JOEL MEKLER’S COLUMN: Does Medicare Cover Long-Life Medical Devices? | Lifestyles

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If you’re like most retirees, you can expect Medicare to automatically pay for mobility aids such as walking sticks, walkers, and wheelchairs; Oxygen devices such as nebulizers and CPAPs; other devices such as continuous glucose monitors, ventilators, infusion pumps, and hospital beds.

This assumption is partly correct. Medicare Part B covers so-called “Durable Medical Equipment” or DME for short.

For DME to be covered by Medicare, it must meet certain criteria. Provided the equipment is eligible, traditional Medicare typically pays 80 percent of the cost after the patient meets the Part B annual deductible. The patient is then responsible for the remaining 20 percent. Of course, some Medicare supplements and Medicare Advantage plans can cover the 20 percent depending on the plan.

Medicares definition of DME is as follows:

• Its durable. This means it has to be something that you will be using over and over again for a long period of time. Items that are disposable after a single use or that are only needed for a short period of time are not eligible. In general, Medicare expects “permanent” items to have a useful life of at least three years.

• It must be necessary and appropriate to the treatment of a condition or injury. The item must be primarily and usually needed for a medical purpose (in general, the DME is not useful for people who are not sick or injured).

• Suitable for use in the “home”. “Home” does not include a hospital or care facility.

In order for a beneficiary to qualify for DME coverage, they must meet the following criteria.

• Beneficiary must be enrolled in Medicare Part B; and

• DME needs are documented by a doctor who has certified the medical need; and

• The doctor executes an order (can be done with the help of a physiotherapist or occupational therapist; and

• After a personal conversation with the attending physician (certifications via telemedicine are permitted).

GENERAL GUIDELINES

To receive DME, ask your doctor to recommend a supplier they know and have worked with. You can go to: (Enter your zip code, then find the covered item or service in the list.) Review the list of suppliers who accept Medicare assignments for that item or service. If no suppliers accept the assignment, search for registered suppliers. Contact multiple suppliers for information.

SPECIFIC ARTICLE

Provider prescribes the specific element.

The provider must document the need for that particular item / supply in the medical record.

The DME supplier must do one of the following:

Provide the exact brand / shape of the item / delivery requested, or

Work with the provider to find another brand / form that the provider believes is both safe and effective.

Under traditional Medicare, the beneficiary costs for Medicare-covered DME are as follows:

Annual deductible part B, if not already met; and

20 percent of the Medicare Approved Amount for Medicare Covered Items if the Medicare Registered Supplier “Participates” in Medicare (accepts Medicare “Assignment” as full price.

If a Medicare registered supplier is not a Medicare member, there is no limit to the amount they can be charged. Remember, Medicare will only pay up to the Medicare Approved / Allowed amount.

If a supplier is not registered with Medicare, no payment will be made through Medicare.

Typically, delivery, setup, and training are included in the Medicare payment for DME when an item is obtained from a Medicare-participating supplier.

NOT COVERED DME

Equipment for comfort / convenience

Physical fitness or self-help devices

Devices and equipments for environmental control

DME in benefit plans

Medicare Advantage plans must cover at least the same items and services as traditional Medicare; The plans can cover more, but not less.

A beneficiary’s DME cost depends on the Medicare Advantage plan chosen, typically 20% to 50% coverage.

The best way to determine if an item is covered and what the cost to a beneficiary is by calling the plan and asking about the Utilization Management Department.

If you are denied DME cover, you can object at any time. Start the appeal process via the Advantage plan. Follow the instructions in the plan’s initial rejection notice and plan materials.

RESOURCES

Find suppliers at:

“Your Guide to Medicare’s Competitive Prosthetics, Orthotics, and Consumables (DMEPOS) Long Life Medical Device Tendering Program”

“Medical coverage of long-life medical devices and other devices”

“The Medicare Wheelchair and Scooter Advantage”

(Joel Mekler is a certified Senior Advisor. Send your Medicare questions to [email protected])

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