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Medicare Guide

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 2018 that premium could be around $134 per month (but could be less) depending on your income. Typically, this amount will be taken from your Social Security check.
  • Medicare Part C is coverage offered through various insurance companies that offer Medicare Advantage Plans.  These plans are offered as an alternative to Medicare Part B.  Medicare Advantage Plans cover the same benefits as your Part B plan but often have limited provider networks and may require authorization for services prior to making payment. Premiums and deductibles vary by plan. Some plans offer perks like gym memberships as a participation benefit.
  • 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 for Medicare Part B Services?

  • In 2018, in addition to your monthly premium, you will have to pay the first $183 of covered expenses out-of-pocket for Part B services, and then 20 percent of all approved charges if the supplier agrees to accept Medicare payments.
  • Unfortunately, your medical equipment supplier 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 meet qualifying financial hardships established by your supplier.
  • 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 supplier 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 supplier 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 supplier 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 form that your supplier 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 supplier 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 will also 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 (which 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 (which excludes any item that is 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 supplier 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 $183.00 for 2018.
  • If you have chosen to receive an upgraded, fancier product than what Medicare typically covers, you will also be responsible for any additional amounts disclosed on the Advance Beneficiary Notice that identifies the additional features and fees that you have approved.
  • If a supplier does not accept assignment with Medicare, you will be responsible for paying the full amount upfront. The supplier will still file a claim on your behalf and any reimbursement made by Medicare will be paid to you directly. (Suppliers must still notify you in advance, using the Advance Beneficiary Notice, when they do not believe Medicare will pay for your claim.)

Mandatory Submission of Claims

  • Every supplier is required to submit a claim for covered services within one year from the date of service. However, if the item is never covered by Medicare, your supplier is not obligated to submit a claim.

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 healthcare provider 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 and healthcare providers have the right to refuse to complete documentation for equipment they did not order, so make sure you consult with your physician or healthcare provider about your need for medical equipment or supplies before requesting an item from a supplier.
  • For every new item prescribed by your physician or healthcare provider, you should have a recent office visit that documents the reasons for ordering the equipment and products.  Most items require you to have an in-person office visit with your doctor or healthcare provider to discuss the need and justification for the prescription of medical equipment (and even replacement equipment) before a supplier can fill those orders.

Prescriptions before Delivery:

  • For some items, Medicare requires your supplier to have completed documentation (which is more than just a call-in order or a prescription from your doctor or healthcare provider) before they can deliver these items to you:
    • Decubitus care (wheelchair cushions, pressure-relieving surfaces placed on a hospital bed and air-fluidized beds)
    • Seat lift mechanisms
    • TENS Units (for pain management)
    • Power Operated Vehicles/Scooters
    • Electric or Power Wheelchairs and related options and accessories
    • Negative Pressure Wound Therapy (wound vacs)
  • The list of items that require an office visit and written order before delivery has been expanded due to new provisions of the Affordable Care Act to include all items that cost more than $1000, and commonly prescribed items such as oxygen, hospital beds, wheelchairs and more. There are over 150 products across multiple product categories that are affected.   Your supplier will be able to tell you if the item ordered by your doctor or healthcare provider is subject to these additional requirements.
  • Your supplier cannot deliver these products to you without a compliant written order from your doctor or healthcare provider. They cannot provide services and get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier when a compliant order is not secured before delivery.  So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.

How does Medicare pay for and allow you to use the equipment?

  1. 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 two additional years), Medicare will limit payments to a small fee for monthly gas or liquid contents, where applicable, and a limited service fee to check the equipment every six months.
  2. After an item has been purchased for you, you will be responsible for calling your supplier 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.

What is competitive bidding?

In many parts of the country, a new program called Competitive Bidding will require you to obtain certain medical equipment from specific, Medicare-contracted suppliers in order for Medicare to pay. Not all products are subject to competitive bidding in the same area.  If you are located in a city where the program is in effect, you will need to obtain some or all of the following items from a contracted supplier:

  • Oxygen, oxygen equipment, and supplies
  • Standard power wheelchairs, scooters, and related accessories
  • Enteral nutrition, equipment, and supplies
  • Continuous Positive Airway Pressure (CPAP) devices and Respiratory Assist Devices (RADs), and related supplies and accessories
  • Hospital beds and related accessories
  • Walkers and related accessories
  • Support surfaces (Group 1 and Group 2 mattresses and overlays)
  • Manual Wheelchairs and accessories
  • Mail-order and local home delivery of diabetic supplies
  • Nebulizers
  • Home infusion therapy including insulin pumps and supplies
  • TENS Units and supplies
  • Patient Lifts
  • Commodes
  • Seat Lift Chairs
  • Negative Pressure Wound Therapy Devices and related supplies and accessories

Competitive Bidding areas are designated based on the zip code of your permanent residence on file with Social Security. To find out if your zip code is affected by Competitive Bidding, call 1-800-MEDICARE (1-800-4227). You may also visit Medicare.gov and lookup suppliers in your area by zip code (a notice will appear if your area is subject to Competitive Bidding). If medical equipment is marked with a yellow/orange star, it will need to be provided by a contracted supplier (also marked with an orange star).  Throughout this guide, products that are potentially impacted by the competitive bidding program will be designated with a double asterisk **.  Your provider can assist you with answering your questions about competitive bidding and can address whether or not they have been contracted to provide the services you need if subject to competitive bid.

Medicare Supplier Standards

Below is a summary of the standards Medicare requires of home medical equipment suppliers. As an approved Medicare provider, our company meets or exceeds all of these standards.

  1. 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.
  1. 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.
  1. An authorized individual (one whose signature is binding) must sign the application for billing privileges.
  1. 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.
  1. 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.
  1. 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.
  1. 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.
  1. 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.
  1. 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.
  1. 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.
  1. 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.
  1. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items, and maintain proof of delivery.
  1. A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.
  1. 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.
  1. 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.
  1. A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item.
  1. A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier.
  1. 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.
  1. 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.
  1. 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.
  1. A supplier must agree to furnish CMS any information required by the Medicare statute and implementing regulations.
  1. 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
  1. All suppliers must notify their accreditation organization when a new DMEPOS location is opened.
  1. All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare.
  1. All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.
  1. Must meet the surety bond requirements specified in 42 C.F.R. 424.57(c). Implementation date- May 4, 2009
  1. A supplier must obtain oxygen from a state- licensed oxygen supplier.
  1. A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F.R. 424.516(f).
  1. DMEPOS suppliers are prohibited from sharing a practice location with certain other Medicare providers and suppliers.
  1. DMEPOS suppliers must remain open to the public for a minimum of 30 hours per week with certain exceptions.

Medicare Coverage for Specific Types of Home Medical Equipment

BiLevel Devices/Respiratory Assist Devices**

  • For a respiratory assist device to be covered, the treating physician or healthcare provider must fully document in your medical record symptoms characteristic of sleep-associated hypoventilation, such as daytime hypersomnolence, excessive fatigue, morning headaches, cognitive dysfunction, dyspnea, etc.
  • A respiratory assist device is covered if you have a clinical disorder characterized as
    • (I) restrictive thoracic disorders (i.e., progressive neuromuscular diseases or severe thoracic cage abnormalities),
    • (II) severe chronic obstructive pulmonary disease (COPD), or
    • (III) central sleep apnea (CSA) or Complex Sleep Apnea (CompSA),
    • (IV) hypoventilation syndrome
  • If you are diagnosed with Obstructive Sleep Apnea, see the coverage criteria for Positive Airway Pressure Devices below.
  • Various tests may need to be performed to establish one of the above clinical disorders.
  • Three months after starting your therapy you must return to your doctor or healthcare provider for a follow-up to confirm the machine is benefitting you and that you are regularly using the device. 
    • This must be documented in your doctor or healthcare provider’s notes from that office visit.  Your physician or healthcare provider will be required to respond in writing to questions regarding your continued use along with how well the machine is treating your condition.
    • If you are not using your machine for an average of four hours per night per 24 hour period at the time you