Both Medicare and private health insurance plans pay
for a large portion or sometimes even all costs
associated with many types of medical equipment used in
the home. This type of equipment is referred to as
durable medical equipment or home medical equipment. The
guide below will help you understand the Medicare
guidelines related to home medical equipment. Most
health insurance plans have similar rules to Medicare,
but you should know that all private health insurance
plans vary and the specific rules of your plan may
differ from these Medicare guidelines. We accept most of
the major health insurance plans. We would be happy to
work with you and your insurance company to help you
understand how your plan works as it relates to home
medical equipment needed by you or a loved one.
Individuals under 65 with permanent kidney
failure (beginning three months after dialysis
begins), or
Individuals under 65, permanently disabled and
entitled to Social Security benefits (beginning 24
months after the start of disability benefits)
The Different Benefits of Traditional
Medicare
Medicare Part A benefits cover hospital stays,
home health care and hospice services
Medicare Part B benefits cover physician visits,
laboratory tests, ambulance services and home
medical equipment
While oftentimes you do not have to pay a
monthly fee to have Part A benefits, the Part B
program requires a monthly premium to stay enrolled.
In 2007 that premium will range between
$93.50-161.40 per month depending on your income.
Typically, this amount will be taken from your
Social Security check.
What Can You Expect to Pay?
Every year, in addition to your monthly premium,
you will have to pay the first $131 of covered
expenses out of pocket and then 20 percent of all
approved charges if the provider agrees to accept
Medicare payments.
Unfortunately, your medical equipment provider
cannot automatically waive this 20 percent or your
deductible without suffering penalties from
Medicare. They must attempt to collect the
coinsurance and deductible if they are not covered
by another insurance plan; however, certain
exceptions can be made if you suffer from qualifying
financial hardships.
If you have a supplemental insurance policy,
that plan may pick up this portion of your
responsibility after your supplemental plan’s
deductible has been satisfied.
If your medical equipment provider does not
accept assignment with Medicare you may be asked to
pay the full price up front, but they will file a
claim on your behalf to Medicare. In turn, Medicare
will process the claim and mail you a check to cover
a portion of your expenses if the charges are
approved.
Other possible costs:
Medicare will pay only for items that meet your
basic needs as prescribed by a physician. Oftentimes
you will find that your provider offers a wide
selection of products that vary slightly in
appearance or features. You may decide that you
prefer the products that offer these additional
features. Your provider should give you the option
to pay a little extra money to get a product that
you really want.
To take advantage of this opportunity, a new
form has been approved by the Centers for Medicare
and Medicaid Services (CMS) that allows patients to
upgrade to a piece of equipment that they like
better than other standard options prescribed by
their physician.
The Advance Beneficiary Notice, or ABN, must
detail how the products differ, and requires a
signature to indicate that you agree to pay the
difference in the retail costs between two similar
items. Your provider will typically accept
assignment on the standard product and apply that
cost toward the purchase of the fancier item, thus
requiring less money out of your pocket.
Purpose of ABN
The Advance Beneficiary Notice also will be used
to notify you ahead of time that Medicare will
probably not pay for a certain item or service in a
specific situation, even if Medicare might pay under
different circumstances. The form should be detailed
enough that you understand why Medicare will not pay
for the item you are requesting.
The purpose of the form is to allow you to make
an informed decision about whether or not to receive
the item or service knowing that you may have
additional out-of-pocket expenses.
Durable Medical Equipment (DME) Defined
In order for any item to be covered under
Medicare, it typically has to meet the test of
durability. Medicare will pay for medical equipment
when the item:
Withstands repeated use (excludes many
disposable items such as underpads)
Is used for a medical purpose (meaning there
is a condition which the item will improve)
Is useless in the absence of illness or
injury (thus excluding any item preventive in
nature such as bathroom safety items used to
prevent injuries)
Used in the home (which excludes all items
that are needed only when leaving the confines
of the home setting)
Understanding Assignment (a claim-by-claim
contract)
When a provider accepts assignment, they are
agreeing to accept Medicare’s approved amount as
payment in full.
You will be responsible for 20 percent of that
approved amount. This is called your coinsurance.
You also will be responsible for the annual
deductible, which is $131.00 for 2007.
If a provider does not accept assignment with
Medicare, you will be responsible for paying the
full amount upfront. The provider will still file a
claim on your behalf and any reimbursement made by
Medicare will be paid to you directly. (Providers
must still notify you in advance, using the Advance
Beneficiary Notice, if they do not believe Medicare
will pay for your claim.)
Mandatory Submission of Claims
Every provider is required to submit a claim for
covered services within one year from the date of
service
The role of the physician with respect to
home medical equipment:
Every item billed to Medicare requires a
physician’s order or a special form called a
Certificate of Medical Necessity (CMN), and
sometimes additional documentation will be required.
Nurse Practitioners, Physician Assistants,
Interns, Residents and Clinical Nurse Specialists
can also order medical equipment and sign CMNs when
they are treating a patient.
All physicians' have the right to refuse to
complete documentation for equipment they did not
order, so make sure you consult with your physician
before requesting an item.
Prescriptions Before Delivery:
For some items, Medicare requires your provider
to have completed documentation (which is more than
just a call-in order or a prescription from your
doctor) before they can deliver these items to you:
Decubitus care (wheelchair cushions and
pressure-relieving surfaces placed on a hospital
bed)
Seat lift mechanisms
TENS Units (for pain management)
Power Operated Vehicles/Scooters
Electric Wheelchairs
Negative Pressure Wound Therapy
How does Medicare pay for and allow you to
use the equipment?
Typically there are three ways Medicare will pay
for a covered item:
They will purchase it outright, then the
equipment belongs to you,
They will rent it continuously until it is
no longer needed, or
They will consider it a “capped” rental in
which Medicare will rent the item for a total of
13 months and consider the item purchased after
having made 13 payments.
Medicare will not allow you to purchase
these items outright (even if you think you
will need it for a long period of time).
This is to allow you to spread out your
coinsurance instead of paying in one lump
sum.
It also protects the Medicare program
from paying too much should your needs
change earlier than expected.
After an item has been purchased for you (either
outright or after 13 payments), you will be
responsible for calling your provider anytime that
item needs to be serviced or repaired. When
necessary, Medicare will pay for a portion of
repairs, labor, replacement parts and for temporary
loaner equipment to use during the time your product
is in for servicing. All of this is contingent on
the fact that you still need the item at the time of
repair and continue to meet Medicare’s coverage
criteria for the item being repaired.
For a respiratory assist device to be covered,
the treating physician must fully document in your
medical record symptoms characteristic of
sleep-associated hypoventilation, such as daytime
hypersomnolence, excessive fatigue, morning
headache, cognitive dysfunction, dyspnea, etc.
A respiratory assist device is covered for those
patients with clinical disorder groups characterized
as (I) restrictive thoracic disorders (i.e.,
progressive neuromuscular diseases or severe
thoracic cage abnormalities), (II) severe chronic
obstructive pulmonary disease (COPD), (III) central
sleep apnea (CSA), or (IV) obstructive sleep apnea (OSA).
Various tests may need to be performed to
establish one of the above diagnosis groups.
Three months after starting your therapy, both
your physician and you will be required to respond
in writing to questions regarding your continued use
along with how well the machine is treating your
condition.
Breast Prostheses
Breast Prostheses are covered after a radical
mastectomy. Medicare will cover:
One silicone prosthesis every two years or a
mastectomy form every six months.
Mastectomy bras are covered as needed.
There is no coverage for replacement prostheses
due to wear and tear before the listed time frame.
However, Medicare will cover replacement of these
items due to:
Loss
Irreparable damage, or
Change in medical condition (e.g.
significant weight gain/loss)
Patients are allowed only one prosthesis per
affected side, others will be denied as not
medically necessary even if attempting asymmetry
(need ABN).
Mastectomy sleeves which are used to control
swelling are not covered in the home setting because
they do not meet Medicare’s definition of a
prosthesis; however, it is possible that they may be
covered under the hospital per diem if you request
one during your hospital stay.
Cervical Traction
Cervical traction devices are covered only if
both of the criteria below are met:
The patient has a musculoskeletal or
neurologic impairment requiring traction
equipment.
The appropriate use of a home cervical
traction device has been demonstrated to the
patient and the patient tolerated the selected
device.
Commodes
A commode is only covered when the patient is
physically incapable of utilizing regular toilet
facilities. For example:
The patient is confined to a single room, or
The patient is confined to one level of the
home environment and there is no toilet on that
level, or
The patient is confined to the home and
there are no toilet facilities in the home.
Heavy-duty commodes are covered for patients
weighing over 300 pounds.
Compression Stockings
Gradient compression stockings worn below the
knee are covered only when used for the treatment of
open venous stasis ulcers. They are not covered for
the prevention of ulcers, prevention of the
reoccurrence of ulcers or treatment of lymphedema
without ulcers.
CPAPs
Continuous Positive Airway Pressure (CPAP)
Devices are covered only for patients with
obstructive sleep apnea (OSA).
You must have an overnight sleep study performed
in a sleep laboratory to establish a qualifying
diagnosis. Home and mobile sleep labs/studies are
not accepted for diagnosing this condition.
Medicare will also pay for replacement masks,
cannulas, tubing and other necessary supplies.
After your first three months of use, you will
be required to verify if you are benefiting from
using the device and how many hours a day you are
using the machine.
Diabetic Supplies
For diabetics, Medicare covers the glucose
monitor, lancets, spring-powered devices, test
strips, control solution and replacement batteries
for the meter.
Medicare does not cover insulin injections or
diabetic pills unless covered through a Medicare
Part D benefit plan.
Diabetics can obtain up to a three month supply
at a time.
Medicare will approve up to one test per day for
non-insulin dependent diabetics and three tests per
day for insulin-dependent diabetics without
additional verification.
Patients who test above these guidelines are
required to be seen and evaluated by their
physician within six months of ordering these
supplies.
In addition, patients must send their
provider evidence of compliant testing (e.g. a
testing log) every six months to continue
getting refills at the higher levels.
If at any time your testing frequency changes,
your physician will need to give your provider a new
prescription.
Glasses
Medicare covers one complete pair of glasses
after the last cataract surgery. These can include:
frames
two lenses
tint, anti-reflective coating, and/or UV
(when the doctor specifically orders these
services for a medical need)
Hospital Beds
A hospital bed is covered if one or more of the
following criteria (1-4) are met:
The patient has a medical condition which
requires positioning of the body in ways not
feasible with an ordinary bed. Elevation of the
head/upper body less than 30 degrees does not
usually require the use of a hospital bed, or
The patient requires positioning of the body
in ways not feasible with an ordinary bed in
order to alleviate pain, or
The patient requires the head of the bed to
be elevated more than 30 degrees most of the
time due to congestive heart failure, chronic
pulmonary disease, or problems with aspiration.
Pillows or wedges must have been considered and
ruled out, or
The patient requires traction equipment
which can only be attached to a hospital bed.
Specialty beds that allow the height of the bed
to vary are covered for patients that require this
feature to permit transfers to a chair, wheelchair
or standing position.
A semi-electric bed is covered for a patient
that requires frequent changes in body position
and/or has an immediate need for a change in body
position.
Heavy-duty/extra-wide beds can be covered for
patients that weigh over 350 pounds.
The total electric bed is not covered because it
is considered a convenience feature. If you prefer
to have the total electric feature, your provider
usually can apply the cost of the semi-electric bed
toward the monthly rental price of the total
electric model by using an Advance Beneficiary
Notice (ABN). You would be responsible to pay the
difference in the retail charges between the two
items every month.
Lymphedema Pumps
Lymphedema Pumps are covered for treatment of
true lymphedema as a result of a:
Primary Lymphedema resulting from a
congenital abnormality of lymphatic drainage or
Milroy’s disease, or
Secondary lymphedema resulting from the
destruction of or damage to formerly functioning
lymphatic channels such as:
radical surgical procedures with removal
of regional groups of lymph nodes (for
example, after radical mastectomy),
post-radiation fibrosis,
spread of malignant tumors to regional
lymph nodes with lymphatic obstruction,
or other causes
Before you can be prescribed a pump, your
physician must monitor you during a four-week
trial period where other treatment options are
tried such as medication, limb elevation and
compression garments. If, at the end of the
trial, there is little or no improvement, a
lymphedema pump can be considered.
The doctor must then document an initial
treatment with a pump and establish that the
treatment can be tolerated.
Lymphedema pumps also are covered for the
treatment of chronic venus insufficiency (CVI).
Before you can be prescribed a pump for this
condition, your physician must monitor you
during a six month trial period where other
treatment options are tried such as medication,
limb elevation and compression garments. If at
the end of the trial the stasis ulcers are still
present, a lymphedema pump can be considered.
The doctor must then document an initial
treatment with a pump and establish that the
treatment can be tolerated, that there is a
caregiver available to assist with the treatment
in the home, and then the doctor must prescribe
the pressures, frequency, and duration of
prescribed use.
Medicare-covered drugs (other than Medicare
Part D coverage)
As of February 2001, all providers of
Medicare-covered drugs are required to accept
assignment on these items.
Traditional Medicare Part B insurance will cover
some nebulizer drugs, some infused drugs using a
pump, specific immunosuppressive drugs, select oral
anti-cancer medications and most parenteral
nutrition.
The Medicare Part D plans may provide additional
coverage of other oral medications, inhalers and
similar drugs.
Mobility Products: Canes, Walkers,
Wheelchairs, and Scooters
Essentially the new Mobility Assistive Equipment
regulations will ensure that Medicare funds are used
to pay for:
Mobility needs for daily activities within
the home
Least costly alternative/lowest level of
equipment to accomplish these tasks.
Most medically appropriate equipment (to
meet the needs, not the wants)
Medicare requires that your physician and
provider evaluate your needs and expected use of the
mobility product you will qualify for.
They must determine which is the least level of
equipment needed to help you be mobile within your
home to accomplish daily activities by asking the
following questions:
Will a cane or crutches allow you to perform
these activities in the home?
If not, will a walker allow you to
accomplish these activities in the home?
If not, is there any type of manual
wheelchair that will allow you to accomplish
these activities in the home?
If not, will a scooter allow you to
accomplish these activities in the home?
If not, will a power chair allow you to
accomplish these activities in the home?
Keep in mind if you have another higher level
product in mind that will allow you to do more
beyond the confines of the home setting, you can
discuss with your provider the option to upgrade to
a higher level or more comfortable product by paying
an additional out of pocket fee using the Advance
Beneficiary Notice (ABN) to select the product you
like best.
A face-to-face examination with your physician
is required prior to the initial setup of a power
chair or scooter.
Your home must be evaluated to ensure it will
accommodate the use of any mobility product.
Nebulizers
Nebulizer machines, medications and related
accessories are usually covered for patients with
obstructive pulmonary disease, but can also be
covered to deliver specific medications to patients
with HIV, CF, brochiectasis, pneumocystosis,
complications of organ transplants, or for
persistent thick or tenacious pulmonary secretions.
Patients can obtain up to a three month’s supply
of nebulizer medications and accessories at a time.
Non-covered items (partial listing):
Adult diapers
Bathroom safety equipment
Hearing aides
Syringes/needles
Van lifts or ramps
Exercise equipment
Humidifiers/Air Purifiers
Raised toilet seats
Massage devices
Stair lifts
Emergency communicators
Low Vision Aides
Grab bars
Orthopedic Shoes
Orthopedic shoes are covered when it is
necessary to attach the shoe(s) to a leg brace.
However, Medicare will only pay for the shoe(s)
attached to the leg braces.
Medicare will not pay for matching shoes or for
shoes that are needed for purposes other than for
diabetes or leg braces.
Ostomy Supplies
Ostomy supplies are covered for people with a:
colostomy
ileostomy
urostomy
Patients can obtain up to a three month’s supply
of wafers, pouches, paste and other necessary items
at a time.
Oxygen
Covered for patients with significant hypoxemia
in the chronic stable state when:
patient has a chronic lung condition or
disease or hypoxemia that might be expected to
improve with oxygen therapy, and
patient’s blood gas levels or oxygen
saturation levels indicate the need for oxygen
therapy, and
alternative treatments have been tried or
deemed clinically ineffective.
Categories/Groups are based on the test results
to measure your oxygen:
I 55≤ mmHg, or 88%≤ saturation
For these results you must return to
your physician 12 months after the initial
visit to continue therapy for lifetime or
until the need is expected to end.
Typically, you will not have to be retested
when you return to your physician for the
follow-up visit.
II 56-59 mmHg, or 89% saturation
For these results, you must be retested
within 3 months of the first test to
continue therapy for lifetime or until the
need is expected to end.
III ≥60 or ≥90% not medically necessary.
Oxygen will be paid as a rental for the first 36
months. After that time if you still need the
equipment Medicare will no longer make rental
payments on the equipment. If your deductible and
copays are met, the equipment title will transfer to
you. Medicare will then pay for refilling your
oxygen cylinders and for repairs and service of your
equipment. Medicare will also separately pay for
oxygen accessories such as tubing, masks and
cannulas after the purchase price has been met.
Parenteral and enteral therapy
Parenteral therapy requires all or part of the
gastrointestinal tract be missing. Nutritional
formulas are delivered through a vein.
Enteral therapy is covered for patients who
cannot swallow or take food orally. Nutrition must
be delivered through a tube directly into the
gastrointestinal tract.
Medicare will not pay for nutritional formulas
that are taken orally.
Patient Lifts
A lift is covered if transfer between bed and a
chair, wheelchair, or commode requires the
assistance of more than one person and, without the
use of a lift, the patient would be bed confined.
An electric lift mechanism is not covered;
because it is considered a convenience feature. If
you prefer to have the electric mechanism, your
provider can usually apply the cost of the manual
lift toward the purchase price of the electric model
by using an Advance Beneficiary Notice (ABN). You
would be responsible to pay the difference in the
retail charges between the two items.
Seat Lift Mechanisms
In order for Medicare to pay for a seat lift
mechanism, patients must be suffering from severe
arthritis of the hip or knee, or have a severe
neuromuscular disease. In addition they must be
completely incapable of standing up from any chair,
but once standing they can walk either independently
or with the aid of a walker or cane. The physician
must believe that the mechanism will improve, slow
down or stop the deterioration of the patient’s
condition.
Transferring directly into a wheelchair will
prevent Medicare from paying for the device.
Medicare will only pay for the lift mechanism
portion. The chair portion of the package is not
covered, and you will be responsible for paying the
full amount for the furniture component of the
chair.
Support Surfaces
Group 1 products are designed to be placed on
top of a standard hospital or home mattress. They
can utilize gel, foam, water or air, and are covered
for patients that are:
Completely immobile OR
Have limited mobility with any stage ulcer
on the trunk or pelvis (and one of the
following):
impaired nutritional status
fecal or urinary incontinence
altered sensory perception
compromised circulatory status
Group 2 products take many forms, but are
typically powered pressure reducing mattresses or
overlays. They are covered for patients with one of
three conditions:
Multiple stage II ulcers on the pelvis or
trunk while on a comprehensive treatment program
for at least a month using a Group 1 product,
and at the close of that month, the ulcers
worsened or remained the same. (Monthly
follow-up is required by a clinician to ensure
that the treatment program is modified and
followed. This product is only covered while
ulcers are still present.) OR
Large or multiple Stage III or IV ulcers on
the trunk or pelvis (Monthly follow-up is
required by a clinician to ensure that the
treatment program is modified and followed. This
product is only covered while ulcers are still
present.) OR
A recent myocutaneous flap or skin graft for
an ulcer on the trunk or pelvis within the last
60 days who were immediately placed on Group 2
or 3 support surface prior to discharge from the
hospital and the patient has been discharged
within last 30 days.
TENS Units
TENS units are covered for the treatment of
chronic intractable pain that has been present for
at least three months or more, and in some cases for
acute post-operative pain.
Not all types of pains can be treated with a
TENS unit. TENS units have proven ineffective in
treating headaches, visceral abdominal pains, pelvic
pains, and TMJ pains, and therefore Medicare will
not pay for the device when used to treat these
conditions.
For chronic pain sufferers, Medicare will pay
for a one or two month trial rental to determine if
this device will alleviate the chronic pain. You
must return to your physician exactly 30-60 days
after initial evaluation to authorize the purchase
of this equipment.
For acute post-operative pain sufferers,
Medicare will consider rental payment for a maximum
of 30 days. Any duration longer than that will
require individual consideration.
Therapeutic Shoes
Special therapeutic shoes, inserts and
modifications can be covered for diabetic patients
with the following foot conditions:
previous amputation of a foot or partial
foot
history of foot ulceration
peripheral neuropathy with callus formation
foot deformity
poor circulation in either foot
Urological Supplies
Urinary catheters and external urinary
collection devices are covered to drain or collect
urine for a patient who has permanent urinary
incontinence or permanent urinary retention.
Permanent urinary retention is defined as retention
that is not expected to be medically or surgically
corrected in that patient within 3 months.
Below is a summary of the standards Medicare requires
of home medical equipment providers. Our company meets
or exceeds all of these standards.
A supplier must be in compliance with all
applicable Federal and State licensure and
regulatory requirements.
A supplier must provide complete and accurate
information on the DMEPOS supplier application. Any
changes to this information must be reported to the
National Supplier Clearinghouse within 30 days.
An authorized individual (one whose signature is
binding) must sign the application for billing
privileges.
A supplier must fill orders from its own
inventory, or must contract with other companies for
the purchase of items necessary to fill the order. A
supplier may not contract with any entity that is
currently excluded from the Medicare program, any
State health care programs, or from any other
Federal procurement or non-procurement programs.
A supplier must advise beneficiaries that they
may rent or purchase inexpensive or routinely
purchased durable medical equipment, and of the
purchase option for capped rental equipment.
A supplier must notify beneficiaries of warranty
coverage and honor all warranties under applicable
State law, and repair or replace free of charge
Medicare covered items that are under warranty
A supplier must maintain a physical facility on
an appropriate site.
A supplier must permit CMS (formerly HCFA), or
its agents to conduct on-site inspections to
ascertain the supplier’s compliance with these
standards. The supplier location must be accessible
to beneficiaries during reasonable business hours,
and must maintain a visible and posted hours of
operation.
A supplier must maintain a primary business
telephone listed under the name of the business in a
local directory or a toll free number available
through directory assistance. The exclusive use of a
beeper, answering machine or cell phone is
prohibited.
A supplier must have comprehensive liability
insurance in the amount of at least $300,000 that
covers both the supplier’s place of business and all
customer and employees of the supplier. If the
supplier manufactures its own items, this insurance
must also cover product liability and completed
operations.
A supplier must agree not to initiate telephone
contact with beneficiaries, with a few exceptions
allowed. This standard prohibits suppliers from
calling beneficiaries in order to solicit new
business.
A supplier is responsible for delivery and must
instruct beneficiaries on use of Medicare covered
items, and maintain proof of delivery.
A supplier must answer questions and respond to
complaints of beneficiaries, and maintain
documentation of such contacts.
A supplier must maintain and replace at no
charge or repair directly, or through a service
contract with another company, Medicare-covered
items it has rented to beneficiaries.
A supplier must accept returns of substandard
(less that full quality for the particular item) or
unsuitable items (inappropriate for the beneficiary
at the time it was fitted and rented or sold) from
beneficiaries.
A supplier must disclose these supplier
standards to each beneficiary to whom it supplies a
Medicare-covered item.
A supplier must disclose to the government any
person having ownership, financial, or control
interest in the supplier.
A supplier must not convey or reassign a
supplier number, i.e., the supplier may not sell or
allow another entity to use its Medicare billing
number
A supplier must have a complaint resolution
protocol established to address beneficiary
complaints that relate to these standards. A record
of these complaints must be maintained at the
physical facility.
Complaint records must include: the name,
address, telephone number, and health insurance
claim number of the beneficiary, a summary of the
complaint, and any actions taken to resolve it.
A supplier must agree to furnish CMS (formerly
HCFA) any information required by the Medicare
statue and implementing regulations.
