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, the Part B program requires a monthly premium to stay enrolled. In 2010 that premium will range between $96.40- $353.60 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 $155of 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 those charges 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. 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 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 patients to upgrade to a piece of equipment that they like better than other standard options they may otherwise qualify for.
The Advance Beneficiary Notice of Non Coverage, 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 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 underpads)
- 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 $155.00 for 2010.
- 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 ClaimsEvery 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 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)
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 for equipment that is not covered under warranty.
Medicare Coverage for Types of Equipment
BiLevel Devices/Respiratory Assist Devices
- Irreparable damage, or
- Change in medical condition (e.g. significant weight gain/loss)
- 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.
- 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.
Positive Airway Pressure Devices (CPAPs and Bi-Level Devices for Obstructive Sleep Apnea)
- The patient tried but was unsuccessful with attempts to use the CPAP device; and,
- Multiple interface (mask) options have been tried and the current interface (mask) is most comfortable to the patient; and,
- The work of exhalation with the current pressure setting of the CPAP prevents the patent from tolerating the therapy; and,
- Lower pressure settings of the CPAP fail to adequately control the symptoms of Obstructive Sleep Apnea or reduce the AHI/RDI (apneas and hypopneas) to acceptable levels.
- Two lenses
- Tint, anti-reflective coating, and/or UV (when the doctor specifically orders these services for a medical need)
- 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.
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.
- 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.
Medicare-covered drugs (other than Medicare Part D coverage)
Mobility Products: Canes, Walkers, Wheelchairs, and Scooters
- 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)
- 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?
- 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
- 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.
- Group I Criteria: mmHG = 55, or saturation = 88%
- 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.
- Group II Criteria: 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.
- Group III Criteria: mmHg=60 or saturation =90%
- not medically necessary.
Parenteral and Enteral Therapy
Seat Lift Mechanisms
- 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
- 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.
- Previous amputation of a foot or partial foot
- History of foot ulceration
- History of pre-ulcerative calluses
- Peripheral neuropathy with callus formation
- Foot deformity
- Poor circulation in either foot
- The patient resides in a nursing facility, or
- The patient has radiologically documented vesico-ureteral reflux while on a program of intermittent catheterization, or
- The patient is a spinal cord injured female with neurogenic bladder who is pregnant (for duration of pregnancy only), or
- The patient has had distinct, recurrent urinary tract infections (formally diagnosed via urine cultures), while on a program of sterile intermittent catheterization and sterile lubricant, twice within the 12-months prior to the initiation of sterile intermittent catheter kits.
- The patient is immunosuppressed, for example (not all-inclusive):
- On a regimen of immunosuppressive drugs post-transplant,
- On cancer chemotherapy,
- Has AIDS,
- Has a drug-induced state such as chronic oral corticosteroid use.
Medicare Supplier Standards
- A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements and cannot contract with an individual or entity to provide licensed services.
- 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. This standard requires that the location is accessible to the public and staffed during posted hours of business. The location must be at least 200 square feet and contain space for storing records.
- A supplier must permit CMS, 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 sign 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, answering service or cell phone during posted business hours 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 customers 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 contacting a Medicare beneficiary based on a physician’s oral order unless an exception applies.
- 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 than 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 any information required by the Medicare statute and implementing regulations.
- All suppliers must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services, for which the supplier is accredited in order for the supplier to receive payment of those specific products and services (except for certain exempt pharmaceuticals). Implementation Date - October 1, 2009
- All suppliers must notify their accreditation organization when a new DMEPOS location is opened.
- All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare.
- All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.
- Must meet the surety bond requirements specified in 42 C.F.R. 424.57(c). Implementation date- May 4, 2009
- A supplier must obtain oxygen from a state- licensed oxygen supplier.
- A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F.R. 424.516(f).
- DMEPOS suppliers are prohibited from sharing a practice location with certain other Medicare providers and suppliers.
- DMEPOS suppliers must remain open to the public for a minimum of 30 hours per week with certain exceptions.