DME and medical supply software in Baltimore: Medicare won’t pay for an auto-ship, and on January 5 competitive bidding goes national

Picture three medical supply businesses in Baltimore with a busy winter ahead. The first is a sleep and oxygen supplier in Towson, co-owned by a respiratory therapist, with about 900 patients on CPAP resupply. Last year she moved her cash customers onto a subscription app on her web store, and her biller asked whether the Medicare patients could go on it too. They cannot. Medicare’s refill rule became a federal regulation in 2024, it measures each item’s window from the day the old supply is expected to run out, and it can treat the moment a shipping label is printed as the date of service; the texting script her vendor still uses asks patients 14 days before shipping, which is the old rule. Her device portal shows each new patient’s average hours of use. What she needs to see is whether that patient still has a thirty-night window left in which to pass Medicare’s adherence test.

The second is a family medical supply store in Highlandtown, now in its second generation. It sells lift chairs, rollators, compression stockings, ostomy and incontinence supplies, delivers and sets up hospital beds and power chairs, takes Maryland Medicaid and has a WooCommerce site with a cart that almost nobody uses. Its owner did not know that setting up an electric bed in a patient’s home is, in Maryland, a licensed home health service, or that Medicare’s next round of competitive bidding, whose bid window opens on January 5, is a single national contest in which a store like his would have to be licensed in every state to compete for its own neighbors’ ostomy supplies. From January 1, 2028, without a contract, those sales to his Original Medicare customers stop.

The third is a former hospital case manager who wants to open a medical supply company in Northeast Baltimore. For six months this year she could not: Medicare froze new enrollments of medical supply companies nationwide from February 27 to August 27. Now that it has reopened, she is pricing a surety bond, an accreditation survey that since January has to be repeated every year, and an online store for CPAP supplies, and she has one question first: can she sell a CPAP mask to anyone who pays for it?

Each of them has a software problem dressed as a compliance problem. The rules now ask which items a patient may be asked about today, whether the yes is on file item by item, how many good nights a new CPAP patient still needs, which rental units are past their paid months, whether a device may be sold without a prescription and whose name has to be on the box. Every one of those questions is answered by the way a supplier keeps its patient records, its item master and its fleet, and the answers have to exist before an auditor or a payer asks. This article goes through those questions for Baltimore City and Baltimore County, using the federal regulations and coverage policies, Maryland’s statutes and Medicaid rules, the State’s and the City’s own documents, Medicare’s supplier directory and claims data, a look at how 41 Baltimore suppliers and 65 online CPAP and medical supply stores show up online, and what the software costs. It covers the online store too, because that is where the rules for the cash customer and the Medicare patient collide. It is our reading of the rules for the products we build, not legal or billing advice.

Baltimore’s medical supply market, by the numbers

Every business that bills Medicare for equipment or supplies has to enroll each location, and Medicare publishes the list. Its supplier directory, released on October 18, 2026, shows each location’s address, whether it accepts assignment and which of several dozen product categories it supplies. We placed every Maryland location in its county by coordinates and counted. Baltimore City has 75 enrolled supplier locations and Baltimore County 153, together 228 of Maryland’s 936. The headline count flatters the trade, because 165 of the 228, about 72%, are pharmacies, grocery stores or department stores that bill Medicare for a few items such as glucose test strips, canes and commodes. The equipment that needs delivery, setup and service is concentrated in very few hands.

Eleven locations in the two jurisdictions list CPAP devices and eight list oxygen; only five of the CPAP locations and three of the oxygen ones accept assignment, which means a Medicare patient using one of the others can be charged more than the Medicare-approved amount. Measured against demand, Baltimore is thin. Using CMS’s June 2026 enrollment counts, there are 13.7 supplier locations per 10,000 Original Medicare Part B beneficiaries in the City and 14.1 in the County, against 19.9 nationally, and 0.55 and 0.73 CPAP-listing locations per 10,000 against 1.99. That matters more here than elsewhere, because Baltimore’s Medicare population is unusually traditional: 63.4% of the City’s 104,499 beneficiaries and 74.0% of the County’s 174,763 are in Original Medicare rather than Medicare Advantage, against 48.9% nationally, so Medicare’s own DME rules, the ones in the sections on refills, CPAP and bidding below, govern most Baltimore patients directly instead of through a private plan’s version of them.

Medicare’s claims files show where the money goes. In 2024, the latest year published, suppliers located in Baltimore City billed $33.8 million in allowed Medicare DME charges, of which Johns Hopkins Pharmaquip, the equipment and infusion company of the Hopkins home care group, accounted for 55.7%; suppliers in Baltimore County billed $42.7 million, with the five largest taking 56.7%. Maryland clinicians ordered about $465 million of DME, devices and supplies that year, while suppliers located in Maryland billed $231.2 million in all, so roughly half or more of what Maryland’s clinicians order is filled from outside the state, a pattern we return to in the section on competitive bidding. Two codes stand out in the state’s mix: alginate wound dressings were 18.5% of Maryland-ordered DME spending against 5.5% nationally, and one intermittent catheter code was 16.9% against 9.8%; catheter billing is exactly what CMS cited when it froze new enrollments this year. We report both as anomalies in the data, not as findings about anyone.

The Census Bureau’s payroll data tell the same story from the employer side, with the usual caveat that County Business Patterns counts only establishments with paid employees and that many DME suppliers are classified as pharmacies. In 2023, Baltimore City had 14 establishments in the category that includes medical equipment, convalescent supply and hearing aid stores, 71% of them with fewer than five employees, and Baltimore County 33; home health equipment rental, the narrow code for rental fleets, had no reportable establishment in the City and three in the County, down from six in 2018, while the national count fell 21% over the same five years. Demand is not the constraint. The City has 91,186 residents aged 65 or older and the County 162,087, and 38.1% of the City’s older residents report a disability.

Nationally, the trade is consolidating around a few large companies, and 2025 and 2026 reshuffled them. AdaptHealth, one of the largest, reported $3.24 billion in revenue for 2025 and about 4.8 million patients a year from roughly 670 locations by mid-2026, with sleep therapy 42% of its revenue and resupply and one-time sales 63%. Owens & Minor called off its planned acquisition of Rotech in June 2025, paying an $80 million termination fee after concluding that clearance from the Federal Trade Commission had “proved unviable,” and now trades as Accendra Health with Apria and Byram; Quipt Home Medical went private in March 2026; and in September Rotech agreed to buy Inogen’s US oxygen rental business. On the device side, ResMed reported $5.65 billion in revenue for its fiscal year ended June 30, 2026, and warned investors that GLP-1 drugs, one of which the FDA approved for obstructive sleep apnea in adults with obesity in December 2024, “could impact” its sales, while Philips remains unable to sell new sleep devices in the United States, which we come back to below. For an independent in Baltimore, the competitors that matter are the national companies’ local branches, the hospital systems’ own equipment arms and the online stores that sell cash-pay supplies into the city from everywhere else.

What DME software costs, and who pays the meters

A medical supply business runs on more software than its size suggests: a billing and intake platform built for DME, a clearinghouse, the manufacturers’ device-data portals, referral platforms that bring orders in, an online store with its payment processor, and, for many suppliers, an outside resupply service. Around them sit the costs of being allowed to bill at all. We checked each vendor’s own pricing page on October 20, 2026, and counted a price only if the vendor publishes it today.

The billing platform: quoted, not published

The category’s best-known systems do not publish a price. Brightree, which ResMed owns, has no pricing on its site, and the pricing address that some guides still link to returns a 404. Bonafide and Fastrack have both been folded into WellSky, and their old domains now redirect to WellSky’s DME pages, where resupply is sold as “S3 Resupply, powered by WellSky”; neither page shows a price. NikoHealth says its pricing is quoted, TIMS now lives at Computers Unlimited, and DMEworks’ pricing page returned an error when we checked. Aggregator sites print per-user estimates for several of these products, and we could not confirm any of them, so we do not repeat them. The one DME billing platform we found with a public price list is TrueSight, at $500 a month for five users plus $75 for each additional user, $500 for onboarding and $1,500 to $3,500 for optional data migration, which its vendor says covers intake through billing, automated resupply and drop-shipping.

The ordering side is priced by the other party. Referral platforms such as Parachute Health and DMEscripts are free to the prescribers who send orders, and the supplier pays; DMEscripts says so plainly and does not publish the per-order fee, and Parachute’s pricing page returns a 404 and its terms of service carry no fee schedule. The manufacturers’ device-data portals, ResMed’s AirView, Philips’ Care Orchestrator and React Health’s Connect, publish no fees either; access goes through a sales representative or a registration form. That last pattern matters more than it looks. The usage report Medicare requires for every CPAP patient lives on a platform the device maker controls, and at ResMed, which also owns Brightree, the platform, the billing system and the machine come from the same company.

The compliance meter now runs every year

The cost of being allowed to bill went up on January 1, 2026, when the annual reaccreditation rule took effect. BOC’s current application form, from an accrediting body headquartered in Owings Mills, charges $2,500 per facility for the annual site survey, “for 1-Year Accreditation,” plus $2,000 for a second visit if files or key staff are not available at the unannounced one. CMS’s own impact analysis assumed a fee of $3,000 a year plus 14 hours of a supplier’s staff time. NABP, which accredits pharmacies that bill DMEPOS, charges $4,000 for a new single location and $3,100 for a renewal. ACHC, HQAA, The Compliance Team and The Joint Commission do not publish their fees. To that add the $750 application fee at enrollment, at each three-year revalidation and for each new location, the $50,000 surety bond for each location, which bond sellers quote at roughly $250 a year for good credit and up to $2,000 for weak credit, and the $300,000 liability insurance policy that supplier standard 10 requires.

Claims cost almost nothing; cards do

The cheapest part of the stack is the one suppliers worry about most. Noridian, which processes Medicare’s DME claims for Maryland, points suppliers to PC-ACE, free claims software for Medicare’s electronic gateway; Office Ally charges nothing for claims to participating payers and $44.95 a month otherwise; Claim.MD’s unlimited plan is $120 a month. For a supplier of the size we model below, the clearinghouse is a thousand to fifteen hundred dollars a year.

The online store is cheap to run and expensive to charge through. Shopify Basic is $29 a month on annual billing with online card fees of 2.9% plus 30 cents; Square’s free plan charges 3.3% plus 30 cents online, 2.9% on paid plans, and 3.5% plus 15 cents on every plan for a charge to a card on file, which is exactly the charge a subscription makes; BigCommerce caps each plan by trailing sales and adds a fee on orders taken through outside payment providers. At $150,000 a year of cash sales, card fees come to about $4,950 against $348 for the Shopify plan itself. And payment processors treat this trade as a special case: Stripe’s list of restricted businesses includes “prescription-only and regulated medical devices,” which means extra review, and possibly proof of licenses, before it will process for them. LegitScript’s healthcare certification, which Google and Microsoft require of online pharmacies but, as far as we can find, not of device sellers, costs $975 per website to apply and $2,150 a year after that.

What the stack costs a real supplier

To put the published numbers together, we modeled a Baltimore independent with one storefront, 1,200 CPAP patients on resupply, 300 rental items in the field, a payer mix of 40% Medicare, 35% commercial and 25% Medicaid, and a cash online store selling $150,000 a year in orders averaging $75. We used TrueSight as the billing platform because it is the only one with a published price, BOC for accreditation, the lowest bond quote, and, for outsourced resupply, the worked example the buying group VGM published in 2023, in which fulfilling resupply for 1,000 CPAP patients cost about $63,000 a year in-house and about $32,000 outsourced, scaled to 1,200 patients. VGM sells that service, so treat the figure as a vendor’s illustration rather than a quote.

Two things stand out. The software is the small part: in Stack A, the store’s card fees alone are nearly as large as the billing platform, and the accreditation that now comes every year costs half as much again as the clearinghouse and the bond together. And the expensive line, resupply, is the one this article is mostly about, because it is the part of the business where Medicare’s refill rule, the patient’s yes and the shipping label have to line up, and where a supplier either builds that discipline into its own system or pays someone else to.

Medicare will not pay for an auto-ship, and the rule is a regulation now

Every e-commerce platform sells the same retention feature. The customer picks a product, picks an interval, and the store charges the card and ships the box every 30, 60 or 90 days until somebody cancels. For a company selling CPAP cushions, filters and tubing to people who pay with a credit card, that is a perfectly good business. For the same company billing Medicare for the same cushions, it is a claim the program has said in writing it will deny.

The rule used to live in CMS’s Program Integrity Manual and in the coverage documents published by the regional contractors that process Medicare’s equipment claims, the local coverage determinations, and it was famous for its numbers: contact the beneficiary no sooner than 14 days before shipping, deliver no sooner than 10 days before the old supply runs out. Those numbers are still everywhere. The American Academy of Sleep Medicine’s page announcing the rule, published in 2012 and still online, gives the 14 days, and a consumer guide that ranks for Medicare CPAP questions follows its table of replacement schedules with the news that many suppliers “ship supplies automatically when each window opens.” Both are wrong today. In the calendar year 2024 home health payment rule, published on November 13, 2023, CMS moved the refill requirement into the Code of Federal Regulations itself, at 42 CFR 410.38(d)(4), and changed the clock. Since January 1, 2024, the regulation reads:

“Evidence of the beneficiary or their representative’s affirmative response of the need for supplies, which should be obtained as close to the expected end of the current supply as possible. Contact and affirmative response must be within 30 calendar days from the expected end of the current supply.” And: “The date of service for DMEPOS items provided on a recurring basis must be no earlier than 10 calendar days before the expected end of the current supply.”

The contractors rewrote their policies to match. The local coverage determination for positive airway pressure devices, L33718, now says that for the PAP supply codes a supplier “must contact the beneficiary, and document an affirmative response, prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the beneficiary,” that contact “must take place no sooner than 30 calendar days prior to the expected end of the current supply,” and that a supplier “must not dispense more than a three (3) - month quantity at a time.” Its revision history records the swap word for word: the 14 days before shipping became 30 days before the expected end of the supply, effective January 1, 2024.

Read as software, those three sentences describe something no general-purpose subscription app does. The unit of the rule is not the customer or the order. It is each item on the order, with its own expected end date, its own window in which the supplier may ask, its own earlier limit on when it may ship, and its own record of a yes.

Thirty days to ask, ten days to ship

Take a patient who started CPAP on a nasal mask and received a three-month supply on January 1. Medicare’s table of “usual maximum” quantities for PAP accessories, also in L33718, allows one nasal mask every three months, two cushions a month, two disposable filters a month and one length of tubing every three months, and only one headgear, one non-disposable filter and one humidifier water chamber every six months. The cushions, filters, mask and tubing that shipped on January 1 are expected to run out around April 1. The supplier may ask the patient whether they need more no earlier than March 2, thirty days before that date. It may create the shipping label, which as we explain below is the date of service, no earlier than March 22. If the patient says yes on March 5, the supplier has a valid request but must still hold the box until March 22. If the supplier texts on February 25, the answer does not count, however enthusiastic it is.

Two things fall out of the table. The first is that a supply “box” is a fiction the supplier maintains by keeping items in step. Six of the ten items above run on a three-month cycle and four on a six-month cycle, so the April box and the July box are different boxes, and a patient who received a replacement headgear in February after breaking a clip now has a headgear on its own six-month clock until the supplier brings it back into line. The second is that the rule cannot be satisfied by a setting. It is satisfied by a record, written before the label is printed, that names the patient, the date of contact, each item requested and an affirmative answer, which is exactly what the contractors’ standard documentation article, A55426, lists as the contents of a refill record.

The shipping label is the date of service

The regulation also defines a term that most systems treat as an afterthought. For items sent “via delivery or shipping service,” the date of service is the shipping date, and the shipping date is “the date the delivery/shipping service label is created” or the date the item is picked up for delivery, two dates that, in the regulation’s words, “must not demonstrate significant variation.” A supplier may use the delivery date instead, and for a patient who collects supplies at the counter the date of service is the day they were handed over. For a supplier that bills on the shipping date, the moment a warehouse worker clicks “create label” is now a regulated event: it fixes the date on the claim, and if it falls more than ten days before the expected end of the current supply, the claim is early.

The proof that the box arrived is regulated too. Under A55426, a supplier that ships must keep a record “tracking the item(s) from the DMEPOS supplier to the beneficiary,” and its own shipping invoice must be linked to the carrier’s record by the carrier’s package number, the invoice number or another clear method. The record must show the patient’s name, the delivery address, a description of each item, the quantity, the delivery date and evidence of delivery, and it has to be kept for seven years from the date of service. A supplier, its employees and anyone else with a financial interest in the delivery may not sign for a box on the patient’s behalf. An order management system that stores a tracking number on the order rather than on each shipped line, or that overwrites the label date when a label is reprinted, is building a record that will not survive an audit.

An affirmative answer, item by item

Medicare does not say how the supplier must ask. The documentation article is explicit that “the refill request communication may be performed via automated text messaging or email as long as each required aspect of the refill request is captured,” and that the request “must occur and be documented before shipment.” It is just as explicit that “a retrospective attestation statement by the supplier or beneficiary is not sufficient.” So a text that says “Reply YES to receive your CPAP supplies” is acceptable only if the system knows which items the yes refers to, when it was received, and that it arrived inside each item’s thirty-day window. A reply that says “yes, but I still have plenty of filters” is a yes for the mask and a no for the filters, and the software has to be able to record it that way.

L33718 carries two further duties that belong in the product, not in a training manual. Suppliers “must not dispense a quantity of supplies exceeding a beneficiary’s expected utilization,” must “stay attuned to changed or atypical utilization patterns” and must check with the treating practitioner when usage changes. And “if there is discontinuation of usage of a PAP device at any time, the supplier is expected to ascertain this and stop billing for the equipment and related accessories and supplies.” A resupply program that keeps shipping cushions to a patient whose machine has not recorded a night of use since spring is not a loyal customer program. On Medicare’s reading it is an overpayment waiting to be found.

Picking up the phone has a rule of its own. Supplier standard 11 in 42 CFR 424.57(c) forbids a supplier to telephone a Medicare beneficiary about a covered item unless the beneficiary has given written permission, the call is to coordinate delivery of an item the supplier has furnished, or, if the call is about an item the supplier has not furnished to that person before, it has furnished at least one covered item to them in the preceding 15 months. The statute behind the standard, section 1834(a)(17) of the Social Security Act, is blunt about the consequence of a knowing violation: “no payment may be made under this part for any item subsequently furnished to the individual by the supplier.” A campaign that calls a resupply list about compression stockings or a new mask style therefore needs two dates for every patient, the last covered item and the written permission on file, before it dials anyone.

None of this is a hypothetical audit risk. According to the Office of Inspector General, Medicare paid about $945.8 million for replacement PAP supplies in 2017 and 2018, and earlier OIG work had found that most supplier claims for those supplies did not meet Medicare’s requirements. Its most recent audit of PAP device claims, which concluded that payments generally complied, still found that 13 of 110 sampled claims lacked the documentation to support them, an estimated $15.2 million in improper payments, and its recommendations to CMS were still open in 2026. Contractors find these gaps by asking for the records, item by item, years later.

Why the subscription app gets it wrong, and the cash store does not

None of this stops a medical supply store from selling subscriptions. A customer who pays cash, or with a health savings account card, and has a prescription on file can be put on a quarterly auto-ship like anyone else; the refill regulation is a condition of Medicare payment, not a rule about retail. The trouble starts when one storefront serves both kinds of customer, which describes many independent suppliers in Baltimore. The cash customer and the Medicare beneficiary want the same cushion, see the same product page and may live on the same block. One may be shipped on a timer. The other may be shipped only after a dated, item-level yes collected inside a thirty-day window, on a label created no more than ten days before the old supply runs out, with a delivery record that can be produced for seven years. Commercial plans and Maryland Medicaid add their own versions, often modeled on Medicare’s and sometimes stricter, which is why the payer, and not the product, has to decide which engine runs a given patient’s refills.

That is the first place where general-purpose retail software and a DME business part ways, and it is the reason this article spends as much time on the online store as on the billing system. The cart is not the problem. The clock behind it is.

The machine decides whether you get paid: CPAP’s 90-day test and the clocks after it

A CPAP machine is the most software-shaped product a medical supply store sells, because Medicare pays for it only if the machine itself testifies that it is being used. The PAP coverage policy, L33718, covers the device once three things are documented: an in-person evaluation before the sleep test, a sleep test showing an apnea-hypopnea index of at least 15 events an hour (or 5 to 14 with qualifying symptoms or conditions), and the supplier’s instruction in how to use and care for the machine. That starts what the policy calls the initial 12-week trial. To keep it covered from the fourth month on, two things must happen. The treating practitioner must see the patient “no sooner than the 31st day but no later than the 91st day after initiating therapy” and document that the symptoms of sleep apnea have improved. And there must be objective evidence of adherence, which the policy defines in one sentence that every sleep supplier in the country can recite:

“Adherence to therapy is defined as use of PAP ≥4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage.”

The companion policy article, A52467, says where that evidence comes from: “through direct download or visual inspection of usage data with documentation provided in a written report format to be reviewed by the treating practitioner and included in the beneficiary’s medical record.” In practice that means the usage report from the machine’s modem or memory card, pulled from the manufacturer’s cloud platform. The article adds a warning that suppliers should take personally: the forms many suppliers send to practitioners to fill in “have not been approved by CMS,” and a completed one “is not a substitute for the comprehensive medical record.”

Twenty-one nights in any thirty

Seventy percent of thirty nights is 21. Taking the first three months as 90 nights, there are 61 distinct thirty-night windows a patient can pass in, the first running from night 1 to night 30 and the last from night 61 to night 90, and the patient needs one of them, not an average across all of them. That produces some arithmetic a resupply team rarely sees laid out. A patient who uses the machine for four hours on each of the first 21 nights has already passed, because the first window will contain those 21 nights whatever happens next, although the re-evaluation still cannot happen before day 31. A patient who has not had a single four-hour night by night 69 can still pass, but only by reaching four hours on every one of nights 70 through 90, which fills exactly 21 of the 30 nights in the last window. A patient who reaches night 71 without a single qualifying night cannot pass, however well they sleep for the rest of the trial.

So the number that matters on a supplier’s dashboard is not the average hours per night that every manufacturer’s app displays. It is, for each new patient, the best thirty-night window so far, how many qualifying nights are still needed in the windows that remain open, and the last date on which the trial can still be rescued. A respiratory therapist who calls a struggling patient on day 40 about a leaking mask has room to fix it. One who calls on day 75 may be calling about a trial that the calendar has already decided.

What a failed trial costs, and who notices first

The policy article lets a supplier choose how to handle the fourth month. It may hold the claims “pending receipt of information from the treating practitioner,” then submit them with the KX modifier that says the coverage criteria are met. If the practitioner does not confirm in time, it may submit them without the modifier, which in practice means they will be denied. If the re-evaluation happened late but the patient is benefiting and adherent, coverage resumes, but “only for dates of service following the date of the clinical re-evaluation.” A patient who fails outright must have a new in-person evaluation and a repeat sleep test “in a facility-based setting” before Medicare will pay for a device again. In Baltimore, where Medicare still pays the rates of the former Baltimore-Columbia-Towson competitive bidding area, the 2026 allowed rental for a standard CPAP device (E0601) is $51.70 a month for each of the first three months and, because the regulation pays 7.5% of the purchase price instead of 10% from the fourth month on, $38.78 a month for months four through thirteen: $542.90 over the whole rental, of which Medicare pays 80% after the Part B deductible. A failed trial forfeits the last ten months, $387.80, and the supplies that ride on them, which are the bigger number. At the usual maximums and Baltimore’s 2026 rates, a nasal-mask patient’s masks, cushions, disposable filters and heated tubing come to $1,185.24 a year, before headgear, water chambers and reusable filters. Over the device’s five-year useful life, a patient who reorders those four items at the usual maximums is worth about eleven times the machine.

Most of that money is decided by a patient’s experience with the mask in weeks two through eight, and most of the information that would predict it is already sitting in the manufacturer’s platform: hours of use, mask leak and residual events, night by night. The supplier usually sees it in a weekly export or not at all, while the reminder to the practitioner’s office about the re-evaluation lives in a different system, if it lives anywhere.

Thirteen months, then the patient owns it

The CPAP device is a “capped rental” item. Under 42 CFR 414.229(f), Medicare pays a monthly rental for no more than 13 months of continuous use, and the supplier “must transfer title to the item to the beneficiary on the first day that begins after the 13th continuous month in which payments are made.” Around that clock the regulation hangs three more duties. Before furnishing the item, the supplier must disclose whether it will accept assignment of all the monthly rental claims. The supplier that furnishes the first month must keep furnishing until medical need or the 13 months end, with narrow exceptions such as the patient moving away or choosing another supplier, and it may not swap the machine for a different one during the rental except for a listed reason. And “no later than two months before the date on which the supplier must transfer title,” it must tell the beneficiary whether it can maintain and service the item once the beneficiary owns it, which for a rental that began on January 1, 2026, means by December 1, 2026, ahead of a title transfer on February 1, 2027.

Continuity is defined just as precisely. Under 42 CFR 414.230, an interruption of “not longer than 60 consecutive days plus the days remaining in the rental month in which use ceases” is temporary, so a patient who stops using the machine during a hospital stay and starts again does not restart the rental count; a longer break, properly documented, can begin a new rental period. Counted from delivery, not from the title transfer, the machine’s reasonable useful lifetime is five years. A device lost, stolen or irreparably damaged in a specific incident inside those five years can be replaced without a new sleep test or trial; after five years, the patient needs an in-person evaluation documenting that they still use and benefit from it, but not a new sleep test.

Oxygen pays for 36 months and lasts for 60

Home oxygen runs on a longer and stranger clock. 42 CFR 414.226 pays a monthly rental for oxygen equipment for “no longer than a period of continuous use of 36 months.” Then the payments stop and the obligation does not. The supplier that furnished the 36th month must “continue to furnish the equipment during any period of medical need for the remainder of the reasonable useful lifetime,” which is five years, or arrange for another supplier if the patient moves away; for liquid or gaseous systems it must keep delivering the oxygen contents too. Medicare pays no rental for the remaining 24 months. For a concentrator it pays nothing for the first six months after the cap, then one maintenance and servicing payment, capped at 10% of a stationary concentrator’s purchase price, at the start of each later six-month period, and only if the supplier visits the home that month to inspect the equipment; for liquid and gaseous systems it pays for the oxygen contents separately. In Baltimore a concentrator rents for $105.30 a month in 2026, or $3,790.80 over the 36 months. Months 37 through 60 are, from the supplier’s point of view, two years of concentrators in living rooms, service calls and tank deliveries for patients who are no longer generating rental revenue, and a fleet system that cannot say which units are in that tail, and for how many more months, cannot price the business.

None of these clocks is exotic to the people who run a sleep or respiratory department; they live with them every day. What is unusual is how few of them a typical system computes. Billing platforms built for this trade handle the claims and many of the modifiers. The adherence window, the rescue date, the two-month maintenance letter, the break-in-use counter and the oxygen tail tend to live in spreadsheets, reminders and the memory of one senior coordinator, which is the kind of knowledge that leaves with the person who has it.

Competitive bidding returns on January 5, and this time it is national

For most of the last decade, what Medicare paid for a hospital bed or a box of CPAP cushions in Baltimore was set, directly or indirectly, by an auction. The DMEPOS Competitive Bidding Program started in nine metropolitan areas in 2011, grew to 130 competitive bidding areas covering about half of Part B enrollees, and paid only the suppliers that won a contract in each area. The Baltimore-Columbia-Towson area was one of them, and when the last full round ended in 2018 and a narrow one covering only off-the-shelf back and knee braces ended on December 31, 2023, Medicare entered what it calls a temporary gap period. It is still in it, and the gap has left a mark on every claim a Baltimore supplier sends.

Baltimore is priced from its own column

During the gap, Medicare prices most equipment in a former bidding area at the last contract prices there, raised each year by inflation, and prices the rest of a state’s non-rural ZIP codes at a separate adjusted fee, with rural ZIP codes on a blend of their own. The October 2026 fee schedule files list 220 ZIP codes in the former Baltimore-Columbia-Towson area, including the 60 that begin with 212, and its rates are not Maryland’s statewide rates. A supplier with patients on both sides of that boundary bills from two price tables, and from a third for a patient in rural western Maryland, so a fee lookup keyed by state alone is wrong for Baltimore before it starts.

The differences between the Baltimore and non-rural columns are small, from nothing on a hospital bed to 9.2% on an oxygen concentrator and nearly 12% on a disposable filter, but they are on every claim, and rural rates run from about 30% above Baltimore’s to nearly double. Medicare pays 80% of the allowed amount after the Part B deductible, the patient or a secondary plan the rest.

Round 2028: seven categories, one bidding area, and nobody in Baltimore can bid locally

The program comes back in a form that looks nothing like the old one. The calendar year 2026 home health payment rule, published on December 2, 2025, set up a “remote item delivery” program, and for Round 2028 CMS is running it as one nationwide competitive bidding area covering every state, the District of Columbia and the territories. Only seven product categories are in it, and they are the ones that already travel by mail.

The calendar is now fixed. According to CMS’s October 8 announcement and the bid instructions that followed, bidder registration opens on December 1, 2026, and closes on February 1, 2027; the bid window opens on January 5, 2027, and closes on March 10; contracts are to be awarded in late summer or early fall of 2027 and run from January 1, 2028, through December 31, 2030. A bidder submits one composite price for the lead item in each category, and CMS derives every other code’s price from it with fixed ratios; the payment amount is now the 75th percentile of the winning bids rather than the highest winning bid, and in CMS’s own worked example a 30% cut on the lead item flows through to every code in the category. A rule finalized in August raised the bid surety bond for the nationwide area to $100,000, against $50,000 elsewhere, and the bid instructions require a contract supplier to hold every state’s and territory’s license for the products it bids, recorded in Medicare’s enrollment system before the window closes, and to be ready to serve the whole country from the first day.

For a Baltimore medical supply store, the arithmetic is simple and uncomfortable. CPAP devices and supplies, oxygen, hospital beds, wheelchairs and lift chairs are not in Round 2028, so they stay on the gap-period prices above. But a store that sells ostomy supplies, urological supplies, catheters or off-the-shelf braces to patients in Original Medicare will not be paid for those items from January 1, 2028, unless it holds one of the handful of national contracts, or an exception applies: physicians, treating practitioners and therapists furnishing off-the-shelf braces (and, for practitioners, insulin pumps) to their own patients, hospitals furnishing them at discharge, a supplier the patient’s primary insurer requires, and suppliers that choose to be grandfathered for CGMs and insulin pumps already on rental. CMS’s fact sheet estimated four to ten contracts per category, with a goal that at least 30% of contract suppliers be small businesses, defined as $3.5 million or less in gross revenue. Even with that goal, few independent stores in Baltimore will win one of so few national contracts. The first six months of 2028 are, in CMS’s words, a grace period for contract suppliers to obtain written orders for the patients who move to them, and “not a transition period during which non-contract suppliers can continue furnishing competitively bid items.”

Maryland’s own claims show why CMS drew the line where it did. By our count from Medicare’s 2024 supplier and referring-provider files, suppliers located in Maryland billed amounts equal to only about 17% of the continuous glucose monitor supplies that Maryland clinicians ordered and about 1% of the intermittent catheters, against about 96% of the CPAP devices and 99% of the oxygen concentrators. Supplies already arrive by mail from somewhere else; equipment that has to be fitted, set up and repaired is still delivered from down the road. Round 2028 writes the first half of that sentence into the payment rules.

The paperwork got heavier this year too

Several smaller changes in 2026 land on the same intake desk. The same December 2025 rule requires every accredited supplier to be “surveyed and reaccredited at least once every 12 months,” in standard 24 of 42 CFR 424.57(c), and extends Medicare’s rule that a change in majority ownership within 36 months of enrolling forces a new enrollment to DMEPOS suppliers. CMS added the oxygen concentrator and other oxygen codes to the list of items that need a face-to-face encounter and a written order before delivery on April 13, 2026, and will add manual wheelchairs and home ventilators on October 28, 2026, which will bring the list to 105 codes; prior authorization was extended to more braces and pneumatic compression devices on April 13 and will be extended to further braces, an ultralightweight wheelchair and an air-fluidized bed on October 28. The enrollment application fee for 2026 is $750, revalidation still comes every three years, and every location needs its own $50,000 surety bond.

And for six months this year, a new medical supply company could not enroll at all. On February 27, 2026, CMS imposed a nationwide moratorium on new Medicare enrollments, and new locations, for seven “medical supply company” supplier types, citing a 17% revocation rate for that group, nearly triple that of other DMEPOS suppliers, and a 2023 urinary catheter scheme involving 15 companies; pharmacies, grocery stores and providers whose main business is not DMEPOS were generally outside it. The moratorium was allowed to expire on August 27, 2026, and, according to the trade association AAHomecare, CMS urged suppliers planning to bid to file their enrollment applications quickly so they could be processed before the bid window opens. For a new Baltimore supplier the checklist is now enrollment, accreditation for every product line it will bill, a bond for each location and, if it will set up equipment in patients’ homes, the Maryland license described below, all before the first claim. And the proposed 2027 home health rule would require contract suppliers to report the country of origin of the lead items they furnish, one more catalog field if it is finalized.

The prescription is a field in the cart, and the label has to name the prescriber

Medicare decides whether a claim is paid. The Food and Drug Administration decides something prior: whether a device may be sold to a given person at all. A device whose label says “Rx only” is exempt from the requirement to carry directions a layperson could follow only if, in the words of 21 CFR 801.109, it “is to be sold only to or on the prescription or other order of such practitioner.” The next section, 801.110, sets the condition for the retail sale itself, and it reads like a fulfillment specification: the device is exempt at delivery to the ultimate purchaser if it is delivered “upon a prescription or other order lawfully issued in the course of his professional practice, with labeling bearing the name and address of such licensed practitioner and the directions for use and cautionary statements, if any, contained in such order.”

For an online store, that sentence does two things. It makes the prescription a precondition of shipment rather than a document filed somewhere afterward, and it puts the prescriber’s name and address, with any directions or cautions from the order, on what goes into the box: the label or the packing slip, not just a database row. The FDA has been blunt about the same rule in a neighboring market, telling consumers that websites selling decorative contact lenses without a prescription “are breaking the law” and that they should buy from a seller that requires one “whether you purchase them in person or shop online.” As our census of online stores below shows, most online CPAP stores take the payment first and hold the order; a better design holds the payment too, authorizing the card and capturing it only once the order is on file and checked.

Prescription status belongs to the model, not the category

It is tempting to tag whole categories, CPAP as prescription and wheelchairs as retail, and the FDA’s own clearance documents show why that fails. Each cleared device comes with an indications-for-use form on which the manufacturer checks prescription use, over-the-counter use or both, and the boxes differ inside a category.

So the flag belongs on the SKU and comes from the device’s label or its clearance, not from the category tree. Oxygen adds a twist of its own: under 868.5655, “an empty portable liquid oxygen unit is a device, while the oxygen contained therein is a drug.” And Medicare sits on top of all of it: an over-the-counter power chair can be sold for cash to anyone, but the same chair billed to Medicare needs a written order, a face-to-face encounter, the order before delivery and prior authorization, because Medicare’s rules and the FDA’s are separate layers that a catalog has to hold side by side.

Recalls and consent decrees live on the SKU too

The largest event in this market in a decade is still shaping what a Baltimore supplier can stock. Philips Respironics recalled about 15 million sleep and respiratory devices worldwide in June 2021 over a degrading sound-abatement foam, and the consent decree entered in federal court in Pittsburgh on April 9, 2024, bars it from distributing devices from its covered facilities “unless and until” a list of conditions is met, the last being the FDA’s written notice that the company appears to be in compliance. The decree’s appendices still allow masks, consumables, accessories and replacement parts, and a list of medically necessary devices that includes some oxygen concentrators and ventilators, with Philips paying the government a share of the net revenue on those, 25% from 2026. In its annual report filed in February 2026, Philips said that until the decree’s requirements are met, “Respironics will not sell new CPAP or BiPAP sleep therapy devices or other respiratory care devices in the US,” and we found no later notice lifting that. A supplier’s catalog therefore needs a way to say that a brand’s masks are orderable and its new machines are not.

Masks carry a warning of a different kind. In a Class I recall that the FDA publicized in January 2024, ResMed corrected the labeling of several AirFit and AirTouch masks whose headgear clips contain magnets, after reports that the magnets can interfere with implanted metallic devices; the FDA’s safety communication tells patients to stop using such a mask if they “or anyone in close physical contact with the mask” have one of a long list of implants, from pacemakers and neurostimulators to aneurysm clips and cochlear implants, and to keep the mask “at least six inches away” from them. That is a product-page warning, a question for the intake form and a rule for the cart at once, because the same patient record that holds the prescription should hold the answer. The recall records identify affected units by device identifier and user-guide version, which is one more reason to store those fields when a mask ships. The cleaning gadgets sold beside the masks have their own trap: the FDA has authorized a device only as an add-on that reduces bacteria on CPAP accessories, and its consumer page says there are no devices cleared or approved for cleaning, disinfecting or sanitizing CPAP machines, so product copy calling one an “FDA-approved CPAP cleaner” is a claim the store cannot make.

Two federal rules that reach into the bundle

The first is a Medicare rule that breaks a popular online product. Under 42 CFR 424.57(f), “no Medicare payment will be made to the supplier of a CPAP device if that supplier, or its affiliate, is directly or indirectly the provider of the sleep test used to diagnose the beneficiary,” unless the test was an attended polysomnogram in a facility. A store that sells a home sleep test and then the machine it leads to can serve cash customers that way; for a Medicare patient, the bundle makes the machine unbillable.

The second is the FDA’s device tracking rule, which applies to a short list of devices that include home ventilators, apnea monitors and breathing-frequency monitors, though not CPAP machines, concentrators or wheelchairs. A supplier that rents a tracked device to one patient after another is a “multiple distributor” under 21 CFR 821.30(c) and must keep, for each unit, the patient’s name, address, telephone number and Social Security number if available, the location of the device and the prescribing and following physicians, and produce that record within five working days of a manufacturer’s request or ten of the FDA’s, keeping it for the useful life of the device. A patient may refuse to have identifying information released, and the system has to record that too. For hospital beds, the FDA’s 2006 guidance on entrapment recommends dimensional limits for the gaps around a bed, and adult portable bed rails made after August 21, 2023, fall under a separate Consumer Product Safety Commission standard, so a bed, its rails and its mattress are a combination to check, not three unrelated SKUs.

Maryland adds a license, a second refill clock and a checkout page

A common answer to “do you need a license to sell medical equipment in Maryland?” is no, because the state has no license called a DME license. The answer is wrong for most of the businesses this article is about, and the state’s Medicaid program, its insurance code and its consumer rules each add a layer that a supplier’s software has to carry on top of Medicare’s.

Delivering oxygen is home health care

Maryland’s pharmacy law steps aside for this trade on purpose. Health Occupations §12-102(i) says the Pharmacy Act “does not apply to a person who only dispenses” prescription devices that contain no prescription drug, devices “within which the only prescription drug is medical oxygen,” durable medical equipment as Medicare defines it, and prosthetics and orthotics. The Board of Pharmacy has no DME permit at all. But the health facilities law picks the trade up at the patient’s front door. Under Health-General §19-4A-01, “home health care” includes “home medical equipment services,” defined as “the delivery, installation, maintenance, or replacement of, or instruction in the use of, medical equipment used by a sick or disabled individual to allow the individual to be maintained in a noninstitutional environment,” and “medical equipment” means “technologically sophisticated medical devices,” a list that begins with oxygen and oxygen delivery systems, ventilators, respiratory disease management devices and electronic wheelchairs and seating systems and continues through apnea monitors, TENS units, pressure-relief and compression devices and feeding pumps. The regulations add electrically powered hospital beds.

A business that employs or contracts with people to provide home health care in a patient’s residence is a residential service agency, and it needs a license from the Office of Health Care Quality. Under COMAR 10.07.05 the license costs $1,000 for three years, and the regulation’s special requirements for home medical equipment services read like a delivery checklist: staff who can demonstrate competency in delivering and installing the equipment, written instructions to the client at installation, a telephone number for equipment failure or emergency, a client record that includes the physician’s order, and installation, maintenance, repair and storage that follow the manufacturer’s specifications. Operating without the license can bring a civil penalty of up to $10,000 per violation and a misdemeanor charge, and Maryland Medicaid requires every DME provider to prove either the license or an exemption. Our reading is that a CPAP setup counts as a respiratory disease management device; a store that hands walkers across a counter or only ships supplies is outside the definition. For comparison, Florida simply requires a home medical equipment provider license. Maryland reaches the same businesses through a home care statute, which is easy to miss.

Maryland Medicaid runs a different refill clock

The state’s Medicaid rules for medical supplies and equipment, COMAR 10.09.12, have their own refill requirement, and it is not Medicare’s. A provider “shall contact the recipient or designee regarding refills no earlier than 7 business days before the anticipated delivery date or anticipated shipping date,” and “shall deliver the items no earlier than 5 days before the end of usage for the current product,” documenting the contact. Medicare allows a month to ask and ten days to ship; Maryland Medicaid allows about a week and a half to ask and five days to ship. For a patient whose supply runs out on April 1, a Medicare refill may go out from March 22 and a Medicaid one from March 27. A resupply engine that hard-codes one clock gets the other payer wrong every time.

Rentals end sooner too. Medicaid pays months one to three of a rental without prior approval, needs approval for months four to ten, and treats month ten as “the final rental month, after which the item is considered purchased”; items of $1,000 or more need approval from the first month, and the prescriber has to recertify the need every 90 days. What Medicaid buys, the state owns: the supplier must mark the equipment with a state identification tag recorded on the delivery ticket, recover it when the patient no longer needs it, and bill 75% of the original payment when it is reissued. A supplier may not charge a Medicaid recipient any fee or deposit. Payment is the lesser of the supplier’s customary charge and 85% of the lowest Medicare rate set each January, so the Medicaid fee schedule pays $42.53 a month to rent a CPAP device, or $425.34 to buy one, and $95.10 for a full face mask, against Medicare’s $51.70 a month and $121.98 in Baltimore. The state promised in January to update that schedule every quarter; the file online on October 20, 2026, still said “Effective 4/1/2026.”

Incontinence supplies, a large part of many stores’ Medicaid volume, have quantity rules of their own: prior approval above 180 pull-ons or briefs or 100 underpads per 30 days for patients 16 and older, above 240 and 135 for children three to fifteen, and for every unit for children under three, with minimum absorbency standards by size and payment of $0.63 to $0.98 a brief, a rate that has not changed since July 1, 2013. Since January 1, 2026, Medicaid’s unit-of-service limits have been realigned toward Medicare’s medically unlikely edits, and new codes for hydrophilic catheters replaced the old ones, two more changes an item master had to absorb this year.

From January, Medicaid eligibility changes twice a year

The federal budget law signed on July 4, 2025, changes the eligibility check that every Medicaid resupply depends on. For adults covered through the Medicaid expansion, Public Law 119-21 requires redeterminations every six months instead of every twelve and a work or community engagement requirement, both starting with the first quarter after December 31, 2026, and it cuts retroactive coverage for those adults to one month for applications from January 2027. CMS’s interim final rule requires states to implement by January 1, 2027. The Maryland Department of Health says the changes apply to about 300,000 Marylanders, and its January 2026 briefing to legislators estimated that about 115,000 adults could lose coverage. For a supplier, a monthly order for an expansion adult now crosses two renewals a year instead of one, and retroactive coverage is no longer a safety net for a delivery made in a hurry. The eligibility check belongs at every shipment, not just at intake.

Commercial plans must answer in two working days

Maryland’s 2024 prior authorization reform, Chapter 847, requires carriers to decide non-emergency requests within two working days after receiving the information they need, to ask for missing information within three calendar days, and treats a request as approved if the deadline passes; a new enrollee’s active course of treatment may not be disrupted for 90 days, a rule that expressly reaches carriers that contract “with a third party to dispense medical devices.” Maryland’s insurance mandates add product rules: §15-853 covers gradient compression garments for lymphedema when prescribed and custom-fit, but not over-the-counter stockings; §15-822 forbids cost-sharing on diabetes test strips outside high-deductible plans; §15-836 covers one hair prosthesis, up to $350, for hair loss from chemotherapy or radiation for cancer. Each is a field: whether the plan is state-regulated, whether the item is custom-fit, whether a deductible applies.

The online store has Maryland rules of its own

Three state rules land directly on a web store. Since July 6, 2026, Maryland’s retail refund regulation, COMAR 02.01.05.04, has required an online merchant to disclose its refund or exchange policy, or that it gives none, “on a webpage the consumer must view before completing the transaction,” which for a store that does not take back opened masks or hygiene items is a step in the checkout flow, not a link in the footer. The Stop the Spam Calls Act, in force since January 1, 2024, requires signed written consent for automated sales calls and texts, bars them between 8 p.m. and 8 a.m., limits them to three in 24 hours on the same subject and lets the person called recover up to $500 or actual damages, whichever is greater, and up to three times that if the violation was willful or knowing; a resupply reminder that turns into a sales pitch needs the consent on file. And since October 1, 2025, a business whose primary business is providing medical products or devices may not report medical debt to the credit bureaus, under Chapter 121 of 2025, and its collection contracts must say so.

Two older rules matter for the parts of the business that happen in living rooms and at the register. Maryland’s Door-to-Door Sales Act gives a buyer who agrees to a purchase of $25 or more at home, including after inviting the seller in, until midnight of the third business day to cancel, with a written notice of cancellation and a refund within ten business days, which describes most in-home sales of lift chairs, scooters and stair lifts. And Maryland’s sales tax treats this trade item by item: under the Comptroller’s list, walkers, power scooters, hospital beds, respiratory equipment and single-use incontinence products are exempt, while lift chairs are taxable, and CPAP masks, tubing and filters are not named at all. We covered how that list works in our article on optical stores and our article on hearing aids; for a supply store, the practical point is that each SKU needs a recorded decision, and the unnamed ones need advice rather than a guess.

Why discharge day matters more in Maryland

Maryland’s hospitals are paid differently from almost everyone else’s. Under the state’s agreement with CMS, signed on November 12, 2025, and now part of the AHEAD model that runs through 2035, Maryland hospitals operate on global budgets, a fixed annual revenue that, in CMS’s words, “encourages hospitals to eliminate avoidable hospitalizations.” A hospital on a global budget gains nothing from an extra day in bed and loses from a readmission, so a discharge planner in Baltimore has every reason to value the supplier that can set up a concentrator or a bed at home on the day of discharge and keep the patient there. That is our inference from the design of the model, not a statistic, but it is the commercial case for the intake speed this article keeps returning to.

What the City, the County and the power company add

Federal rules decide whether a claim is paid. The local layer decides some less obvious things: whether a patient’s oxygen concentrator keeps its electricity, how much tax a rental bed pays on the first of January, which free wheelchair is competing with yours, and who may fix a power chair. None of it shows up in a national billing platform.

A concentrator needs a clinician’s letter to the power company, every 30 days

Maryland protects households that depend on powered medical equipment from a utility shutoff, but only through paperwork, only for a while and only if somebody files. Under COMAR 20.31.03.01, electric or gas service “may not be terminated for an initial period of up to 30 days beyond the scheduled date of service termination when the termination will aggravate an existing serious illness or prevent the use of life-support equipment of any occupant of the premises.” The certification must come from a licensed physician, a certified nurse practitioner or a physician assistant; it must give the patient’s name and address, the clinician’s license number and signature and a statement that termination would prevent the use of the equipment; it can arrive on paper, by fax or as a scanned original attached to an email; and it can be renewed “by providing another certificate,” which the legislature’s analysts have read as renewable without limit. Within 30 days of filing, the customer must also enter a payment agreement with the utility.

The protection does not reach outages. BGE’s special needs page says that “it’s not possible to provide restoration priority to individual customers,” and that it will attempt to contact certified customers before planned outages and severe storms; since 2023 the Public Service Commission has required utilities to measure what share of these “vulnerable individual” customers they notified ahead of a storm. Backup cylinders and batteries are, in practice, the supplier’s problem. For a supplier with oxygen and ventilator patients in Baltimore, that turns into a record per patient: utility, account, which clinician signed, when the certificate was sent and by what channel, when it lapses, whether the patient consented to sharing contact details with emergency responders, and what backup equipment is in the home. The form is the Commission’s own, PSC-801, and a system that pre-fills it for the prescriber’s signature saves a fax and a week.

The rental fleet pays the City’s rate, and the tax return names the patients

A Baltimore supplier pays property tax on more than its building: its business personal property includes every rental hospital bed, concentrator and wheelchair it owns. Baltimore City and Baltimore County both exempt commercial inventory held for sale, so the stock on the shelves is untaxed, but the rental fleet is not. The annual return, filed with the State Department of Assessments and Taxation by April 15, wants property held by others reported in detail, with the “names and addresses of lessees, lease numbers, description of property, installation date and original cost by year of acquisition,” and its instructions add: “Provide the physical street address of lessees. Post Office Box numbers are not acceptable.” For a medical supplier, that schedule is a list of patients’ home addresses next to the equipment that keeps them breathing, prepared every spring from whatever the fleet records say.

The rates make the address matter. For fiscal 2027, SDAT’s rate table shows a personal property rate of $5.62 per $100 of assessed value in Baltimore City and $2.75 in Baltimore County. On a newly acquired $250,000 fleet assessed at full cost, that is $14,050 a year in the City against $6,875 in the County; with one year of the default 10% depreciation, $12,645 against $6,187.50. Assessments for that class of property fall by 10% a year to a floor of 10% of original cost, down from a 25% floor in the instructions SDAT used as recently as 2022, a figure some summaries still repeat. The software consequence is simple and usually missing: the fleet register needs a serial number, an original cost, an acquisition year, a depreciation class and the patient’s physical address on January 1 for every unit, kept apart from the sale inventory, and the ability to export the schedule without a week of reconciliation.

The same inventory number turns up in a third place. Maryland’s trader’s license, issued by the Clerk of the Circuit Court, is required for each store, and in Baltimore City Business Regulation §17-1807 sets its fee by the value of stock in trade, from $20 for the smallest stores to $2,125 for stock above $750,000, using the inventory reported on the same personal property return.

Free equipment down the road

A retail medical supply store in Baltimore competes, for its simplest items, with the State. The Maryland DME Re-Use Program run by the Department of Aging gives away donated wheelchairs, power chairs, scooters, hospital beds and lifts “regardless of age or insurance coverage” and “without the need for a prescription,” although complex equipment needs a health professional’s section on the request form. Its nearest site is at The Arc Baltimore on York Road in Towson, open two days a week for pickups by appointment, and its current site list has no location in Baltimore City. In 2025 the General Assembly also put the Maryland Assistive Technology Program, which runs short-term device loans, into statute. For a store, these programs are less a threat than a referral partner: the patient who cannot pay for a shower chair is better served by a store that tells them where to get one free, and that store is the one they come back to for the items the program does not stock, such as CPAP supplies, which it does not accept as donations.

Payers that set the network before you do

Some of the market is closed before a new supplier arrives. CareFirst’s application for ancillary providers states that the plan “is not accepting additional Durable Medical Equipment (DME) providers for Sleep Apnea (CPAP) equipment and supplies,” a note that appears in documents dated 2017 and 2022 and that we could not confirm has been lifted. Its Medicaid plan, CareFirst Community Health Plan Maryland, requires prior authorization for any DME or disposable supply purchase over $500 and for every rental and repair. An online store that sells CPAP supplies in Baltimore therefore needs to know, at checkout, whether a CareFirst member can be billed at all or should be sent to cash pay or an in-network supplier, which is a question no shopping cart asks.

A repair law for power wheelchairs

Since October 1, 2025, Maryland’s right-to-repair law for powered wheelchairs, Chapter 546 of 2025, now Commercial Law §§14-5001 to 14-5004, has required manufacturers to make documentation, parts, embedded software, firmware and tools available on fair and reasonable terms to independent repair providers and owners for ten kinds of parts: batteries and chargers, nonprogrammable joysticks, joystick housings and brackets, wheel assemblies, nonpositioning accessories, anti-tip devices, armrests, caster spheres, cosmetic shrouding and nonpowered leg lowerers, with security-lock reset tools covered separately. The duties fall on manufacturers rather than suppliers, and the law sets no repair deadline. But it changes what a supplier’s repair desk can promise, and it rewards one that records the manufacturer, model, serial number and firmware of every chair it services and knows which of those ten categories a broken part falls into.

What 41 Baltimore medical supply businesses show a patient, and a machine

To see what a Baltimore patient, or an AI assistant answering for one, finds when they look for a medical supply store, we started from Medicare’s own supplier directory, released on October 18, 2026, which lists every enrolled location with the product categories it supplies. We placed each location in Baltimore City or Baltimore County by its coordinates rather than its ZIP code, because 13 ZIP codes straddle the city line and dozens of County addresses carry a Baltimore mailing city. Of the 228 locations inside the two jurisdictions, about half were chain, grocery or club pharmacies. We set those aside, along with hospital pharmacies, eye care and physician practices, pharmacies that carry no home medical equipment and orthotics-only clinics, added two stores that appear only in OpenStreetMap, and were left with 41 businesses that sell or rent medical equipment as a business: 17 in the City and 24 in the County, 33 of them independent. We read every one of them, rather than a sample, on October 20, 2026.

The first finding is that 17 of the 41 have no website we could find, beyond directory listings, and four more are unreadable: one hides behind a bot challenge, one kept timing out, one domain is suspended and one chain has no page for its Baltimore location. Among independents, 14 of 33 have a site we could read. The second finding is how little the readable sites let anyone do. Twelve say they bill Medicare and ten say they take Maryland Medicaid, but only two name CareFirst, Maryland’s Blue Cross Blue Shield plan. Ten mention rentals and one publishes rental prices. Two have a working cart, both on WooCommerce, and neither sells a prescription device online. None takes a prescription upload, none has an online form to check insurance, and none mentions paying with a health savings or flexible spending card. One, Lincare’s national site, offers resupply reorders through a patient portal; no site says it ships supplies automatically, which, after the previous sections, is the right answer for a Medicare patient and a missed sale for a cash one.

The machines see even less. Three sites publish an llms.txt file, and all three were generated by a plugin or a website builder rather than written by the business, one of them naming an unrelated organization. Of 18 sites whose code we could read, five carry LocalBusiness or MedicalClinic markup and one marks up a product; the rest describe themselves as a generic organization or not at all. None blocks AI crawlers in its robots.txt, although two health-system sites refuse automated requests outright and one independent sits behind a bot challenge that has the same effect. WordPress runs 12 of the 20 readable sites, with WooCommerce installed on six and working on two; we found no Shopify or BigCommerce store, and no independent’s own site built by VGM Forbin, the web agency many home medical equipment dealers use, although one chain’s location pages carry its credit.

Several businesses are doing something worth copying, and we name them because a patient can use what they publish. Northern Pharmacy & Medical Equipment publishes a plain return policy, 30 days in original sealed packaging, with hygiene items, commodes and raised toilet seats excluded, and posts Medicare documentation checklists for the items it bills. Lincare states that unopened PAP supplies can be returned within 60 days. Hereford Pharmacy publishes a rental rate card, a nebulizer at $5 a day, $15 a week or $45 a month with a $60 deposit, which is the only rental price we found in either jurisdiction. Mid-Atlantic Medical Supply & Equipment in Reisterstown runs a WooCommerce store whose catalog interface reports 2,796 products, and offers same-day delivery and rentals on its main site. Numotion, the complex rehab provider, explains on its insurance page that it needs a patient’s Medicare Beneficiary Identifier to verify coverage and how Medicare treats a replacement wheelchair, and its Baltimore location page carries LocalBusiness and FAQ markup. Caring Touch Medical lists CareFirst, Medicare, Maryland Medical Assistance and the state’s Medicaid managed care plans by name. Johns Hopkins Care at Home, which bills through the Pharmaquip company, shows its Joint Commission accreditation and explains rent-or-buy, delivery and setup.

The directory is also out of date in ways a patient never sees. A wheelchair provider is still listed under a legal name whose domain is now for sale, a store’s directory name differs from the brand on its own website, a pharmacy trades under a different name, and one listed supplier’s domain is suspended. Medicare’s geocode for one hospital pharmacy places it in the wrong county. None of this is unusual, and all of it is what an AI assistant reads when it answers “medical supply store near me” for someone in Hamilton or Catonsville.

What 65 online CPAP and medical supply stores do at checkout

Baltimore’s suppliers barely sell online, so to see what an online medical supply store actually does with a prescription device, we looked further afield. We built two frames on October 20, 2026: the 30 national online CPAP and sleep stores that the main buying guides and our own searches turned up, excluding marketplaces, Canadian stores and domains that simply redirect to another store, and every independent medical supply store with a web store that we could find through OpenStreetMap across the 12 metro areas we started with and 65 more we added when the first dozen yielded too few. Two national stores could not be reached, which left 28 national and 37 local web stores. We did not place orders, so what follows comes from product pages, cart behavior up to payment and the stores’ published policies.

Nineteen of the national stores sell CPAP machines through an ordinary cash cart. Not one of them blocks payment until a prescription has been verified. Eleven, the most common design, take the money first and hold the order until the prescription arrives, with wording such as cpap.com’s “You can upload it after checkout” next to “This product requires a prescription before shipment.” Four ask for the prescription or the prescriber’s details during checkout but let the buyer supply them later, and four say a prescription is required without showing any way to provide one. Among the 37 local web stores, three sell a CPAP machine through an ordinary add-to-cart button, and two of those three show no prescription notice anywhere. Across all 22 stores that sell machines, 18 take payment before they have the prescription. On masks the market splits: nine of the 19 national machine sellers state that a complete mask or mask pack needs a prescription, and three openly sell “non-prescription” mask kits or a parts route around the rule.

The most careful stores are worth reading, because between them they describe the right design. Lofta says prescription orders “can’t be processed and shipped until a valid prescription is provided and verified,” and requires a signature on delivery for devices. Resmed Shop lists exactly which products need a prescription, PAP devices, mask packs, heated tubing and setup packs among them, and limits shipping to the states where it is a licensed DME provider, the only store in the sample that ships by license. Direct Home Medical tells the buyer in the cart that a prescription is required and asks how it will be provided. CPAPsupplies.com will contact the doctor for the buyer and states in its terms that it is not a Medicare supplier. Easy Breathe keeps the prescription on file with its length of need. Two local stores stand out too: New Hampshire Medical Supply runs a separate prescription order form, and LNS Medical Supply obtains the prescription from the doctor and bills Medicare.

The commercial pattern is just as clear. Thirteen of the 19 national machine sellers offer cash auto-ship or subscribe-and-save on masks and filters, mostly through Shopify subscription apps such as ReCharge and Seal, with 3-, 6- and 9-month cadences; RespShop offers delivery every three months at 15% off. None of the 37 local stores has a subscription we could confirm. And Medicare is almost absent from online checkout: no national store takes Medicare through its web checkout, eight say outright that they do not bill Medicare or insurance at all, and only a handful offer insurance-billed resupply, of which one says it ships automatically. The online CPAP market, in other words, has been built around the cash customer, and the Medicare customer is handled, if at all, by phone. That is not an accident. It is the shape the rules in the first half of this article produce.

One finding deserves its own paragraph because it is new. Shopify now publishes an automatically generated llms.txt on its stores, and all 13 national Shopify stores we could check, and six of the eight local ones, serve the same text, a copy of an agent instruction file. It tells AI agents that they can browse the store “on your user’s behalf,” build carts and checkouts through the Universal Commerce Protocol and “complete buyer-authorized purchases.” It says nothing about prescription items. The two local stores that sell CPAP machines with no prescription notice both publish it. The file asks for the buyer’s authorization, but whatever the merchant intended, it tells every shopping agent that the catalog, prescription devices included, can be bought through software, which makes the prescription hold an engineering requirement for agent checkouts as well as human ones.

The rest is ordinary e-commerce. More than half of the national stores run on Shopify and the rest mostly on Magento or WooCommerce, while WooCommerce leads among local stores; buy-now-pay-later options are common nationally and rare locally; dedicated HSA and FSA checkout widgets appear on only two national stores, although about a dozen say they accept the cards; most national product pages carry Product and Offer markup; and almost no one blocks AI crawlers. Return policies vary from mask-fit guarantees of 30 to 75 nights to restocking fees of 15% to 25%, and some stores refuse returns of opened masks outright.

Selling medical supplies online: one catalog, two kinds of customer

Put the previous sections together and the shape of a medical supply web store stops looking like retail. The same nasal cushion is three products: a cash item that may be sold to anyone with a prescription on file and shipped on a timer, a Medicare item that may be shipped only after a dated yes inside a thirty-day window, and a Medicaid or commercial item whose rules belong to the patient’s plan. The online store has to know which one it is selling before it shows a button.

One catalog, two subscription engines

For the cash customer, a subscription is a good product. Thirteen of the 19 national stores that sell CPAP machines offer one, and nothing in Medicare’s rules forbids it for a customer who is not billing Medicare. The design questions are ordinary ones done carefully: the prescription on file with its date and length of need, a check at each renewal that it is still valid, cadences that match how the items wear out, and payment terms that reflect what a card on file costs; at Square that is 3.5% plus 15 cents on every plan, more than a card at the counter. For the insured patient, the same page needs a different engine: a reminder when each item’s window opens, an item-by-item confirmation that is stored as the refill record, a label that cannot be printed early, tracking stored on every shipped line, and, for Maryland Medicaid, the plan’s own quantity limits, which since January 2026 follow the federal medically unlikely edits more closely. The payer, not the product, decides which engine runs, and the switch has to survive a patient’s 65th birthday: when someone moves from a commercial plan or Medicare Advantage into Original Medicare, A55426 treats the first claim as a new initial claim, and Medicare “does not automatically continue coverage for any item obtained from another payer.”

Promotions a Medicare customer may not be offered

A web store’s marketing tools assume every customer may be offered every coupon. For a Medicare or Medicaid customer that is not true. The beneficiary inducement provision of the Civil Monetary Penalties Law, section 1128A(a)(5) of the Social Security Act, bars offering a beneficiary anything of value that the supplier “knows or should know is likely to influence” the choice of supplier, with a penalty of up to $20,000 per item or service in the statute, $25,595 after the latest inflation adjustment. The Office of Inspector General’s policy on gifts of nominal value allows no more than $15 per item and $75 in total per patient per year, never in cash or cash equivalents. Coupons and loyalty points generally survive only under the “retailer rewards” exception, which requires that they be offered to the general public on equal terms regardless of insurance and not be tied to items billed to Medicare or Medicaid. So “a free mask with your next resupply order,” a copay routinely waived and advertising copy such as “Medicare accepted as payment in full,” which OIG’s 1994 fraud alert on routine waivers singles out, are offers a store must not show to a Medicare customer. The promotions engine has to know who the customer is, and which lines on the order are billed to a federal program, before it decides which banner to display.

The channels that will not carry you

A medical supply store that wants to sell where shoppers already are runs into a wall of policies. eBay bans any medical device that requires a prescription and names CPAP machines “along with masks, humidifiers, heated water chambers, and heated tubing,” plus oxygen equipment and nebulizers. Amazon allows prescription devices only through its invitation-only professional healthcare program, which sells to licensed buyers, keeps them out of its fulfillment network and prohibits used and refurbished devices. Walmart Marketplace prohibits prescription devices and their prescription accessories, used and refurbished devices, recalled devices and devices subject to state or local registration or quantity rules. Meta’s commerce policy bars the sale of medical devices in its shops and Marketplace altogether. And a store cannot even show its catalog on its own Google Business Profile: the Business Profile guidelines exclude “health or medical devices” from the products feature, and a violation can remove the whole catalog. Advertising is looser than selling: Google’s and Microsoft’s healthcare advertising policies for the United States address pharmacies and drugs and, as far as we can find, say nothing specific about prescription devices, so the legal duty to sell one only on a practitioner’s order falls on the store’s own checkout rather than on the ad platform.

AI shopping agents, and the protocol your store may already speak

The newest channels are the strictest. Google’s agentic checkout in AI Mode and Gemini runs on the Universal Commerce Protocol it launched in January 2026, and its merchant guide lists what is not eligible: subscriptions, installment plans, refurbished and used items, “equipment rentals, or leasing,” items that need installation or setup, freight shipping and healthcare and pharmaceutical products, with each product opting in through a feed attribute that defaults to false. That excludes, by name, most of what a DME supplier does, and the healthcare exclusion may reach the rest. OpenAI’s commerce policies prohibit “prescription-only medications or medical products” and recalled products in ChatGPT shopping. The interesting problem is on the other side: as the national census found, Shopify’s automatically generated agent file invites every AI agent to “complete buyer-authorized purchases” on stores that sell prescription devices, without a word about prescriptions. A store that will meet agents should decide for itself, in its own catalog, which items an agent may buy, and make the prescription hold apply to a software buyer exactly as it does to a person.

What search engines and AI assistants can read

The vocabulary for describing this trade to a machine is thin. Schema.org has no type for a medical supply store, so the closest honest description is a LocalBusiness typed as both a MedicalBusiness and a Store, which Google’s local business documentation allows as an array of types. Its MedicalDevice type describes a medical entity, not a product, and cannot carry an offer; the prescription status property applies only to drugs; and the closest place to say “Rx only” on a product is a new consumer notice property that is still pending. Rentals have better support: an offer can declare that it leases equipment out, and an individual product can carry a serial number. Google does not publish its Business Profile categories, but the lists that track them include a medical supply store, a medical equipment supplier, an oxygen equipment supplier, a mobility equipment supplier and wheelchair rental and repair services, and no category for a durable medical equipment supplier as such. As for llms.txt, Google’s own AI optimization guide says that such files are not needed to appear in Google Search, “as Google Search itself doesn’t use them,” and its page on AI features says there are “no additional requirements to appear in AI Overviews or AI Mode.”

What people ask is more useful than any file. Google’s autocomplete for this trade, which we pulled on October 20, 2026, centers on Medicare’s rules rather than on products: “cpap supplies medicare replacement schedule,” “medicare cpap compliance after 90 days,” “lift chair medicare documentation,” “auto ship cpap supplies,” “can you buy a cpap machine without a doctor’s order,” “medical supply store near me open to public,” “zepbound vs cpap for sleep apnea” and, closer to home, “maryland medicaid incontinence supplies.” The pages that answer them are often old or wrong: the 2012 refill page with its 14 days, content-farm pages claiming that CPAP prescription rules vary by state, when the federal rule applies everywhere, and speculation about when Philips will return to the American market. A supplier that answers those questions plainly and correctly, on its own site, with its own name and address on the page, is the one an AI assistant has something to cite.

Health data in the cart

Which privacy law governs the cart depends on how the business bills. A supplier that sends claims electronically, itself or through a clearinghouse, is a HIPAA covered entity, and Medicare requires electronic claims from any supplier with ten or more full-time equivalent employees, so most insured-side businesses are covered and their web store data is protected health information. A cash-only store that never bills insurance is not a covered entity, but that does not leave it unregulated. The Federal Trade Commission’s Health Breach Notification Rule, as amended in 2024, reaches a vendor of personal health records that is not covered by HIPAA, which includes a site or app that can draw health information from more than one source, such as a resupply app that pulls usage data from a CPAP machine; the Commission said a general retailer’s app that only sells products and shows past purchases is outside the rule because it is “only tangentially related to health.” And Maryland’s Online Data Privacy Act treats consumer health data, “personal data that a controller uses to identify a consumer’s physical or mental health status,” as sensitive data that a business may collect only where strictly necessary to provide what the customer asked for, and may not sell, for any business above the act’s thresholds of 35,000 consumers, or 10,000 consumers and more than a fifth of revenue from selling data. A list of who bought incontinence briefs or a CPAP mask can be health data under all three regimes. We covered what that means for advertising pixels in our hearing aid article and for Maryland’s law in general in our article on the Online Data Privacy Act.

A note for our readers in Lithuania

Part of our team works from Lithuania, and the comparison this time is unusually direct, because Lithuania only started paying for CPAP therapy this summer and had to decide, from scratch, the questions Medicare answered decades ago. Until July 2026 the state health insurance fund covered ventilators for central sleep apnea but nothing for the far more common obstructive kind, and patients bought or rented machines at their own cost; in 2024 an MP wrote on LRT that a patient might have to wait “trejus metus ar net daugiau,” three years or more, just for the sleep study. Since July 25, 2026, under the Health Minister’s order V-718, the fund rents a CPAP or auto-CPAP device to patients with moderate or severe obstructive sleep apnea confirmed by polysomnography, at a base price of €54.32 a month or €1.81 a day including 21% VAT, with no co-payment; under a companion order in force since August 1, the decision belongs to a panel of doctors at a hospital able to perform polysomnography, including a pulmonologist or neurologist.

The interesting choice was rental. In February 2026 the reimbursement commission recommended buying devices through an e-referral; by April it had gone back to the rental list, and the adopted rule rents for up to five years, with the supplier keeping title. That is the opposite of Medicare’s design, where the rental is capped at 13 months, $542.90 in total in Baltimore, and the patient then owns the machine. Over five years the Lithuanian fund pays €3,259.20 per patient, and a supplier there is paid to keep the device working rather than to transfer it. The rules read like Medicare’s translated into one standard contract: the supplier files the patient’s request and the panel’s conclusion in the fund’s rental subsystem, the fund decides within five working days, the supplier records the model and serial number and uploads a signed handover act, reports the start or end of therapy within three working days, replaces a broken device within 24 hours at its own cost and invoices by the 10th of each month. The device specification adopted by the fund in order 1K-313 in August requires a memory that records usage time, respiratory events and leaks, and includes one circuit and one mask a year, against Medicare’s mask every three months and cushions twice a month. The doctors’ societies had proposed Medicare’s own adherence test, four hours on 70% of nights, during the drafting; it did not make it into the adopted list. Three companies hold the fund’s CPAP contracts as of October 9, 2026, and the device’s official Lithuanian name begins “Deguonies aparatas,” oxygen apparatus, although a CPAP delivers no oxygen at all: a small trap for anyone searching, and for any AI system reading the registers.

Selling online is looser than in the United States. The EU’s Medical Device Regulation leaves prescription status to national law, and we found no Lithuanian rule that makes a CPAP machine or mask prescription-only. What the regulation does require of an online seller is product-level paperwork: under Article 6, a device offered at a distance to someone in the EU must comply with the regulation and the seller must produce the declaration of conformity when a regulator asks for it, and under Article 14 a distributor must check the CE marking, the declaration, the labeling and the device identifier before selling, and keep registers of complaints, non-conforming devices and recalls. Since May 28, 2026, the EU device database, EUDAMED, has been mandatory, with data for devices already on the market due by November 28. The market behaves more cautiously than the law: the leading Lithuanian seller handles CPAP machines through an inquiry form and asks for the doctor’s settings, while masks and parts go through an ordinary cart, and EU consumer law lets a shop refuse returns of sealed hygiene goods once opened.

Two more Lithuanian details are worth knowing on both sides of the Atlantic. The state’s technical aids center, now the Techninės pagalbos priemonių centras, lends wheelchairs, beds and walkers on a loan for use, takes them back clean and complete, refurbishes them and reissues them at lower fees, an automatic bed for €100 new or €50 reissued; it served 37,878 people in 2025, which is the same reuse logic as Maryland’s DME Re-Use Program at national scale. And value-added tax depends on the channel, not just the product: the standard rate is 21%, but 5% applies to technical aids for people with disabilities and to medical aids whose cost is reimbursed, so the same medical aid can carry two tax rates depending on who pays. For software, both systems ask for the same core record that a Baltimore supplier needs, a serialized unit with its patient, its paperwork and its clock, which is why the code we would write for one is most of the code we would write for the other.

What custom actually costs, and when it pays

We price every project at a fixed fee, agreed before we start, and publish the starting points on our pricing page. For a Baltimore medical supply store, a sleep and respiratory supplier or a small group of DME locations, the packages map onto this article like this.

Most of our projects land between $6,000 and $30,000, and none requires you to give up a billing platform, a clearinghouse or a device-data portal that already works; the demos page shows finished work. In Maryland, the state’s 3% tax on software and IT services applies to a custom build, so the Online Store package starts at $6,180 with tax and a Custom App at $12,360.

Whether custom pays depends on what it replaces. The clearest case is the CPAP trial. In Baltimore, a new Medicare CPAP patient who passes is worth $542.90 in device rental over 13 months and, at the usual maximums, up to $1,185.24 a year in supplies; one who fails forfeits $387.80 of the rental at once and most of the supplies with it. A supplier that sets up 300 new patients a year and rescues ten more trials than it does today keeps about $3,900 of rental revenue and up to about $11,850 a year of supply revenue. That is revenue rather than profit, and the supplies themselves cost money, but it is the right order of magnitude to set against a $3,500 Prototype Sprint or a $12,360 Custom App. The refill ledger pays in a less visible way: it is the difference between a resupply program that can show a dated, item-level yes for every box it shipped in the last seven years and one that repays whatever an auditor samples and cannot find. The online store pays on volume, and for most suppliers its value is less the cash sales than the patients who stop calling to ask what their plan covers and when their next box ships.

What we would build for a Baltimore medical supply business

We would not build a billing system. The platforms built for this trade have spent years on payer rules, HCPCS codes and modifiers, clearinghouse connections, eligibility checks and the denial codes that come back, and a supplier that bills Medicare, Maryland Medicaid and a dozen commercial plans should keep the one it has. We would not build a device-data platform either; the manufacturers already run them and supply the usage reports Medicare asks for. Nor a delivery fleet, a pharmacy system or a claims scrubber. What we would build is the layer those systems all lean on and that nobody sells to a supplier this size: one correct record of who has what, since when, until when, on whose order and with whose permission.

The first piece is a patient-item ledger. Every item a patient has, by HCPCS code and payer, carries its order, its quantity, its date of service, the expected end of the current supply, the window in which the supplier may ask about a refill and the earliest date it may ship one. Refill answers are stored item by item, with the channel and the time they arrived, so that a text reply saying “mask yes, filters no” becomes two records rather than one note. When a refill is ready to go, the ledger releases the label and stores the carrier’s tracking number against each shipped line, which turns proof of delivery into a lookup instead of a scramble seven years later. The billing system receives claims-ready orders from it rather than reconstructing them from phone notes.

The second is a board for the clocks. For each new CPAP patient it imports the usage data the supplier already receives, computes the best thirty-night window so far, the nights still needed and the last date the trial can be rescued, and shows whether the practitioner’s re-evaluation has been scheduled inside days 31 to 91. For every rental it counts the continuous months, the breaks in use and the days left in each break, queues the maintenance letter two months before a title transfer, and lists the oxygen patients past month 36 with the months of service they are still owed. It is the coordinator’s spreadsheet, with the rules in it.

The third is the online store, built as two engines behind one catalog. Cash and HSA customers get an ordinary store with one difference: a prescription device does not ship until a prescription is on file and checked, and the store can run subscriptions for them like any other shop. Insured patients get a resupply portal instead, where they confirm the items they need inside each item’s window, see what their plan covers and track what is on the way. Product pages carry the warnings a device needs, promotions are shown only to the customers they may lawfully be offered to, and every product is described in markup that search engines and AI shopping assistants can read. It is the store’s own front door, with its own customer list, and it can sit beside the referral platforms and marketplace listings a supplier already uses.

The fourth is the binder a supplier is always about to organize: accreditation and survey dates, the surety bond and its renewal, Medicare enrollment and revalidation, the Maryland license that covers home medical equipment services, complaint records with their deadlines, recall notices matched to the serial numbers in the field, the personal property listing for the rental fleet, and the utility medical certifications that hold off a shutoff for patients who depend on a concentrator. None of it replaces the billing platform, the clearinghouse or the device portal. It connects them through the supplier’s own data, built on its own database, exportable in full and the supplier’s to keep.

Build, buy, or leave it alone

Most medical supply businesses should buy almost everything and build very little. Billing, claims, eligibility and the clearinghouse should come from a vendor built for DME and answerable to its rules. The device-data portals belong to the device makers, which publish no fees for them. Payment processing, shipping labels and accounting are commodities. A store that sells canes, bath benches and compression socks for cash and never bills an insurer has no reason to pay for anything we describe here beyond a decent web store, and we would say so on a call. A supplier whose referral volume comes through a platform that works, and whose resupply program already runs inside its billing system, should keep both.

Choose vendors by the meter rather than the logo. Billing platforms for this trade are usually quoted rather than published, and priced by user, location or claim; resupply services are priced per patient, per contact or per order; e-commerce platforms charge a plan fee plus card processing; referral platforms are free to the prescriber and paid for by somebody else. Of the billing platforms we checked, only one, TrueSight, publishes a price, $500 a month for five users; accreditation now costs about $2,500 a year per location at BOC’s published rate; and a card on file costs more to charge than a card at the counter. Ask for the full price in writing, including what renews automatically and what the price becomes in year two, and then ask every vendor these questions before you sign:

• For each patient and each item, can your system show the expected end of the current supply, the 30-day contact window and the earliest ship date, and will it refuse to release a label early?
• Do you store a refill confirmation item by item, with the time and channel, and can I see that record for any shipment from the last seven years?
• Can I keep cash customers on subscriptions and insured patients on confirmed refills in the same catalog, without one rule leaking into the other?
• For new CPAP patients, can you show the best 30-night window so far and the last day the trial can still be passed, from the device data I already receive?
• Does your online store hold a prescription device until a prescription is on file, and who checks it?
• Who owns my patient list, my order history and my rental fleet records, and can I export all of it, in full, whenever I like, including after I leave?

A vendor that answers all six well has earned the contract. Build when the honest answers are “a spreadsheet” or “ask our coordinator” for the questions that carry your risk: when refill windows are tracked by hand, when the cash and insured customers share a subscription app that cannot tell them apart, when adherence is checked once a week in a portal, when the rental fleet lives in a list nobody trusts, or when the only record of a patient’s yes is a call log. Leave alone what is cheap and works: the billing platform, the clearinghouse, the device portals, the shipping software and the referral relationships that still bring patients in.

Our guide to custom software in Baltimore explains how we work, our article on independent pharmacies covers the drug side of the same counter, our article on hearing aid stores covers selling a regulated device online, and our article on home care agencies covers the Maryland licensing regime that also reaches home medical equipment. If you want to find out which of these would pay for you, bring us an export of your active patients and items, last quarter’s denials and your rental fleet list, and we will show you.

Frequently asked questions

How often does Medicare pay for CPAP supplies?

Medicare’s PAP coverage policy, L33718, sets usual maximum quantities: a nasal or full face mask once every three months, nasal cushions and pillows two a month, a full face mask cushion one a month, disposable filters two a month, standard or heated tubing once every three months, and headgear, a chinstrap, a non-disposable filter and a humidifier water chamber once every six months. A supplier may not dispense more than a three-month quantity at a time, and quantities above the usual maximums are denied as not reasonable and necessary. Each refill also has to meet Medicare’s refill rule.

Can a DME supplier automatically ship CPAP supplies to Medicare patients?

No. Medicare’s PAP policy says suppliers must contact the beneficiary and document an affirmative response before dispensing a refill and must “not automatically ship on a pre-determined basis, even if authorized by the beneficiary.” Since January 1, 2024, 42 CFR 410.38(d)(4) has required contact and the patient’s yes to come within 30 calendar days of the expected end of the current supply, and the date of service to be no earlier than 10 days before it. Automated texts or emails are allowed if they capture each item, the yes and the date. Cash customers can be put on ordinary subscriptions.

What is Medicare’s CPAP compliance rule after 90 days?

To keep a CPAP covered after the first three months, the patient must use it at least four hours a night on 70% of nights, 21 of 30, during any consecutive 30-night period in the first three months, shown by downloaded usage data reviewed by the treating practitioner, and the practitioner must see the patient between the 31st and 91st day and document that symptoms improved. If the re-evaluation is late but shows benefit, coverage resumes from that date. A patient who fails needs a new evaluation and a repeat sleep test in a facility before Medicare will pay again.

Can you buy a CPAP machine without a prescription?

Not legally in the United States for a device labeled “Rx only,” which includes CPAP machines and many masks. Under 21 CFR 801.109 such a device is to be sold only to or on the order of a licensed practitioner, and under 801.110 the retail sale must be made on a lawful order, with labeling that carries the practitioner’s name and address and any directions from the order. Online stores typically ask for the prescription during or after checkout and hold the order until it arrives. Prescription status is set model by model, so some power wheelchairs and scooters are cleared for over-the-counter sale.

Does Medicare pay for a CPAP if the supplier also did my home sleep test?

No. Under 42 CFR 424.57(f), no Medicare payment is made to the supplier of a CPAP device if that supplier or its affiliate, directly or indirectly, provided the sleep test used to diagnose the patient’s obstructive sleep apnea. The only exception is an attended polysomnogram in a sleep facility. Cash-pay bundles of a home sleep test and a CPAP from the same company are possible; for a Medicare patient they make the machine unbillable.

Does Medicare pay for a lift chair?

Only for the motorized seat-lift mechanism, billed as HCPCS E0627 when the coverage criteria are met; the chair itself is furniture that Medicare does not cover. In the former Baltimore-Columbia-Towson bidding area, Medicare’s 2026 allowed amount for a new seat-lift mechanism is $310.34. Because the chair is excluded by statute, an advance beneficiary notice is optional for that part. In Maryland, lift chairs are on the Comptroller’s list of taxable items.

How long does Medicare pay for home oxygen?

Medicare pays a monthly rental for oxygen equipment for up to 36 months of continuous use. After that the supplier that furnished the 36th month must keep furnishing the equipment, and for liquid or gaseous systems the oxygen contents, for the rest of the equipment’s five-year reasonable useful lifetime, with no further rental payment. For concentrators, Medicare pays nothing for the first six months after the cap and then one maintenance and servicing payment per six-month period, if the supplier inspects the equipment in the home. In Baltimore a concentrator rents for $105.30 a month in 2026.

When does Medicare competitive bidding start again?

Round 2028 of the DMEPOS Competitive Bidding Program opens bidder registration on December 1, 2026, and the bid window on January 5, 2027; bids close March 10, 2027, and contracts are to run from January 1, 2028, to December 31, 2030. It is one nationwide remote item delivery area covering seven categories: class II CGMs and insulin pumps, hydrophilic urinary catheters, ostomy supplies, urological supplies and off-the-shelf back, knee and upper extremity braces. Bidders need a $100,000 bid bond and licenses in every state for the products they bid. CPAP, oxygen, hospital beds and wheelchairs are not included.

Is Baltimore a competitive bidding area?

Not in Round 2028, which uses a single nationwide area. Baltimore-Columbia-Towson was a competitive bidding area in earlier rounds, and Medicare still prices most items in its 220 ZIP codes from the last contract prices there, raised for inflation. Those rates differ from Maryland’s statewide amounts: in 2026 a CPAP device rents for $51.70 a month in the former Baltimore area against $50.04 elsewhere in non-rural Maryland, and an oxygen concentrator for $105.30 against $96.39.

Do you need a license to sell medical equipment in Maryland?

Maryland has no license called a DME license, and its Pharmacy Act does not apply to a business that only dispenses DME, prescription devices without drugs, devices whose only drug is medical oxygen, or orthotics and prosthetics. But delivering, installing, maintaining or instructing patients in the use of oxygen systems, ventilators, respiratory devices, power wheelchairs, electric hospital beds and similar equipment at home is “home medical equipment services,” a form of home health care, which requires a residential service agency license from the Office of Health Care Quality, $1,000 for three years. Maryland Medicaid requires the license or an exemption.

What does Maryland Medicaid pay for CPAP and incontinence supplies?

Maryland Medicaid pays the lesser of the supplier’s customary charge and 85% of the lowest Medicare rate set each January. Its fee schedule pays $42.53 a month to rent a CPAP device or $425.34 to buy one, and $95.10 for a full face mask every three months. Rentals become purchases after month 10, and the state owns what it buys. Briefs pay $0.63 to $0.98 each, with prior approval needed above 180 in any 30 days for patients 16 and older. A supplier may contact a Medicaid patient about a refill no earlier than 7 business days before the planned delivery and deliver it no earlier than 5 days before the current supply runs out.

Is Philips selling new CPAP machines in the US in 2026?

No. Under the consent decree entered in April 2024, Philips Respironics may not distribute devices from its covered US facilities until a list of conditions is met, including written notice from the FDA. In its annual report filed in February 2026, Philips said that until then it will not sell new CPAP or BiPAP sleep therapy devices in the United States. The decree still allows masks, consumables, accessories and replacement parts, and certain medically necessary devices such as some oxygen concentrators and ventilators.

Are CPAP machines and medical supplies taxable in Maryland?

Maryland’s 6% sales tax exempts many medical items. The Comptroller’s list exempts respiratory equipment, walkers, power scooters, hospital beds and single-use incontinence products, and treats lift chairs and standard canes as taxable. CPAP masks, tubing and filters are not named on the list, and neither are compression stockings, so a supplier should record a decision for each item and get advice on the ones the list does not name.

How many medical supply stores are there in Baltimore?

Medicare’s supplier directory, released October 18, 2026, lists 75 enrolled supplier locations in Baltimore City and 153 in Baltimore County. Of those 228, 165 are pharmacies, grocery stores or department stores; 11 list CPAP devices, 8 oxygen, 20 hospital beds and 25 wheelchairs. After excluding chain and hospital pharmacies, pharmacies with no home medical equipment, eye care, physician practices and orthotics-only clinics, and adding two stores found only in OpenStreetMap, we counted 41 businesses that sell or rent medical equipment as a business: 17 in the City and 24 in the County.

How much does DME software cost?

Most DME billing platforms, including Brightree, WellSky’s Bonafide and Fastrack and NikoHealth, do not publish prices. TrueSight publishes $500 a month for five users plus $75 per additional user. Around the platform, a Baltimore supplier pays about $2,500 a year per location if it accredits with BOC, and reaccreditation is now required every 12 months, a $750 Medicare enrollment fee at each three-year revalidation, a surety bond premium, clearinghouse fees of about $1,000 to $1,500 a year and card processing on its web store. Our modeled stack for a supplier with 1,200 CPAP patients came to $15,738 a year, or $54,138 with outsourced resupply.

Can you sell CPAP supplies on Amazon, eBay or Facebook?

Mostly not. eBay bans prescription medical devices, naming CPAP machines with their masks, humidifiers, water chambers and heated tubing. Amazon allows prescription devices only through an invitation-only professional program for licensed buyers. Walmart Marketplace prohibits prescription, used, refurbished and recalled devices, and Meta’s commerce policy bars medical devices in Shops and Marketplace. Google’s Business Profile product catalog excludes health and medical devices, and Google’s AI checkout excludes subscriptions, rentals and healthcare products. A supplier’s own web store is usually the only place it can sell them.