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Medicare Coverage of Durable Medical Equipment

 

If you need medical equipment and supplies and you live at home, it’s important to learn what Medicare covers. Whether you have Original Medicare or a Medicare Advantage Plan, the rules for which pieces of equipment are covered should be the same. Medicare Part B will cover equipment that you use in the home if it qualifies as durable medical equipment (DME).

DME is equipment that is durable, meaning you can use it again. Also, the items must be

  • Designed to help a medical condition or injury;
  • Suitable to use in the home (although you can also use them outside the home); and
  • Likely to last for 3 years or more.

If you are in a skilled nursing facility (SNF) or a hospital inpatient, DME is covered under Part A.

Some examples of DME covered by Medicare are walkers, crutches, wheelchairs, power scooters, seat lifts, hospital beds, home oxygen equipment, diabetes self-testing equipment, and certain nebulizers.

Medicare will also cover certain prescription medications and supplies that you use with your DME, even if they are disposable or will only be used once. For example, Medicare covers medications used with nebulizers. Medicare also covers lancets and test strips used with diabetes self-testing equipment.

Medicare does not pay for all medical equipment and supplies that you use in the home. Below are some common examples of equipment that Medicare does not cover.

  • Equipment that is not suitable to use in the home. This includes some types of DME used in hospitals or skilled nursing facilities. For example, paraffin bath units and oscillating beds.
  • Equipment mainly intended to help you outside of the home. For example, if you can walk on your own for short distances, enough to get around your house, Medicare will not cover a motorized scooter that helps you get around outside the home.
  • Most items that will make things more convenient or comfortable for you. This includes stairway elevators, grab bars, air conditioners and bathtub and toilet seats.
  • Items that get thrown away after use or that do not get used with equipment will not be covered by Medicare. For example, Medicare does not cover incontinence pads, catheters, surgical facemasks and compression leggings. However, if you receive Medicare home health care, Medicare will pay for some disposable supplies, such as intravenous supplies, gauze and catheters.

Medicare will also not cover modifications to your home, such as those for improving wheelchair access, like installing ramps or widening doors.

Keep in mind that Medicaid may cover some forms of equipment that Medicare will not cover, contact your local Medicaid office for more information.

Medicare should pay for DME, except wheelchairs, if you follow two basic steps explained below. There is a different process when you want Medicare to pay for your manual or power wheelchair or scooter.

  1. Start with your doctor or primary care provider. If you think you need DME, ask your doctor about it. Or, your doctor may be the one to recommend DME to you. For example, when you are leaving the hospital, the doctor who treated you in the hospital may order equipment for your use when you return home. Or, during a doctor’s office visit, the doctor may suggest DME to help you function better in the home.

    Medicare will only pay for your DME if your doctor or other primary care provider signs an order, prescription or certificate that states that you need the DME to help a medical condition or injury. Your doctor must also confirm that you will use the equipment in the home. Starting July 1, 2013, you must have an office visit with your doctor or other health care professional before Medicare will cover your DME. The visit must deal with the reasons you need the DME and happen no more than 6 months before the date of your equipment order. The order must include a statement from your doctor confirming the required office visit took place.
  2. Use the right kind of supplier. Once you have the doctor’s order or prescription, you must take it to the right supplier to get coverage. Be sure only to use suppliers with approval from Original Medicare or your Medicare Advantage Plan.

    If you have Original Medicare, the type of supplier Medicare has approved for you will depend on how Medicare pays for equipment in your area and the kind of DME you need. In many areas, called competitive bidding regions, Medicare will usually only pay for most DME from a select group of suppliers known as contract suppliers. In other areas, you can use any supplier that has signed up to bill Medicare. Pay special attention if you need diabetic supplies.

    Starting July 1, 2013, in all regions of the United States, a competitive bidding program will apply to all diabetic supplies gotten through mail order. This means that you must use contract suppliers if you get your diabetic supplies through mail order. Mail order can mean diabetes supplies that are sent to you by a supplier in the mail, or supplies that are delivered to your home by a pharmacy. If you get your diabetic supplies from a local pharmacy, you should make sure you use a pharmacy that accepts Medicare assignment.

If you need a manual wheelchair, follow these two steps to get Medicare coverage.

Start with your doctor. If you think you need a manual wheelchair, ask your doctor about it. Or, your doctor may be the one to recommend a manual wheelchair to you.

In any event, starting July 1, 2013, you must have a face-to-face visit with your doctor or other health care provider before Medicare will cover your DME. The visit should happen no more than 6 months before your doctor prescribes or orders your manual wheelchair and should deal with the medical reasons you need the manual wheelchair. Your order for the manual wheelchair must include a statement

Your provider must sign an order or fill out a prescription or certificate that states that you need the manual wheelchair to function in the home. The order must say that:

Your health makes it very hard to move around in your home even with the help of a walker or cane; • You have significant problems in your home performing activities of daily living such as getting to the toilet, getting in and out of a bed or a chair, bathing, and dressing and • You can safely use the wheelchair yourself or always have someone with you to help you use it and • A statement from your doctor confirming that you the required office visit took place.

Keep in mind that the equipment must be necessary for you in the home but you can also use it outside the home. You can get only one piece of equipment at a time to address your mobility problem. Your doctor or other provider will determine what equipment you need based on your condition, what equipment can be used in your home, and what equipment you are able to use.

Use the Right Kind of Supplier Once you have the doctor’s order or prescription, you must take it the right kind of supplier to get coverage. Be sure to only use suppliers with approval from Original Medicare or your Medicare Advantage Plan.

If you need a power wheelchair or power scooter, follow these two steps to get Medicare coverage.

Start with your doctor.  If you think you need a power wheelchair or scooter, ask your doctor about it. Or, your doctor may be the one to recommend a wheelchair or scooter to you.

In any event, before you get your wheelchair or scooter, you must have an office visit with your doctor. The visit should take place no more than 45 days before the DME order and should deal with the medical reasons you need the wheelchair or scooter.

Your provider must sign an order or fill out a prescription or certificate that states that you need the power wheelchair or scooter to function in the home. The order must state:

  • Your health makes it very hard to move around in your home even with the help of a walker or cane;
  • You have significant problems in your home performing activities of daily living such as getting to the toilet, getting in and out of a bed or a chair, bathing, and dressing;
  • If you need a power wheelchair, you cannot  use a manual wheelchair or scooter, but you can safely use a power wheelchair and
  • The required office visit with your doctor took place.

The equipment must be necessary for you in the home but you can also use it outside the home. You can get only one piece of equipment to address your at-home mobility problem. Your doctor or other provider will determine what equipment you need based on your condition, what equipment can be used in your home, and what equipment you are able to use.

Upgrades or special features for durable medical equipment (DME)

Medicare will usually only pay for the most basic form of DME you need to help your medical condition.  Medicare will not typically pay for special features or upgrades for your durable medical equipment (DME) items. For example, Medicare will cover a power wheelchair that your health calls for to get around the house, but not added features such as a special kind of backrest or a tilt function for the seat that your health does not require.

Keep in mind Medicare will only pay for special features or upgrades for your durable medical equipment (DME) items if your provider says your condition justifies them and includes them in your DME order or prescription. For example, if your provider states you do not have the strength or balance to lift a standard walker without wheels, Medicare should pay for a model with wheels.

Understand that if you want additional features or upgrade that your health does not require, you can still get some coverage from Medicare for your upgraded DME, if you agree to pay more. Here’s how this works. If your supplier thinks that Medicare may not pay for additional features, the supplier should have you sign a waiver form called an Advance Beneficiary Notice (ABN) before you get the items. On the ABN, you must check the box stating you want the upgrades and will agree to pay their full cost if Medicare ends up denying coverage for them when the supplier submits the bill. Even if Medicare does refuse the upgrade, it will still pay the amount it would have paid for the basic model of the equipment. Also, you can appeal the denial if you believe your health required the upgrade.

If Medicare refuses to cover upgrades and the supplier failed to provide you an ABN, you do not owe the supplier for the added features.

Buying or renting durable medical equipment (DME) (except oxygen)

If you have Original Medicare and need DME, it is important to know that Medicare will either pay for you to rent or to buy your DME from a supplier.

Whether or not Medicare requires you to rent or buy equipment, or allows you a choice of doing either, depends on the kind of equipment you need.

For example, Medicare requires that you rent certain types of equipment, including power and manual wheelchairs. On the other hand, Medicare requires you to buy certain items that are made to fit you. Finally, Medicare allows you a choice to rent or buy certain items, such as certain power wheelchairs, items costing less than $150 and parenteral/enteral infusion pumps.

Keep in mind that most equipment Medicare covers is rented. If you rent your DME, it is important to know Medicare will help you pay a monthly rental fee for the item, for up to 13 months. After 13 months, you will automatically own the equipment. Oxygen equipment has different rules for rental.

Durable medical equipment (DME) repairs, maintenance, and replacement (except for oxygen)

If you need DME, your equipment may need regular maintenance and repairs from your supplier. Repairs by a supplier involve fixing equipment that is worn or damaged. Maintenance means checking, cleaning and servicing your equipment. If possible, you are expected to do regular maintenance yourself using the owner’s manual. However, a supplier should do maintenance if it is more complicated and requires a professional. Medicare coverage of repairs and maintenance that is more specialized depends on whether the supplier owns the equipment or you do. 

If you need oxygen equipment, Medicare pays for repairs and maintenance differently.

As long as you are paying a monthly rental fee for your equipment, your supplier must perform all needed repairs and maintenance that require the work of a professional. The supplier cannot charge you for this work.

On the other hand, Medicare will pay a separate amount to the supplier for repairs and maintenance if you buy your equipment or if you now own your equipment after first renting it. The repairs and maintenance must require a professional and must not be covered by warranty. Medicare will pay 80% of the Medicare approved amount and you will be responsible for the 20% balance. 

Replacing Durable Medical Equipment (DME)

If you have a chronic condition and will need DME for a long period of time, it important to learn about Medicare’s rules for replacing your equipment. Replacement means substituting one item for an identical or nearly identical item. For example, Medicare will pay for you to switch from one manual wheelchair to another, but will not pay for you to upgrade to an electric wheelchair or a motorized scooter.

Medicare will pay to replace equipment that you rent or own at any time if it is lost, stolen, or damaged beyond repair in an accident or a natural disaster. Medicare should cover a new piece of equipment with proof of the damage or theft.

If your equipment is worn out, Medicare will only replace it if you have had the item in your possession for its whole lifetime. An item’s lifetime depends on the type of equipment. An item’s lifetime is never less than five years from the date that you began using the equipment in the context of DME replacement. Note that this five-year time frame differs from the three-year minimum lifetime requirement that most medical equipment and items must meet in order to fall under Medicare’s definition of DME. The item must also be so worn down from day-to-day use that it can no longer be fixed. Keep in mind that Medicare will repair worn out equipment up to the cost of replacement before the end of its lifetime.

Medicare will only cover replacement equipment if your doctor writes you a new order or prescription with an explanation of the medical need.

Special rules for oxygen equipment rental, repairs, and maintenance if you have Original Medicare

If you need oxygen equipment, it’s important to learn how Medicare pays for it and covers rentals, repairs, and maintenance. Remember you must still use the right kind of supplier to obtain coverage and to limit your costs.  

Rental 

You must always rent your oxygen equipment; you never have the option to buy it. Equipment is rented in five-year cycles.   

  • Medicare will pay the supplier a monthly rental fee for the first 36 months. The fee includes all equipment, oxygen, and supplies. You must pay 20% of each months’ rental fee.
  • For the next 24 months after that, the supplier must allow you to keep the equipment, but Medicare rental payments stop. You pay no more rental fees, although the supplier still owns the equipment. Also, if you use oxygen tanks or cylinders, you must pay a 20% coinsurance for liquid or gaseous oxygen each month.
  • Finally, at the end of five years, you will have to choose whether to get new oxygen equipment from your original supplier or to switch suppliers. 

If you need the oxygen equipment for less than five years, the supplier will take it back when you no longer need it.

Repairs and Maintenance

Keep in mind that during your entire rental period (5 years), your supplier must keep your equipment in good working condition and provide you with supplies, parts, and maintenance free of charge.

However, during the last 24 months of the rental period, charges may apply if you use a stationary or portable oxygen concentrator or transfilling equipment (machines that fill portable tanks in your home). After the first 36 months of the rental period, suppliers can bill you for general in-home maintenance visits every six months. You must pay a 20% coinsurance for this servicing.

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