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The costs of medical equipment for patients to use at home is often partially, or fully, covered by health insurance or Medicare. This medical equipment is also known as home medical or durable medical equipment. We have provided this guide to educate you about Medicare guidelines for this type of equipment. While most private insurance companies have similar guidelines, the specific rules may differ from company to company.
We accept most major private health insurance plans. Additionally, we offer help for individuals and health insurance companies to understand how your plan covers home medical equipment for you and family members.
I Guide to Medical Coverage
Who qualifies for Medicare?
•People 65 and older
•People under 65 with permanent kidney failure, after 3 months of dialysis
•People under 65 with a permanent disability and receiving Social Security benefits, starting 24 months after disability benefits begin
Traditional Medicare Benefits
•Medicare Part A covers a stay in the hospital, hospice, and home health services.
•Medicare Part B covers visits to the doctor, laboratory tests, home medical equipment, and ambulance services.
•Often, there is no monthly fee for Part A, but Part B requires a monthly premium for enrollment. The premium depends on income and can range from $115.40 to $369.10. The premium is usually deducted from the Social Security check each month.
•Medicare Part D is optional and covers prescription drugs.
•You can find additional information about benefits and making decisions regarding coverage at Medicare’s official website at www.medicare.gov.
What You Can Expect to Pay
•In addition to the monthly premium, you are required to pay the first $162 over covered expenses for Part B services and then 20% of all approved charges.
•Medicare equipment providers cannot waive this 20% or your deductible, or they are subject to Medicare penalties. If charges are not covered by another insurance plan, they must attempt to collect the deductible and coinsurance. Some exceptions can be made, if you meet qualifying financial hardships.
•Supplemental insurance policies may cover this portion, after the supplemental plan’s deductible.
•When a medical equipment provider does not accept Medicare assignment, you may be required to pay upfront and the provider will file a claim on your behalf. When Medicare processes the claim, you will be mailed a check to cover a portion of the approved expenses.
•Medicare only covers for items that meet basic needs. You will find a large selection of products that offer additional features. Your provider will likely offer the option of paying some extra money to get the product with the features you want.
•Centers for Medicare and Medicaid Services (CMS) has approved a form that allows individuals to upgrade to equipment that is better than the standard option. The form is called the Advance Beneficiary Notice (ABN).
•The provider must complete the ABN form with details about the differences between the products and you must sign the form indicating that you agree to pay the difference. Generally, providers will accept the assignment on the standard product and apply the cost to the more expensive item.
•The Advance Beneficiary Notice of Non Coverage is used to notify you that Medicare will not pay for a specific item, even if it is covered under other circumstances. The form details why Medicare will not pay for the item you want.
•The information on the form helps you make decisions about receiving the item, knowing you will have to pay additional expenses.
Durable Medical Equipment (DME)
For an item to be covered by Medicare, it generally must meet the durability test and will pay when:
•The item withstands repeated uses, rather than disposable items.
•The equipment is used for a medical purpose.
•It has limited use for illness or injury, which excludes items preventative items, such as bathroom safety products.
•The product is used in a home setting.
•Providers accepting assignment agree to accept the Medicare payment as payment in full.
•You are responsible for the 20 percent coinsurance and annual deductible of $162.00.
•Providers not accepting Medicare assignment can file a claim on your behalf and you will be paid by Medicare. However, they must provide the Advance Beneficiary Notice, if they think Medicare will not pay the claim.
Mandatory Claim Submission
•Providers are required to submit a claim for covered services within one year.
The Role of the Physician
•A physician’s order is required for items billed to Medicare. The form is a Certificate of Medical Necessity (CMN) and additional documentation may be required, such as test results or office visit notes.
•When Nurse Practitioners, Physician Assistants, Interns, Residents, or Clinical Nurse Specialists are treating you, they are able to sign the CMN.
•Physicians may refuse to complete documentation, if they did not order the equipment, so you should always consult with your physician before ordering an item.
Prescriptions before Delivery
•Medicare may require documentation prior to delivering certain items.
•Decubitus care, such as wheelchair cushions and pressure relieving surfaces for a hospital bed.
•Seat lift mechanisms
•Power Operated Vehicles or Scooters
•Negative Pressure Wound Therapy products
•Providers cannot deliver these items without a written order and documentation because Medicare may never make the payment. Please understand that your provider must collect the required documentation before delivery.
Four Ways Medicare May Pay for Equipment:
•Purchase the equipment for you to keep
•Rent the equipment until it is not needed
•Capped rentals, which are rented for a total of 13 months, and after that time the item is considered purchased
Medicare does not allow you to purchase items outright, which means you won’t need to pay your coinsurance in one payment. In addition, it protects Medicare from paying too much, if your needs change sooner than expected.
Medicare makes rental payments for 36 months for oxygen therapy. For an additional two years after this time, Medicare limits payments to fees for monthly gas or liquid contents and limits service fees for checking equipment to once every six months.
After purchasing an item, you are responsible for calling the provider when it needs to be repaired or serviced. Medicare will pay a portion of the cost of labor, repairs, replacement parts, and loaner equipment when yours is being serviced. This is contingent that you meet the coverage criteria and still require the item at the time of repair or servicing.
In certain areas, Competitive Bidding requires the use of Medicare contracted suppliers. If you live in these areas, the contracted supplier will need to provide you with the following items:
•Oxygen and related supplies and equipment
•Standard power wheelchairs, scooters, and accessories
•Rehabilitative power wheelchairs and accessories, for Group 2 only
•Mail order supplies for diabetes
•Enteral nutrition supplies and equipment
•Continuous Positive Airway Pressure (CPAP) and Respiratory Assist Devices (RAD), accessories and supplies
•Hospital beds and accessories
•Walkers and accessories
•Support surfaces (Group 2 mattresses and overlays for Miami only)
You can determine if your zip code is located in a Competitive Bidding area by calling 1-800-MEDICARE (1-800-633-4227). You can also check Medicare.gov and enter your zip code for suppliers in your area. There will be a notice, if you live in an area that is subject to Competitive Bidding.
II Medicare Coverage for Specific Home Medical Equipment
Bi-Level and Respiratory Assist Devices
•A physician must document symptoms of sleep associated hypoventilation in order for a respiratory assist device to be covered by Medicare. These include excessive fatigue, hypersomnolence during the day, headaches in the morning, dyspnea, and cognitive dysfunction.
•Medicare covers respiratory assist devices when an individual has a clinical disorder that is characterized as a restrictive thoracic disorder, severe chronic obstructive pulmonary diseases, central sleep apnea, or complex sleep apnea. For obstructive sleep apnea, refer to coverage for Positive Airway Pressure Devices.
•Specific medical tests may be required to establish these diagnostic groups.
•You and your physician will be required to answer questions in writing about your continued use and the effects of the machine for treating your condition three months after beginning therapy.
Medicare Coverage for Breast Prostheses after Radical Mastectomy
•One silicone prosthesis is covered every two years and mastectomy forms every six months.
•Nipple prosthesis is covered every three months.
•Mastectomy bras are covered, when needed.
•Replacement prosthesis before the specific time frames are not covered, due to wear and tear, but will be required for loss, irreparable damage, or a change in condition, such as substantial weight loss or gain.
•Only one prosthesis per affected side is allowed, including situations where asymmetry is attempted. The provider should give an ABN in this case.
•Mastectomy sleeves to control swelling do not qualify Medicare’s definition of prosthesis, but may be covered when you are in the hospital.
•Mastectomy bras are covered when the bra’s pocket holds a covered mastectomy form or prosthesis.
Criteria for Medicare Coverage of Cervical Traction Devices
•Neurologic or musculoskeletal impairment that requires traction equipment
•Appropriate use of the home cervical traction device has been demonstrated and you are able to tolerate the device.
•Commodes are covered when you are incapable of using toilet facilities, such as being confined to a single room, a level of the home with no toilet, or there are no toilet facilities in the home.
•Heavy duty commodes are covered for people weighing in excess of 300 pounds.
•Detachable arms are covered when extra width is required, due to body configuration, or when they are needed for moving you in and out of the chair.
•Gradient compression stockings worn below the knee are covered to treat open venous stasis ulcers, but not for prevention or reoccurrence of ulcers, swelling without ulcers, or lymphedema.
Positive Airway Pressure Devices and Bi-level Devices for Obstructive Sleep Apnea
•CPAP devices are only covered for the treatment of Obstructive Sleep Apnea (OSA)
•Required testing includes an overnight sleep study in a sleep laboratory or through an in hoe sleep test for a qualifying diagnosis of OSA.
•Medicare covers tubing, replacement masks, and other supplies
•Medicare requires verification that you are benefiting from the treatment and information about the number of hours the machine is used each day, after the first three months of using the device. In addition, a visit with the physician to document symptom improvement is required between 31 and 91 days after using the treatment. The machine’s data report must show that the machine is used for at least 4 hours each night on 70 percent of the nights in a 30 day period.
•Your doctor may use a bi-level or Respiratory Assist Device, if the CPAP is not working or you cannot tolerate it.
•If you are having trouble adjusting, talk to your provider to learn about variations to make the therapy more comfortable.
•Medicare covers glucose monitors, replacement batteries, lancets, test strips, spring powered lancing devices, and control solution.
•Insulin injections and diabetic pills are only covered through Medicare Part D.
•Up to three months of testing materials can be obtained at one time.
•Medicare approves up to one test each day for non-insulin dependent and three tests per day for insulin dependent diabetics.
•If you need to test more than the allowable number of times, additional verification is needed and you will need to be evaluated by your physician within six months.
•You must send a testing log with evidence of compliant testing to your provider every six months.
•If testing frequency changes, you will need a new prescription from your doctor.
•After the last cataract surgery, Medicare will cover one complete pair of glasses, including frames and two lenses.
•The doctor must specify a medical need for tint, anti-reflective coating or UV for these services to be covered.
•Medicare covers a hospital bed for a medical condition that requires positioning that is not possible in a regular bed.
•A regular bed cannot position the body in a way that is needed to alleviate pain.
•The head of the bed needs to be elevated more than 30 degrees for individuals with chronic pulmonary disease, heart failure, or aspiration problems. Pillows or wedges must be ruled out for the bed to be covered.
•Traction equipment is needed that needs to be attached to a hospital bed.
•Specialty beds that vary the height of the bed are covered when needed to transfer the person to a chair, standing position or wheelchair.
•Semi electric beds are covered when frequent body position changes are required or there is an immediate need for a change in position.
•Heavy duty ad extra wide beds are covered for individuals weighing more than 350 pounds.
•Total electric features are not covered, but your provider may apply the cost of the semi electric bed toward the monthly cost of a total electric bed. You will need to pay the difference between the beds and sign an Advance Beneficiary Notice (ABN).
Lymphedema Pumps are covered for:
•Primary lymphedema that results from a congenital abnormality affecting lymphatic drainage or Milroy’s disease.
•Secondary lymphedema resulting from damage or destruction of lymphatic channels.
•Radical surgical procedures for removal of groups of lymph nodes, such as radical mastectomy.
•Post radiation fibrosis
•Spread of malignant tumors to lymph nodes
•Treatment of chronic venous insufficiency (CVI)
•Your physician must attempt other treatment methods and treatments over at least a six month period. These may include limb elevation, compression garments, and medication before a lymphedema pump is considered.
•Physicians are required to document the initial pump treatment to determine that it can be tolerated.
Covered Drugs Outside of Medicare Part D
•Beginning in 2001, all providers of drugs covered by Medicare have been required to accept assignment.
•Specific drugs are covered under Medicare Part B. These include certain nebulizer drugs, specific oral anti-cancer drugs, immune suppressive drugs, certain infused drugs requiring a pump, and most parenteral nutrition.
•Medicare Part D may cover additional oral medications, inhalers, and other drugs.
Mobility Equipment: Walkers, Canes, Scooters, and Wheelchairs
•Under the Mobility Assistive Equipment regulations, Medicare will cover:
•Products to meet the daily mobility needs at home
•Medicare covers the lowest level of equipment suitable and most medically appropriate equipment
•Your physician and provider must evaluate your unique requirements for a mobility product and expected use. In order to determine the lowest level of equipment that will meet your daily needs, they must ask questions, such as:
•Can the activities be performed with crutches or a cane?
•If not, will you be able to accomplish your activities with a walker?
•If not, can a manual wheelchair help you perform the activities?
•If not, is a scooter sufficient for accomplishing the activities?
•If not, will a power chair enable you to perform the activities?
•It is important not understand that you can discuss the option of upgrading to a higher level product by paying more out of profit and using the Advance Beneficiary Notice (ABN)
•Prior to setting up a power chair or scooter, you need an examination with your physician to discuss your mobility limitations.
•Your home will need to be evaluated to make sure it can accommodate the mobility product.
•It is possible that you will be required to see a physical therapist or occupational therapist for equipment selection to ensure the best fit.
•Nebulizer machines, accessories, and the medications are covered for people with obstructive pulmonary disease, as well as for specific medications for people with cystic fibrosis, HIV, pneumocystosis, bronchiectasis, organ transplant complications, and persistent or tenacious pulmonary secretions.
•Up to three months’ supply of the medications and accessories for the nebulizer can be obtained, provided you regularly use the medicines with the machine.
•You must notify your provider, if you stop using the medicines.
Partial List of Items Not Covered
•Bathroom Safety Equipment
•Emergency Communication Devices
•Humidifiers or Air Purification Equipment
•Low Vision Aides
•Raised Toilet Seats
•Stair Lift Equipment
•Syringes and Needles
•Van Lifts and Ramps
•The shoes are covered when needed to attach a leg brace.
•Medicare only pays for shoes that are attached to leg braces.
•Medicare does not pay for matching shoes, other than for leg braces or diabetes.
Ostomy Supplies Covered for People with:
•It is possible to obtain a supply for three months at a time for pouches, wafers, paste, and other required products
Oxygen Covered for:
•Significant hypoxemia in a chronic stable state
•Severe lung disease, which would improve with the use of oxygen therapy
•Need for therapy indicated by oxygen saturation or blood gas level
•Results of oxygen study by a qualified physician or sleep lab
•When alternate treatments have been ineffective
•Categories and groups are based on oxygen measurement test results
•Group I: mmHg of 55 or oxygen saturation level of 88%
•Individuals with results that fall in the Group I category are required to visit their physicians between 9 and 12 months after the initial visit to determine whether oxygen is needed for a specific period of time or will continue for life. Retesting is generally not required.
•Group II: mmHg of 56-59 or oxygen saturation level of 89%
•People with results in the Group II range are required to see their physicians for another office visit and for retesting within 3 months from the initial test. The physician will determine whether oxygen is needed for life or if the need is expected to end.
•Group III: mmHg of 60 or oxygen saturation level of 90%. This group is considered not medically necessary.
For the first 36 months, oxygen is paid as a rental. When treatment is required beyond this point, your provider will continue to supply the equipment for up to 24 additional months and Medicare will pay for refilling the cylinders and the semiannual maintenance fee.
After 60 months of service, you may receive new equipment.
Parenteral Therapy and Enteral Therapy
•Parenteral therapy is provided when part, or all, of the gastrointestinal tract is missing. Nutritional formulas are provided through a vein.
•Enteral therapy is covered when an individual is unable to swallow or eat food. Nutrition is delivered directly into the gastrointestinal tract through a tube.
•Medicare does not cover oral nutritional formulas.
•Specialty nutritional formulas are covered when there is a nutritional need or specific disease. This must be documented in the physician’s records and documentation that standard formulas have not been successful may be required for specialty nutrients to be covered.
Patient Lift Devices
•Medicare will cover lifts when assistance of more than one person is needed to transfer between a bed and a commode, wheelchair, or chair, and you would be confined to a bed without the lift.
•Electric mechanisms are considered to be a convenience feature and not covered. When you want the electric lift mechanism, you will have to pay the difference between the manual and electric model and sign the Advance Beneficiary Notice (ABN).
•These are capped rental items and not purchased. After Medicare makes 13 payments for a rental, you will own the item.
Seat Lift Mechanisms
•Medicare will pay for the mechanism, if you are suffering from severe neuromuscular disease or severe arthritis of the knee or hip. In order for the device to be covered, you must be incapable of standing from a chair, but walk independently or with a walker or cane, once upright. Your physician must believe that the device will improve, slow or stop deterioration.
•If you are transferring from a chair to a wheelchair, the device is not covered.
•Medicare only pays for the lift mechanism, the chair is not covered. You will need to pay for the furniture component in full.
•Providers are not able to deliver the product without a written order or certificate of medical necessity from your doctor. Medicare may not make payments, if documentation is not provided before delivery.
•Group 1 products are used on top of a home mattress or hospital bed. These can be made with gel, water, air, or foam. They are covered when:
•You are completely immobile
•There is limited mobility or ulcer on the trunk or pelvis, as well as one of the following:
•Nutritional status is impaired
•Urinary or fecal incontinence is a problem
•Sensory perception is altered
•Circulatory status is compromised
•Group 2 Products are typically powered by pressure reducing mattresses or overlays. Medicare will pay, if you have the following conditions:
•The presence of multiple stage II ulcers on the trunk or pelvis and you were on a comprehensive treatment program with a Group 1 product for at least a moth and the ulcers stayed the same or got worse. Monthly follow up is required to ensure that the treatment program is followed and modified, as needed.
•There are large or multiple state III or IV ulcers on the pelvis or trunk. Monthly follow up is required and the product is only covered when the ulcers are present.
•In the past 60 days, you had a myocutaneous flap or skin graft to treat an ulcer on the pelvis or trunk and were immediately placed on a Group 2 or 3 support service and discharged from the hospital within the past 30 days.
•Physicians are required to assess whether use of the equipment is still needed on a monthly basis. Your physician may have a home health nurse come to your home for the assessments.
•Group 3 products are air fluidized beds. Medicare covers these products, if you meet all the following conditions:
•Stage III or IV pressure ulcer
•Confined to a bed or chair, due to limited mobility
•Without the bed, you would need institutional care
•The wound has not improved with at least a month of conservative treatment
•Other alternative treatments and equipment have been ruled out
•Medicare requires an assessment from your physician or a health care professional within one month before ordering a Group 3 support surface.
•You need to have a trained adult caregiver to provide support, as Medicare does not cover the cost of a caregiver or structural modifications to your home.
•Medicare does not allow the products to be delivered without a written order or documentation to be provided at a later date, or they may never make payment for the products.
TENS Unit Coverage
•Medicare covers TENS Units for chronic intractable pain treatment, when pain has continued for three months or more and for acute post-operative pain, in certain situations.
•A TENS Unit is not suitable for all types of pain. For example, they are not effective for headaches, TMJ pain, pelvic pain, and visceral abdominal pain. As a result, devices are not covered for treating those conditions.
•When chronic pain has persisted for three or more months, Medicare will allow a trail rental for one or two months to determine whether the device will help alleviate the pain. You will be required to visit your physician 30-60 days after the initial evaluation to evaluate the effectiveness of the treatment and get authorization for the purchase of a TENS Unit.
•Medicare will consider rental payment for a TENS unit for a maximum of 30 days for acute, post-operative pain. After that time, individual consideration is required.
•Providers are unable to deliver this product without a written order or certificate of medical necessity from your physician. Medicare may never make payment for the product, if they deliver before the required documentation is received, so please be patient.
•Medicare may cover therapeutic shoes, modifications, and inserts for diabetic patients with a previous amputation of a partial or entire foot, foot ulceration history, peripheral neuropathy with callus formation, poor circulation in one or both feet, and foot deformity.
•You will be required to schedule visit with your physician within six months to document diabetes management and why the shoes are needed. Each time you need replacement shoes, you will need to visit the physician.
•Your provider is required to perform an in person evaluation of your feet and verify proper fit.
•This product cannot be delivered until a written physicians order or certificate of medical necessity is received by the provider. If they deliver before the necessary documentation is received, Medicare may never make a payment for the products.
•Urinary catheters and urinary collection devices are covered to drain or collect urine for individuals with permanent urinary incontinence or retention. Permanent urinary retention is not expected to be corrected within three months.
•Medicare allows a maximum of six catheters per day, or 200 per month. If a higher number is required, it must be shown to be medically necessary and documented by your physician in your medical records.
•You can receive a supply for up to three months, when at home.
III Medicare Supplier Standards
The following is a summary of Medicare standards for providers of home medical equipment. Our company meets or exceeds these standards.
•Suppliers are required to remain in compliance with all Federal and State licensure and regulatory requirements and licensed services cannot be contracted out to an organization or individual.
•Suppliers are required to provide accurate information on the DMEPOS supplier application and changes must be reported within 30 days to the National Supplier Clearinghouse.
•Authorized individuals are required to sign the application for billing privileges.
•Suppliers must fulfill orders from their inventory or contract with other companies for items required to fill the order. They are not allowed to contract with an entity that is excluded from the Medicare program, State health care program, or other Federal procurement programs and non-procurement programs.
•Suppliers are required to advise beneficiaries that durable medical equipment may be rented or purchased and abut the capped rental equipment purchase option.
•Suppliers must provide notice of warranty coverage and hon or warranties under applicable state law and replace Medicare covered items that are under warranty without additional charges.
•Suppliers are required to maintain a physical facility. The location must be accessible to the public and staffed during their posted business hours. There should be at least 200 square feet and have space for storing records.
•Suppliers must allow CMS or its agents to perform on-site inspections to evaluate compliance with the standards. The location must be accessible during business hours, have a visible sign, and hours of operation must be posted.
•Suppliers are required to have a listing for a primary business phone in the local directory or toll free number that can be accessed through directory assistance. Medicare prohibits the exclusive use of cell phones, answering services, beepers, and answering machines during the supplier’s posted business hours.
•Medicare requires that suppliers maintain at least $300,000 in liability coverage for the place of business, employees, and customers. When the supplier manufactures the items, they must have product liability and completed operations coverage.
•Suppliers must not initiate telephone contact with beneficiaries and are prohibited from contacting a Medicare beneficiary with only an oral order from a physician.
•Suppliers must provide delivery, instruct beneficiaries on product usage, and maintain proof of delivery.
•Suppliers are required to answer questions and handle complaints, while maintaining documentation of these contacts.
•Suppliers are required to maintain, repair, or replace equipment or contract with another company for Medicare covered rental products.
•Supplier standards must be provided to beneficiaries of Medicare covered items.
•Suppliers are required to disclose individuals with ownership, financial, or a controlling interest in the supplier.
•Supplier numbers may not be reassigned, conveyed, or shared with any other entity.
•Suppliers must establish a complaint resolution protocol to address complaints and maintain a record at the facility with information about complaints.
•The complaint record must include the name, address, telephone number, and health insurance claim number of the beneficiary with the complaint, a brief summary of the complaint and actions taken to resolve the problem.
•A supplier must furnish CMS with information required under the Medicate stature and regulations.
•In order to receive a supplier billing number, the supplier must be accredited by a CMS approved organization. The accreditation must indicate which products and services they are accredited for, in order to receive payment. There is an exception for specific pharmaceutics, which are exempt.
•Suppliers must notify their accreditation organization about the opening of a new DMEPOS location.
•Supplier locations are required to meet the DMEPOS quality standards and hold separate accreditation
•Suppliers are required to disclose the products and services for which they are seeking accreditation upon enrollment.
•Every supplier must comply with surety bond requirements, which are explained in 42 C.F.R. 424.57(c)
•Oxygen may be obtained from state licensed oxygen suppliers.
•Suppliers are required to maintain documentation regarding orders and referrals using the provisions of 42 C.F.R. 424.516(f).
•Sharing practice locations is prohibited for DMEPOS suppliers.
•Suppliers are required to be open to the public for at least 30 hours per week, with some exceptions.
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