Medicare Durable Medical Equipment Policies and Information

Medicare Durable Medical Equipment Policies and Information
★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★
CENTERS FOR MEDICARE & MEDICAID SERVICES
Medicare Coverage
of Durable Medical
Equipment and
Other Devices
This official government
booklet explains the following:
★ What durable medical equipment is
★ Which durable medical equipment,
prosthetic, and orthotic items are
covered in Original Medicare
★ Where to get help with your questions
Do you need durable medical equipment or
other types of medical equipment?
Medicare can help.
This booklet explains Medicare coverage for durable medical
equipment, prosthetic devices, orthotic items, prostheses and
therapeutic shoes in Original Medicare (sometimes called
fee-for-service) and what you might need to pay. Durable
medical equipment includes things like the following:
• Home oxygen equipment
• Hospital beds
• Walkers
• Wheelchairs
This booklet also explains coverage for prosthetic equipment
(like cardiac pacemakers, enteral nutrition pumps, and
prosthetic lenses), orthotic items (like leg, neck, and back
braces) and prostheses (like artificial legs, arms, and eyes). It’s
important for you to know what Medicare covers and what you
may need to pay. Talk to your doctor if you think you need
some type of durable medical equipment.
If you have questions about the cost of durable medical
equipment or coverage after reading this booklet, call
1-800-MEDICARE (1-800-633-4227). TTY users should call
1-877-486-2048.
Note: The information in this booklet was correct when it was
printed. Changes may occur after printing. For the most up-to-date
information, visit www.medicare.gov on the web, or call
1-800-MEDICARE (1-800-633-4227). A customer service
representative can tell you if the information has been updated.
TTY users should call 1-877-486-2048.
1
Table of Contents
What is durable medical equipment? . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Does Medicare cover durable medical equipment? . . . . . . . . . . . . . . . . 3
When does Original Medicare cover durable
medical equipment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
What if I need durable medical equipment and I am in a
Medicare Advantage Plan? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3–4
If I have Original Medicare, how do I get the
durable medical equipment I need? . . . . . . . . . . . . . . . . . . . . . . 4–5
Power wheelchairs and scooters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
What is covered, and how much does it cost? . . . . . . . . . . . . . . . . . . 6–7
What is “assignment” in Original Medicare, and why
is it important? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
How will I know if I can buy durable medical equipment or
whether Medicare will only pay for me to rent it? . . . . . . . . . . . 8–9
New Rules for How Medicare Pays Suppliers for Oxygen
Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10–11
Words to know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12–13
(Definitions of red words in text)
“Medicare Coverage of Durable Medical Equipment and Other Devices” isn’t a legal
document. Official Medicare Program legal guidance is contained in the relevant
statutes, regulations, and rulings.
2
What is durable medical equipment?
Durable medical equipment is reusable medical equipment such
as walkers, wheelchairs, or hospital beds.
Does Medicare cover durable medical
equipment?
Anyone who has Medicare Part B can get durable medical
equipment as long as the equipment is medically necessary.
When does Original Medicare cover durable
medical equipment?
If you have Part B, Original Medicare covers durable medical
equipment when your doctor or treating practitioner (such as a
nurse practitioner, physician assistant, or clinical nurse specialist)
prescribes it for you to use in your home. A hospital or nursing
home that is providing you with Medicare-covered care can’t
qualify as your “home” in this situation. However, a long-term
care facility can qualify as your home.
Note: If you are in a skilled nursing facility and the facility
provides you with durable medical equipment, the facility is
responsible for this equipment.
What if I need durable medical equipment and
I am in a Medicare Advantage Plan?
Words in red
are defined
on pages
12–13.
Medicare Advantage Plans (like an HMO or PPO) must cover
the same items and services as Original Medicare. Your costs will
depend on which plan you choose, and may be lower than
Original Medicare. If you are in a Medicare Advantage Plan and
you need durable medical equipment, call your plan to find out
if the equipment is covered and how much you will have to pay.
3
What if I need durable medical equipment and I am in a
Medicare Advantage Plan? (continued)
If you are getting home care or using medical equipment and you
choose to join a new Medicare Advantage Plan, you should call the new
plan as soon as possible and ask for Utilization Management. They can
tell if your equipment is covered and how much it will cost. If you
return to Original Medicare, you should tell your supplier to bill
Medicare directly after the date your coverage in the Medicare
Advantage Plan ends.
Note: If your plan leaves the Medicare Program and you are using
medical equipment such as oxygen or a wheelchair, call the telephone
number on your Medicare Advantage Plan card. Ask for Utilization
Management. They will tell you how you can get care under Original
Medicare or under a new Medicare Advantage Plan.
Words in red
are defined
on pages
12–13.
If I have Original Medicare, how do I get the
durable medical equipment I need?
If you need durable medical equipment in your home, your doctor or
treating practitioner (such as a nurse practitioner, physician assistant,
or clinical nurse specialist) must prescribe the type of equipment you
need. For some equipment, Medicare also requires your doctor or one
of the doctor’s office staff to fill out a special form and send it to
Medicare to get approval for the equipment. This is called a
Certificate of Medical Necessity. Your supplier will work with your
doctor to see that all required information is submitted to Medicare.
If your prescription and/or condition changes, your doctor must
complete and submit a new, updated certificate.
The chart on page 6 shows which items require a Certificate of
Medical Necessity.
4
If I have Original Medicare, how do I get the durable medical
equipment I need? (continued)
Medicare only covers durable medical equipment if you get it
from a supplier enrolled in the Medicare Program. This means
that the supplier has been approved by Medicare and has a
Medicare supplier number.
To find a supplier that is enrolled in the Medicare Program, visit
www.medicare.gov and select “Find Suppliers of Medical
Equipment in Your Area.” You can also call 1-800-MEDICARE
(1-800-633-4227) to get this information. TTY users should call
1-877-486-2048.
A supplier enrolled in the Medicare Program must meet strict
standards to qualify for a Medicare supplier number. If your
supplier doesn’t have a supplier number, Medicare won’t pay
your claim, even if your supplier is a large chain or department
store that sells more than just durable medical equipment.
Power wheelchairs and scooters
For Medicare to cover a power wheelchair or scooter, your doctor
must state that you need it because of your medical condition.
Medicare won’t cover a power wheelchair or scooter that is only
needed and used outside of the home.
Most suppliers who work with Medicare are honest. There are a
few who aren’t honest. Medicare is working with other
government agencies to protect you and the Medicare Program
from dishonest suppliers of power wheelchairs and scooters.
For more information about Medicare’s coverage of power
wheelchairs or scooters, view the publication “Protecting
Medicare’s Power Wheelchair and Scooter Benefit.” Visit
www.medicare.gov and select “Find a Medicare Publication.” You
can also call 1-800-MEDICARE (1-800-633-4227). TTY users
should call 1-877-486-2048.
5
What is covered, and how much does it cost?
The chart below and on page 7 shows some of the items Medicare covers and how much
you have to pay for these items. This list doesn’t include all covered durable medical
equipment. For questions about whether Medicare covers a particular item, call
1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you
have a Medigap policy, it may help cover some of the costs listed below and on page 7.
Durable Medical Equipment
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What Medicare Covers
What You Pay
Air fluidized beds
Blood glucose monitors
Bone growth (or osteogenesis) stimulators*
Canes (except white canes for the blind)
Commode chairs
Crutches
Home oxygen equipment and supplies*
Hospital beds
Infusion pumps and some medicines used in them
Lymphedema pumps/pneumatic compression
devices*
Nebulizers and some medicines used in them
(if reasonable and necessary)
Patient lifts*
Scooters
Suction pumps
Traction equipment
Transcutaneous electronic nerve stimulators (TENS)*
Ventilators or respiratory assist devices
Walkers
Wheelchairs (manual and power)
Generally, you pay 20% of the
Medicare-approved amount after
you pay your Medicare Part B
deductible for the year ($135 in
2009). Medicare pays the other
80%. The Medicare-approved
amount is the lower of the actual
charge for the item or the fee
Medicare sets for the item.
However, the amount you pay
may vary because Medicare pays
for different kinds of durable
medical equipment in different
ways. You may be able to rent or
buy the equipment.
* You must get a Certificate of Medical Necessity before you can get this equipment.
See page 4.
6
What is covered, and how much does it cost? (continued)
Prosthetic and Orthotic Items
What Medicare Covers
• Arm, leg, back, and neck braces
• Artificial limbs and eyes
• Breast prostheses (including a surgical brassiere) after
a mastectomy
• Ostomy supplies for people who have had a
colostomy, ileostomy, or urinary ostomy. Medicare
covers the amount of supplies your doctor says you
need based on your condition.
• Prosthetic devices needed to replace an internal body
part or function
• Therapeutic shoes or inserts for people with diabetes
who have severe diabetic foot disease
The doctor who treats your diabetes must certify
your need for therapeutic shoes or inserts. A
podiatrist or other qualified doctor must prescribe
the shoes and inserts. A doctor or other qualified
individual like a pedorthist, orthotist, or prosthetist
must fit and provide the shoes. Medicare helps pay
for one pair of therapeutic shoes and inserts per
calendar year. Shoe modifications may be
substituted for inserts.
Corrective Lenses
What Medicare Covers
• Prosthetic Lenses
—Cataract glasses
—Conventional glasses and contact lenses after
surgery with an intraocular lens
—Intraocular lenses
An ophthalmologist or an optometrist must
prescribe these items.
Important: Only standard frames are covered.
Eyeglasses and cataract lenses are covered even if
you had the surgery before you had Medicare.
Payment may be made for lenses for both eyes even
if cataract surgery involved only one eye.
What You Pay
You pay 20% of the
Medicare-approved amount after
you pay your Medicare Part B
deductible for the year ($135 in
2009). Medicare pays the other
80%. These amounts may be
different if the supplier doesn’t
accept assignment. See page 8.
What You Pay
You are covered for one pair of
eyeglasses or contact lenses after
each cataract surgery with an
intraocular lens. You pay 20% of
the Medicare-approved amount
after you pay the Medicare Part B
deductible for the year ($135 in
2009). Medicare pays the other
80%. Costs may be different if
the supplier doesn’t accept
assignment. See page 8. If you
want to upgrade the frames, you
pay any additional cost.
7
What is “assignment” in Original Medicare and why
is it important?
Assignment is an agreement between you (the person with Medicare),
Medicare, and doctors or other health care providers, and suppliers of health
care equipment and supplies (like durable medical equipment and prosthetic
or orthotic devices). Doctors, providers, and suppliers who agree to accept
assignment accept the Medicare-approved amount as full payment. After you
have paid the Part B deductible ($135 in 2009), you pay the doctor or
supplier the coinsurance (usually 20% of the approved amount). Medicare
pays the other 80%.
Suppliers who agree to accept assignment on all claims for durable medical
equipment and other devices are called “participating suppliers.” If a durable
medical equipment supplier doesn’t accept assignment, there is no limit to
what they can charge you. In addition, you may have to pay the entire bill
(Medicare’s share as well as your coinsurance and any deductible) at the time
you get the durable medical equipment. The supplier will send the bill to
Medicare for you, but you will have to wait for Medicare to reimburse you
later for its share of the charge.
Important Note: Before you get durable medical equipment, ask if the
supplier is enrolled in Medicare. If the supplier is not enrolled in Medicare,
Medicare won’t pay your claim at all. Then, ask if the supplier is a
participating supplier in the Medicare Program. A participating supplier must
accept assignment. A supplier that is enrolled in Medicare, but isn’t
“participating,” has the option whether to accept assignment. You will have to
ask if the supplier will accept assignment for your claim.
To find suppliers who accept assignment, visit www.medicare.gov and select
“Find Suppliers of Medical Equipment in Your Area.” You can also call
1-800-MEDICARE (1-800-633-4227). TTY users should call
1-877-486-2048.
Words in red
are defined
on pages
12–13.
8
How will I know if I can buy durable medical
equipment or whether Medicare will only pay for
me to rent it?
If your supplier is a Medicare-enrolled supplier, they will know whether
Medicare allows you to buy a particular kind of durable medical equipment,
or just pays for you to rent it. Medicare pays for most durable medical
equipment on a rental basis. Medicare only purchases inexpensive or
routinely purchased items, such as canes, power wheelchairs, and, in rare
cases, items that must be made specifically for you.
How will I know if I can buy durable medical equipment or
whether Medicare will only pay for me to rent it?
(continued)
Buying equipment
If you own Medicare-covered durable medical equipment and
other devices, Medicare may also cover repairs and replacement
parts. Medicare will pay 80% of the Medicare-approved amount
for purchase of the item. Medicare will also pay 80% of the
Medicare-approved amount (up to the cost of replacing the item)
for repairs. You pay the other 20%. Your costs may be higher if the
supplier doesn’t accept assignment.
Note: The equipment you buy may be replaced if it’s lost,
stolen, damaged beyond repair, or used for more than the
reasonable useful lifetime of the equipment.
Renting equipment
If you rent durable medical equipment and other devices,
Medicare makes monthly payments for use of the equipment. The
rules for how long monthly payments continue vary based on the
type of equipment. Total rental payments for inexpensive or
routinely purchased items are limited to the fee Medicare sets to
purchase the item. If you will need these items for more than a
few months, you may decide to purchase these items rather than
rent them. Monthly payments for frequently serviced items, such
as ventilators, are made as long as the equipment is medically
necessary. The payment rules for other types of rented equipment,
called “capped rental items,” are on page 10. Medicare will pay
80% of the Medicare-approved amount each month for use of
these items. You pay the other 20% after you pay the Medicare
Part B deductible ($135 in 2009).
The supplier will pick up the equipment when you no longer
need it. Any costs for repairs or replacement parts for the rented
equipment are the supplier’s responsibility. The supplier will also
pick up the rented equipment if it needs repairs. You don’t have
to bring the rented equipment back to the supplier.
9
New Rules for How Medicare Pays Suppliers for Oxygen
Equipment
Changes in law require Medicare to change the way it pays suppliers for oxygen
equipment and supplies. You will still be able to get your oxygen equipment.
However, you should know about the new rules that start January 1, 2009.
Previously, the law stated that you would own the oxygen equipment after you
rented it for 36 months. Under the new law, the rental payments will end after 36
months, but the supplier continues to own the equipment. The new law then
requires your supplier to provide the oxygen equipment and related supplies for 2
additional years (5 years total), as long as oxygen is still medically necessary.
How does Medicare pay for oxygen equipment and related supplies
and what do I pay?
The monthly rental payments to the supplier cover not only your oxygen
equipment, but also any supplies and accessories such as tubing or a mouthpiece,
oxygen contents, maintenance, servicing and repairs. Medicare pays 80% of the
rental amount, and the person with Medicare is responsible for any unpaid Part B
deductible, and the remaining 20% of the rental amount.
What happens with my oxygen equipment and related services after
the 36 months of rental payments?
Your supplier has been paid over 36 months for furnishing your oxygen and
oxygen equipment for up to 5 years, and your supplier is required to continue to
maintain the oxygen equipment (in good working order) and furnish the
equipment and any necessary supplies and accessories, as long as you need it until
the 5 year period ends. The supplier can’t charge you for performing these services.
If you use oxygen tanks or cylinders that need delivery of gaseous or liquid oxygen
contents, Medicare will continue to pay each month for the delivery of contents
after the 36-month rental period. The supplier that delivers this equipment to you
in the last month of the 36-month rental period must provide these items, as long
as you medically need it, up to 5 years.
Will Medicare pay for any maintenance and servicing after the
36-month period ends?
If you use an oxygen concentrator or transfilling equipment (a machine that fills
your portable tanks in your home), for 2009 only, Medicare will pay for routine
maintenance and servicing visits every 6 months starting 6 months after the end of
the 36-month rental period.
10
New Rules for How Medicare Pays Suppliers for Oxygen
Equipment (continued)
What happens to my oxygen equipment after 5 years?
At the end of the 5-year period, your supplier’s obligation to continue
furnishing your oxygen and oxygen equipment ends, and you may elect to
obtain replacement equipment from any supplier. A new 36-month payment
period and 5-year supplier obligation period start once the old 5-year period
ends and the new oxygen and oxygen equipment you require is furnished.
What if I’m away from home for an extended period of time or I
move to another area during the 36-month period?
If you travel away from home for an extended period of time (several weeks or
months) or permanently move to another area during the 36-month rental
period, ask your current supplier if they can help you find a supplier in the
new area. If your supplier can’t help you locate an oxygen supplier in the area
where you are visiting or moving to, call 1-800-MEDICARE
(1-800-633-4227). TTY users should call 1-877-486-2048.
What if I’m away from home for an extended period of time or I
move to another area after the 36-month period?
If you travel or move after the 36-month rental period ends, your supplier has
been paid for furnishing your equipment for 5 years and is generally
responsible for ensuring that you are provided with oxygen and oxygen
equipment in the new area. Your supplier may choose to make arrangements
for a different supplier in your new area to provide the oxygen and oxygen
equipment. However, a supplier may not charge you for the equipment,
supplies, accessories or other services identified above that are provided after
the 36-month rental payment period. The only exceptions to this rule are
noted above.
What if my supplier refuses to continue providing my oxygen
equipment and related services as required by law?
If your supplier is not following Medicare laws and rules, call 1-800MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
A customer service representative will refer your case to the appropriate area.
11
Words to know
Assignment—An agreement between a person with Medicare, a
doctor or supplier, and Medicare. Doctors or suppliers who accept
assignment from Medicare agree to accept the Medicare-approved
amount as full payment.
Capped rental item—Durable medical equipment (like oxygen,
nebulizers, and manual wheelchairs) that costs more than $150,
and is rented to people with Medicare more than 25% of the time.
Certificate of Medical Necessity—A form required by Medicare
that your physician must complete to get Medicare coverage for
certain medical equipment.
Coinsurance—An amount you may be required to pay for services
after you pay any plan deductibles. In Original Medicare, this is a
percentage (like 20%) of the Medicare-approved amount. You have
to pay this amount after you pay the Part A and/or Part B
deductible.
Deductible—The amount you must pay for health care or
prescriptions, before Original Medicare or other insurance begins to
pay. For example, in Original Medicare, you pay a new deductible
for each benefit period for Part A, and each year for Part B. These
amounts can change every year.
Durable Medical Equipment—Medical equipment that is ordered
by a doctor (or, if Medicare allows, a nurse practitioner, physician
assistant, or clinical nurse specialist) for use in the home. A hospital
or nursing home that mostly provides skilled care can’t qualify as a
“home” in this situation. These medical items must be reusable,
such as walkers, wheelchairs, or hospital beds.
Medically Necessary—Services or supplies that are needed for the
diagnosis or treatment of your medical condition.
Medicare Advantage Plan (Part C)—A type of Medicare plan
offered by a private company that contracts with Medicare to
provide you with all your Medicare Part A and Part B benefits. Also
called Part C, Medicare Advantage Plans are HMOs, PPOs, Private
Fee-for-Service Plans, or Medicare Medical Savings Account Plans.
If you are enrolled in a Medicare Advantage Plan, Medicare services
are covered through the plan, and are not paid for under Original
Medicare.
12
Words to know
Medicare-Approved Amount—In Original Medicare, this is the
amount a doctor or supplier that accepts assignment can be paid.
It includes what Medicare pays and any deductible, coinsurance,
or copayment that you pay. It may be less than the amount a
doctor or supplier charges for the item.
Medigap Policy —Medicare Supplement Insurance sold by
private insurance companies to fill “gaps” in Original Medicare
coverage. Except in Massachusetts, Minnesota, and Wisconsin, all
Medigap policies must be one of 12 standardized Medigap
policies labeled Medigap Plan A through Plan L. Medigap
policies only work with Original Medicare.
Nebulizers —Equipment that delivers medicine in a mist form to
your lungs.
Original Medicare—Original Medicare has two parts: Part A
(Hospital Insurance) and Part B (Medical Insurance). It is a
fee-for-service health plan. After you pay a deductible, Medicare
pays its share of the Medicare-approved amount, and you pay
your share (coinsurance and deductibles).
Orthotics —Devices that correct or support the function of body
parts. Examples include leg, arm, and neck braces.
Patient Lifts—Equipment designed to move a patient from a
bed or wheelchair.
Prostheses —Devices that substitute for a missing body part.
Examples include artificial legs, arms, and eyes.
Prosthetic Devices —Medical equipment (other than dental)
that replaces all or part of an internal body organ.
U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, Maryland 21244-1850
Official Business
Penalty for Private Use, $300
CMS Publication No. 11045
Revised December 2008
To get this publication in Spanish, call
1-800-MEDICARE (1-800-633-4227).
TTY users should call 1-877-486-2048.
Para obtener este folleto en español,
llame GRATIS al 1-800-MEDICARE
(1-800-633-4227). Los usuarios de TTY
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