General
Chapter 1
Addendum B
Figures
Revision:
Figure 1.B-1 Suggested
Wording To The Beneficiary Concerning Rental vs. Purchase Of Durable
Medical Equipment (DME)
“We have determined under the
Regulation that the total TRICARE benefit allowable, subject to
usual deductible and cost-sharing requirements, is $________. This
amount is equal to (the allowable purchase price of the equipment)
(____ months of estimated medically necessary rental, at $______
allowable rental per month).
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“You may obtain this equipment
under any arrangement you wish. However, it would be advantageous
for you to obtain the equipment by (rental) (purchase or lease/purchase).
Any expenses you incur in excess of the TRICARE-allowable amount
will be your own responsibility.
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“If you are not satisfied with
the action taken on your case, you have the right to a review. Your
written request for a review must state the specific matter with
which you do not agree and must be received in this office within
90 calendar days of this notice.
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“Accordingly, TRICARE payments
for this equipment will end with whichever of the following occurs first:
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1.
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When $_______ has been reimbursed,
subject to usual deductible and cost-share amounts.
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2.
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When you no longer require
the equipment medically.
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3.
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When your TRICARE eligibility
ends.”
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