I. 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)

• 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.

• 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.

• 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.

• 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.

• 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)

• 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.)

• Every provider is required to submit a claim for covered services within one year from the date of service

• 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.

• 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

1. 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.
2. 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.

II. Medicare Coverage for specific types of home medical equipment

• Cervical traction devices are covered only if both of the criteria below are met:
  1. The patient has a musculoskeletal or neurologic impairment requiring traction equipment.
  2. The appropriate use of a home cervical traction device has been demonstrated to the patient and the patient tolerated the selected device.

• A commode is only covered when the patient is physically incapable of utilizing regular toilet facilities. For example:
  1. The patient is confined to a single room, or
  2. The patient is confined to one level of the home environment and there is no toilet on that level, or
  3. 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.

• 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.

• A hospital bed is covered if one or more of the following criteria (1-4) are met:
  1. 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
  2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or
  3. 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
  4. 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.

• 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.

• 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.

• 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.

• 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 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.

• 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.

• 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