Medicare Coverage for Home Medical Equipment
Click on the “+” below for more information on Medicare coverage for the following categories:
Ostomy supplies are covered for people with a colostomy, ileostomy or urostomy. The quantity of ostomy supplies covered is determined primarily by the type of ostomy, its location, its construction, and the condition of the skin surface surrounding the stoma. There will be variation according to individual patients need and their needs may vary over time.
You may obtain up to a three month’s supply of wafers, pouches, paste and other necessary items at a time if you have nearly exhausted your existing supply and make a specific request for refill supplies.
Urinary catheters and external urinary collection devices and related supplies and accessories are covered to drain or collect urine if you have permanent (at least 3 months) urinary incontinence or permanent urinary retention.
A maximum of six intermittent catheters may be used per day (up to 200 per month), or one indwelling catheter per month, or 35 male external catheters unless it is determined that a higher number is medically necessary by your physician, and these unique circumstances are specifically documented in your medical records.
If your doctor wants you to use a sterile intermittent catheter kit, there are additional criteria you must meet before Medicare will pay for the sterile kits:
- You reside in a nursing facility, or
- You are immunosuppressed, (e.g. on cancer chemotherapy or have AIDS); or
- You have radiologically documented vesico-ureteral reflux while on a program of intermittent catheterization, or
- You are a spinal cord injured female with neurogenic bladder who is pregnant (for duration of pregnancy only), or
- You have had distinct, recurrent urinary tract infections, while on a program of sterile intermittent catheterization with A4351/A4352 and sterile lubricant A4332, twice within the 12-month prior to the initiation of sterile intermittent catheter kits.
When at home, you may receive up to a 3-month supply at one time if you have nearly exhausted your existing supply and you have specifically requested such refill supplies.
Guide to Medicare Coverage
Who qualifies for Medicare benefits?
- Individuals 65 years of age or older
- 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 (you only have to pay money when you use the services), the Part B program requires a monthly premium to stay enrolled (even if you do not use the services). In 2011 that premium will range between $115.40- $369.10 per month depending on your income. Typically, this amount will be taken from your Social Security check.
Medicare Part D offers optional program benefits that cover prescription drugs.
For more information about your benefits or making coverage decisions, you can visit the official website for Medicare benefits at www.medicare.gov.
What Can You Expect to Pay?
Every year, in addition to your monthly premium, you will have to pay the first $162 of covered expenses out of pocket for Part B services, 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 those charges are not covered by another insurance plan.
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. Often times 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 allow you to privately pay a little extra money to get the 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 you to upgrade to a piece of equipment that you like better than the other standard option you may otherwise qualify for. This form is known as the Advance Beneficiary Notice or ABN.
The ABN your provider completes for you 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 of Non Coverage 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 probably 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 under pads)
- Is used for a medical purpose (meaning there is an underlying condition which the item should 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 $162.00 for 2011.
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 such as copies of office visit notes from prior visits with your physician or copies of test results relevant to the prescription of your medical equipment.
Nurse Practitioners, Physician Assistants, Interns, Residents and Clinical Nurse Specialists can also order medical equipment and sign CMNs when they are treating you.
All physicians have the right to refuse to complete documentation for equipment they did not order, so make sure you consult with your physician about your need for medical equipment or supplies before requesting an item from a provider.
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 or Power Wheelchairs
- Negative Pressure Wound Therapy (wound vacs)
- Pressure reducing pads/mattresses
Your provider cannot deliver these products to you without a written order from your doctor, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your provider. So please be patient with your provider while they collect the required documentation from your physician.
How does Medicare pay for and allow you to use the equipment?
Typically there are four ways Medicare will pay for a covered item:
- Purchase it outright, then the equipment belongs to you,
- Rent it continuously until it is no longer needed, or
- 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.
- If you have oxygen therapy, Medicare will make rental payments for a total of 36 months during which time this fee covers all service and accessories.
- Beyond the 36 months (for a period of 2 additional years), Medicare will limit payments to a small fee for monthly gas or liquid contents and a limited service fee to check the equipment every six months.
After an item has been purchased for you, 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.