolitan Atlanta.
• HHS Office of Inspector General Hotline at 1-800-447-8477: Medicare fraud and improper billing reports.
• HHS Office of Civil Rights at 1-800-368-1019: discrimination complaints in DME provision.
• Eldercare Locator at 1-800-677-1116: connects callers to Georgia Area Agencies on Aging.
• VA Benefits at 1-800-827-1000: for veterans who may have VA DME coverage in addition to Medicare.
• 211 Georgia: connects to community resources statewide.
• Brevy at brevy.com: comprehensive eldercare guides covering Medicare, Medicaid, VA benefits, and caregiving for Georgia families and across the country. Brevy is not affiliated with the federal government or with the State of Georgia.

This guide is for general educational purposes only and is not legal advice or medical advice. Specific cases should be discussed with a licensed attorney, certified Medicare counselor, or qualified medical provider. Brevy is committed to providing the most trustworthy and current eldercare information available; please report any inaccuracies to our editorial team at brevy.com. :::