Medicare Coverage for Home Medical Equipment
Click on the “+” below for more information on Medicare coverage for the following categories:
A commode is only covered when you are physically incapable of utilizing regular toilet facilities. For example:
- You are confined to a single room, or
- You are confined to one level of the home environment and there is no toilet on that level, or
- You are confined to the home and there are no toilet facilities in the home.
Heavy-duty commodes are covered if you weigh over 300 pounds. Commodes with detachable arms are covered only to help transfer you if your body configuration requires extra width.
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 or swelling without ulcers.
CPAP/BiLevel Devices for Obstructive Sleep Apnea (OSA)
For a CPAP device to be covered, the treating physician must fully document in your medical record symptoms characteristic of sleep-associated hypoventilation, such as daytime tiredness, excessive fatigue, morning headaches, cognitive dysfunction, dyspnea, etc. You must also have a sleep test to determine if you have OSA. (If you need a PAP for another condition, please see Respiratory Assist Devices).
Bi-Level devices are covered only if it is proven that a CPAP is ineffective in treating your OSA despite proper mask fitting.
For ongoing coverage (after 3 months) you must have a compliant download from your machine (proving use ≥ 4 hours per night during a consecutive 30 day period within the first 3 months) and see your doctor again between the 31st and 91sat day from start of therapy, who must document use and benefit of your PAP.
Medicare will also pay for replacement masks, tubing and other necessary supplies if you are compliant with treatment, have nearly exhausted your existing supply and you have specifically requested such supplies.
For diabetics, Medicare covers the glucose monitor, spring-powered lancing devices, lancets, test strips, control solution and replacement batteries for the meter if you meet these guidelines:
- You have diabetes which is being treated by a physician; and
- The glucose monitor and related accessories and supplies have been ordered by that treating physician and the doctor maintains records about your care including, but not limited to, evidence that the prescribed frequency of testing is reasonable and necessary; and
- You or your caregiver has successfully completed training or is scheduled to begin training in the use of the monitor, test strips, and lancing devices; and
- You or your caregiver is capable of using the test results to assure your appropriate glycemic control; and
- The device is designed for home use.
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 of need. Medicare does not cover insulin injections or diabetic pills unless covered through a Medicare Part D benefit plan.
If you test above these guidelines, your doctor must have ordered an increased frequency of testing and must document in your medical records the specific reason(s) for that frequency. You are required to be seen and evaluated by your physician within six months prior to receiving your initial supplies from your provider. In addition, you must send your 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. You can get up to a 3 month supply at one time if you have nearly exhausted your existing supply and specifically requested the refill.
A hospital bed is covered if one or more of the following criteria are met:
- You have 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
- You require positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or
- You require 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
- You require traction equipment which can only be attached to a hospital bed.
A variable height bed is covered if you require this feature to permit transfers to a chair, wheelchair or standing position. A semi-electric bed is covered if you require frequent changes in body position and/or have an immediate need for a change in body position. Heavy-duty/extra-wide beds can be covered if you weigh over 350 pounds. Trapeze equipment is covered if you need this device to sit up because of a respiratory condition, to change body position for other medical reasons, or to get in or out of bed.
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. You will need to sign an Advance Beneficiary Notice (ABN) and will be responsible to pay the difference in the retail charges between the two items every month.
Mobility Assistive Equipment: Canes, Walkers, Scooters and Wheelchairs
Medicare covers mobility assistive equipment (MAE) if you need it to be able to safely and effectively perform mobility related activities of daily living (MRADL’s) in your home, like toileting, grooming, feeding, bathing, etc. Medicare covers the lowest level of equipment required to accomplish these tasks and meet your needs, in this order:
- Manual Wheelchair
- Power Wheelchair
- Custom Rehab Power Wheelchair
Medicare requires that your physician and sometimes other medical professionals evaluate your mobility needs to determine what type of equipment you will qualify for. This is called a “face to face examination.” In addition, you must be capable, willing and able to use the MAE, and your home must be able to accommodate its use.
Keep in mind that if you would prefer a higher level product than what Medicare will cover, 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).
Your provider cannot deliver a scooter or power wheelchair 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. Please be patient with your provider while they collect the required documentation from your physician.
Generally, Small Volume Nebulizer machines, medications and related accessories are covered if:
- It is reasonable and necessary to administer albuterol, arformoterol, budesonide, cromolyn, formoterol, ipratropium, levalbuterol, or metaproterenol (J7669) for the management of obstructive pulmonary disease; or
- It is reasonable and necessary to administer dornase alpha if you have cystic fibrosis; or
- It is reasonable and necessary to administer tobramycin if you have cystic fibrosis or bronchiectasis; or
- It is reasonable and necessary to administer pentamidine if you have HIV, pneumocystosis, or complications of organ transplants; or
- It is reasonable and necessary to administer acetylcysteine for persistent thick or tenacious pulmonary secretions.
Large Volume Nebulizer machines, medications and related accessories are generally covered when:
- It is reasonable and necessary to deliver humidity to a patient with thick, tenacious secretions, who has cystic fibrosis, bronchiectasis, a tracheostomy, or a tracheobronchial stent.
You may obtain up to a three month’s supply of nebulizer medications and accessories at a time as long as you continue to regularly use the medications through your machine, have nearly exhausted your existing supply and make a specific request for refill supplies. If at any time you stop using your medications, please notify your provider.
Non-Covered Items (Partial Listing):
- Adult Diapers
- Bathroom Safety Equipment
- Hearing Aides
- Van Lifts or Ramps
- Exercise Equipment
- Humidifiers/Air Purifiers
- Raised Toilet Seats
- Massage Devices
- Stair Lifts
- Emergency Communicators
- Low Vision Aides
- Grab Bars
- Elastic Garments
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.
Oxygen is covered if one meets the following guidelines:
- You have a severe lung disease or hypoxemia that might be expected to improve with oxygen therapy, and
- Your blood gas levels or oxygen saturation levels indicate the need for oxygen therapy, and
- Your oxygen study was performed by a qualifying physician or lab, and
- Alternative treatments have been tried or considered and deemed clinically ineffective.
You must be either in a chronic, stable state (meaning not during a period of acute illness or exacerbation of your underlying disease) or the test must have been done in hospital the closest to, but no earlier than, 2 days prior to discharge. Some individuals will qualify for oxygen during sleep testing or with exercise. To have a valid exercise test, your saturations must be taken 3 times: once at rest without oxygen, once during exercise without oxygen to show desaturations, and again with oxygen applied with exercise to show how oxygen helps your saturations levels. In general, a valid overnight oximetry must show desaturations or a decrease from your baseline for at least 5 minutes.
Categories/Groups are based on the test results to measure your oxygen.
Generally, Group I Criteria is determined by a PO2 ≤ 55 mm Hg, or saturation of 88% or below. Coverage for Group I patients is limited to 12 months or the length of time your doctor specifies; whichever is shorter. You must then return to your physician between 9-12 months after the initial visit to discuss whether your oxygen therapy should continue for lifetime or for a shorter period if 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.
A group II criterion is generally determined by a PO2of 56-59 mm Hg, or saturation of 89%. Coverage for Group 2 patients is limited to 3 months, or the physician’s length of need; whichever is shorter. For these results, you must see your doctor to discuss your oxygen therapy and you will also have to be retested within 3 months of the first test to continue therapy for lifetime or until the need is expected to end.
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. However, if equipment is still necessary, your provider will continue to provide the equipment to you for an additional 24 months. During this two year service period, Medicare will pay your provider for refilling your oxygen cylinders and for maintenance and servicing. After 60 months of service through Medicare you may choose to receive new equipment.
Parenteral and Enteral Therapy
Parenteral therapy requires all or part of the gastrointestinal tract to be missing. Nutritional formulas are delivered through a vein. Enteral therapy is covered if you have a permanent (at least 3 months) non-function of the structures that permit food to reach your small bowel, or if you have a disease of the small bowel that doesn’t allow proper absorption or digestion of an oral diet. In other words, you cannot be able to swallow or adequately digest food. Enteral nutrition is delivered through a tube directly into the gastrointestinal tract. Medicare will not pay for nutritional formulas that are taken orally.
Specialty nutrients/formulations can be covered if you have unique nutrient needs or specific disease conditions which are well documented in your physician’s records. In some cases you may have to try standard formulas and document that they are unsuccessful before you can receive the specialty nutrients.
A lift is covered if transfer between a bed and a chair, wheelchair or commode is required and, without the use of a lift, you would be bed confined.
It is important to know that if an electric lift or multi-positional support lift is provided, Medicare will discontinue payment for any mobility aids you use, such as cane, crutches, walkers, rollabouts, scooters and wheelchairs.
Patient lifts are a capped rental item, and that means they cannot be purchased outright. You will own the equipment after Medicare makes 13 payments toward the purchase of the equipment.
Respiratory Assist Devices
A respiratory assist device (RAD) is covered if you have a clinical disorder characterized as:
- Restrictive thoracic disorders (i.e., progressive neuromuscular diseases or severe thoracic cage abnormalities)
- Severe chronic obstructive pulmonary disease (COPD)
- Central sleep apnea (CSA) or complex sleep apnea (CompSA); or
- Hypoventilation syndrome.
Your doctor must fully document in your medical record symptoms characteristic of sleep-associated hypoventilation, such as daytime tiredness, excessive fatigue, morning headaches, shortness of breath, etc. Various tests may need to be performed to establish that you meet one of the above diagnosis groups’ criteria.
For ongoing coverage (beyond 3 months) you must be re-evaluated by your doctor on or after the 61st day from start of your therapy, documenting progress of your symptoms and that you use the RAD at least 4 hours per night. Your doctor must also sign a statement documenting your use and benefit.
Medicare will also pay for replacement masks, tubing and other necessary supplies if you are compliant with treatment, have nearly exhausted your existing supply and you have specifically requested such supplies.
Seat Lift Mechanisms
In order for Medicare to pay for a seat lift mechanism, you must meet the following guidelines:
- You must have severe arthritis of the hip or knee or have a severe neuromuscular disease.
- The seat lift mechanism must be a part of the physician’s course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in your condition.
- You must be completely incapable of standing up from a regular armchair or any chair in your home. (If you only have difficulty or are not able to get up from a chair, particularly a low chair, this is not sufficient justification for a seat lift mechanism.)
- Once standing, you must have the ability to ambulate.
The doctor who orders the seat lift mechanism must be the doctor who is treating you for the disease or condition resulting in the need for a seat lift. The physician’s record must document that all other options, like medication and physical therapy, have been tried and failed to enable you to transfer from a chair to a standing position.
If you use a wheelchair or scooter, this will preclude coverage for the seat lift, because, as above, you must be able to ambulate once you are standing.
Medicare will only pay for the lift mechanism portion. The chair portion is not covered, and you will be responsible for paying the full amount for the furniture component of the chair.
Your provider cannot deliver this product to you without a written order or certificate of medical necessity 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. Please be patient with your provider while they collect the required documentation from your physician.
Group 1 products are designed to be placed on top of a standard hospital bed or home mattresses. They can utilize gel, foam, water or air, and are covered if you are:
- Completely immobile; OR
- Have limited mobility or 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 if you have 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 the ulcers worsened or remained the same, or
- Large or multiple Stage III or IV ulcers on the trunk or pelvis, or
- A recent myocutaneous flap or skin graft for an ulcer on the trunk or pelvis within the last 60 days where you were immediately placed on Group 2 or 3 support surface prior to discharge from the hospital or aftercare nursing facility and you have been discharged within the last 30 days. (Coverage limited to 60 days post surgery).
Other than after flap surgery, a Group 2 support surface is generally covered until the ulcer is healed, or your doctor notes that it is not healing but that your care is being modified to promote healing and the surface is still necessary for wound management.
A physician or healthcare professional must make monthly assessments as to whether continued use of the equipment is required. Sometimes your doctor may order a home healthcare nurse to come visit you to make these assessments, or that you visit a wound care specialist.
Group 3 products are air-fluidized beds and are only covered if you meet ALL of the following conditions:
- A stage III or stage IV pressure ulcer, and
- Are bedridden or chair bound as the result of limited mobility, and
- In the absence of an air-fluidized bed would require institutionalization, and
- An alternate course of conservative treatment has been tried for at least one month without improvement of the wound, and
- A trained caregiver is available to help with activities of daily living and other needs, and
- All other alternative equipment has been considered and ruled out.
A physician or healthcare professional must assess and evaluate you after completion of a course of conservative therapy within one month prior to ordering the Group 3 support surface. You must also be re-evaluated on a monthly basis and your doctor must fill out a form to certify medical necessity to continue coverage.
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. Please be patient with your provider while they collect the required documentation from your physician.
TENS units are covered for the treatment of chronic intractable pain that has been present for at least three months and for which other treatments methods have failed, and in some cases for acute post-operative pain.
Not all types of pain can be treated with a TENS unit. TENS units have been proven ineffective in treating headaches, visceral abdominal pain, pelvic pain, and TMJ pain, and therefore Medicare will not pay for the device when used to treat these conditions.
For chronic pain sufferers, Medicare will rent the TENS for you for a 30-60 day trial to determine if it will help or alleviate the chronic pain. For continued coverage, you must return to your physician for re-evaluation and to discuss how the therapy is working and to authorize the purchase of this equipment. The doctor must document in your records at the end of the trial period how often you used the TENS unit, the typical duration of use each time, and the results.
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.
Your provider cannot deliver this product 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. Please be patient with your provider while they collect the required documentation from your physician.
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.