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 2019 the standard premium is $135.50 per month (but could be
waived or higher) 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 unique perks like gym
memberships as a participation benefit.
- Medicare
Part D offers optional program benefits that cover prescription drugs. The
premiums for these plans also vary by plan and income level.
- For
more information about your benefits or making coverage decisions, you can
visit the official website for Medicare benefits at www.medicare.gov. or compare plans
and options during open enrollment which generally runs from October 15
through December 7 to make changes for the coming year. As a result of the
21st Century Cures Act, if you have enrolled in a Medicare
Advantage plan, you can revert back to traditional Medicare or switch to
another Medicare Advantage plan between January 1 through March 31 of each
year.
What Can You Expect to Pay for Medicare Part B Services?
- In 2019,
in addition to your monthly premium, you will have to pay the first $185
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 of Non-Coverage 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 $185.00 for 2019.
- 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 evidence of a recent
office visit with, and 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?
- 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.
- 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.
Please
note: Due to program reform, there will be a temporary gap in the competitive
bidding program for approximately two years beginning January 1, 2019 through
December 31, 2020. During the gap you
can secure all services from any-willing supplier and will not be limited to
designated suppliers. The program is
expected to resume in 2021. Your
supplier can provide additional information when the program resumes.
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
- TENS
Units and supplies
- Patient
Lifts
- Commodes
- Seat
Lift Chairs
- Negative
Pressure Wound Therapy Devices and related supplies and accessories
- Medicare has also proposed expanding
the program to ventilators, back braces and knee braces. Your supplier can
confirm if any of these items are subject to competitive bidding
restrictions when the program resumes.
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 supplier 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.