General Coverage Information
Individuals 65 years of age or older qualify for Medicare, as do people under 65 with permanent kidney failure (beginning three months after dialysis starts), and people 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 and home medical equipment.
- Medicare Part D benefits cover prescription drugs.
Under Medicare Part B, you can expect to pay the following: (a) a monthly premium, (b) an annual deductible, and (c) a 20 percent co-pay on most approved charges. Your medical equipment provider is prohibited by law from waiving your co-pay under Medicare. Medicare generally covers the basic level of equipment. For Medicare to cover medical equipment in the home, it must be considered a covered item and it must be prescribed by your physician.
Covered Items Under Medicare Must:
- (a) withstand repeated use (excludes many disposable items),
- (b) be used for a medical purpose (meaning there is a condition the item will improve,
- (c) be useless in the absence of illness or injury (thus excluding any item preventive in nature),
- and (d) be used in the home (which excludes all items that are needed only when leaving the confines of the home setting).
When a medical equipment provider "accepts assignment," he or she agrees to accept Medicare’s approved amount as payment in full. In these cases, 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.
There are some items billed to Medicare that require a physician’s order on a special form called a Certificate of Medical Necessity (CMN), and sometimes additional documentation will be required.
For some items, Medicare requires your provider to have completed documentation (which is more than just a prescription from your doctor) before they can be provided to you.
For most types of equipment, there are options and upgraded features available, and you can elect to purchase the equipment with the upgraded features you desire. In those cases, you have the option to pay a little extra money to get a product that you really want. This upgrading is done via the Advance Beneficiary Notice or ABN. The ABN details how the products differ and require a signature to indicate that you agree to pay the difference in the retail costs between two similar items. Normally when you upgrade through the use of an ABN, Medicare pays the cost of basic equipment and you pay the difference between the basic and upgraded equipment.
What Type of Items Will Medicare Cover?
Many home medical products are covered by Medicare. What Medicare doesn’t cover, secondary insurance often will. Home modifications are usually not covered by Medicare or insurance, but may be through non-profits, waiver programs, reverse mortgages, special home improvement loans, foundations and churches.
Remember to weigh the cost of alternative care versus the cost of making your home environment more accessible through modification.
- The average annual cost of skilled care at a nursing home is $78,000 for a private room or $69,000 for a semi-private room.
- Assisted living costs an average of $36,000 annually.
- The average rate for an in-home health aide is $19 per hour.
- Adult day services average about $16,000 if care is provided five days a week.
If you need help with financing, your home medical equipment provider can help.
| Equipment | Covered* | Normal Coverage Requirements | |
|---|---|---|---|
| Bathroom Safety Equipment | No | ||
| Canes, Walkers | Yes | Mobility limitations, please call us for specifics. | |
| Cervical Traction | Yes | Patient has an impairment and home traction has proven effective. | |
| Commode | No | ||
| Compression Stockings | Sometimes |
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| CPAP | Yes | Covered with the diagnosis of obstructive sleep apnea and specific test documentation of apnea events. | |
| Diabetic Supplies | Yes | Covers glucose monitor, lancets, test strips, control solution and replacement batteries. Does not cover insulin injections or pills (except as may be covered under Part D). | |
| Emergency Communicators | No | ||
| Enteral or Parenteral | Yes | Enteral covered for patients unable to swallow, delivered via tube. Not covered for those taken orally. | |
| Grab Bars | No | Bathroom safety equipment is not covered. | |
| Van Lifts and Ramps | No | ||
| Hospital Beds | Yes | Covered if one of these conditions is met: (1) medical condition requires body positioning not feasible in ordinary bed, (2) patient requires head of bed elevated more than 30 degrees most of the time due to a medical condition, or (3) patient requires traction equipment. | |
| Incontinence/Adult Diapers | No | ||
| Lift Chairs | Rarely | Only covered if the patient is unable to stand up from any chair, but once standing he or she can walk. Medicare pays only for the lift mechanism, not the chair portion. | |
| Manual Wheel Chairs | Yes |
Usually covered. We can help assess patient needs. |
|
| Mobility Equipment | Covers the least level of equipment needed to help a patient be mobile within his or her home and accomplish daily activities. Canes and crutches are the lowest level, followed by walkers, followed by manual wheelchairs, followed by scooters, followed by power wheelchairs. Requires face-to-face evaluation by a physician and home evaluation. | ||
| Orthopedic Shoes | Sometimes | Paid when needed to attach shoe to leg brace. | |
| Ostomy Supplies | Yes | Covered for patients with colostomy, ileostomy and urostomy. | |
| Oxygen | Yes | Covered for patients with significant hypoxemia when blood gas or oxygen levels indicate a need. Equipment rental paid for a limited period of time. | |
| Patient Lifts | Sometimes | Covered if transfer between bed and chair requires the assistance of more than one person and the patient would otherwise be confined to bed. Electric lift mechanisms are not covered. | |
| Power Wheelchairs | Often | Several specific criteria. We can help assess patient needs. | |
| Raised Toilet Seats | No | Bathroom safety equipment is rarely if ever covered. | |
| Scooters | Sometimes | We can help determine coverage. | |
| Stair Lifts | No | ||
| Support Surfaces | Usually | Many coverage criteria, all based on medical necessity. | |
| TENS Units | Yes | For certain chronic pain lasting more than three months. | |
| Therapeutic Shoes | Yes | Shoes, inserts and modifications are covered for diabetic patients with specific foot conditions. | |
| Urological Supplies | Yes | Covered for permanent urinary incontinence. | |
| Wound Care | Yes | Covers primary and secondary dressings. Must have surgery/debridement. |
*For items that are covered by Medicare, Medicare pays 80 percent and the patient is responsible for 20 percent. For private insurance, the percentage of coverage varies by plan.