Medicare Insurance Guidelines

Both Medicare and private health insurance plans pay for a large portion or sometimes even all costs associated with many types of medical equipment used in the home. This type of equipment is referred to as durable medical equipment or home medical equipment. The guide below will help you understand the Medicare guidelines related to home medical equipment. Most health insurance plans have similar rules to Medicare, but you should know that all private health insurance plans vary and the specific rules of your plan may differ from these Medicare guidelines. We accept most of the major health insurance plans. We would be happy to work with you and your insurance company to help you understand how your plan works as it relates to home medical equipment needed by yoBoth Medicare and private health insurance plans pay for a large portion or sometimes even all costs associated with many types of medical equipment used in the home. This type of equipment is referred to as durable medical equipment or home medical equipment. The guide below will help you understand the Medicare guidelines related to home medical equipment. Most health insurance plans have similar rules to Medicare, but you should know that all private health insurance plans vary and the specific rules of your plan may differ from these Medicare guidelines. We accept most of the major health insurance plans. We would be happy to work with you and your insurance company to help you understand how your plan works as it relates to home medical equipment needed by you or a loved one.

Reference directory:

I. Guide to Medicare Coverage
II. Medicare Coverage for specific type of home medical equipment
III. Medicare Supplier Standards

I. 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, the Part B program requires a monthly premium to stay enrolled. That premium will range depending on your income. Typically, this amount will be taken from your Social Security check.

What Can You Expect to Pay?

  • Every year, in addition to your monthly premium, you will have to pay a deductible before Medicare will reimburse the covered items.  Once that is met, you will be responsible for 20 percent of all approved charges if the provider agrees to accept Medicare payments.
  • Unfortunately, your medical equipment provider cannot automatically waive this 20 percent or your deductible without suffering penalties from Medicare. Your provider 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 suffer from qualifying financial hardships.
  • 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 provider 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 provider 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 provider 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 patients to upgrade to a piece of equipment that they like better than other standard options for which they may otherwise qualify.
  • The Advance Beneficiary Notice, or ABN, 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 provider 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 also will 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 (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 (thus excluding any item 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 providers accept 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 has varied between $135.00 – $165.00 in the last several years.
  • If a provider does not accept assignment with Medicare, you will be responsible for paying the full amount upfront. The provider will still file a claim on your behalf and any reimbursement made by Medicare will be paid to you directly. (Providers must still notify you in advance, using the Advance Beneficiary Notice, if they do not believe Medicare will pay for your claim.)

Mandatory Submission of Claims

  • Every provider is required to submit a claim for covered services within one year from the date of service

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.
  • Nurse Practitioners, Physician Assistants, Interns, Residents and Clinical Nurse Specialists can also order medical equipment and sign CMNs when they are treating a patient.
  • All physicians have the right to refuse to complete documentation for equipment they did not order, so make sure you consult with your physician before requesting an item from a provider.

How does Medicare pay for and allow you to use the equipment?

  1. 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.
  2. Medicare will not allow you to purchase these items outright (even if you think you will need it for a long period of time).
  3. This is to allow you to spread out your coinsurance instead of paying in one lump sum.
  4. It also protects the Medicare program from paying too much should your needs change earlier than expected.
  5. If you have oxygen therapy, Medicare will make rental payments for a total of 36 months during which time this fee covers all service, accessories, and oxygen contents.
  6. Beyond the 36 months, Medicare will limit payments to replacement of accessories, and allows a small fee for monthly content and to check the equipment every six months.
  7. After an item has been purchased for you, you will be responsible for calling your provider any time 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.

Face-to-Face Appointments

The Affordable Care Act requires that a physician (MD, DO or DPM), physician assistant (PA), nurse practitioner (NP) or clinical nurse specialist (CNS) has had a face-to-face examination with the beneficiary within six months of the written order for and delivery of select medical devices supplied by a DME. Aeroflow Healthcare can help assist patients in determining if a face-to-face exam is necessary.


II. Medicare Coverage for Specific Types of Home Medical Equipment

Mobility Products: Scooters and Power Wheelchairs

  • Essentially the new Mobility Assistive Equipment regulations will ensure that Medicare funds are used to pay for:
    • Mobility needs for daily activities within the home
    • Least costly alternative/lowest level of equipment to accomplish these tasks.
    • Most medically appropriate equipment (to meet the needs, not the wants)
  • Medicare requires that your physician and provider evaluate your needs and expected use of the mobility product you will qualify for.
  • They must determine which is the least level of equipment needed to help you be mobile within your home to accomplish daily activities by asking the following questions:
    • Will a cane or crutches allow you to perform these activities in the home?
    • If not, will a walker allow you to accomplish these activities in the home?
    • If not, is there any type of manual wheelchair that will allow you to accomplish these activities in the home?
    • If not, will a scooter allow you to accomplish these activities in the home?
    • If not, will a power chair allow you to accomplish these activities in the home?
  • Keep in mind if you have another higher level product in mind that will allow you to do more beyond the confines of the home setting, you can discuss with your provider the option to upgrade to a higher level or more comfortable product by paying an additional out of pocket fee using the Advance Beneficiary Notice (ABN) to select the product you like best.
  • A face-to-face examination with your physician is required prior to the initial setup of a power chair or scooter.
  • Your home must be evaluated to ensure it will accommodate the use of any mobility product.

Mobility Products: Braces

  • Medicare guidelines stipulate that a brace must be medically necessary in order for them to pay towards its cost.
    • This would include reducing pain in the back, facilitating healing of an injury or surgical procedure to the spine or related soft tissue, or support weak spinal muscles.
  • Medicare will pay for 80% of the cost of your brace if you qualify and if you have met your Part B deductible.
  • If you have a secondary insurance, or a Medicare advantage plan, you are likely covered at 100%, depending on the specifics of your policy and the status of your deductibles.

Lift Chair Mechanisms

  • In order for Medicare to pay for a seat lift mechanism, patients must be suffering from severe arthritis of the hip or knee, or have a severe neuromuscular disease. In addition they must be completely incapable of standing up from any chair, but once standing they can walk either independently or with the aid of a walker or cane. The physician must believe that the mechanism will improve, slow down, or stop the deterioration of the patient’s condition.
  • Transferring directly into a wheelchair will prevent Medicare from paying for the device.
  • Medicare will only pay for the lift mechanism portion. The chair portion of the package is not covered, and you will be responsible for paying the full amount for the furniture component of the chair.

TENS Units

  • TENS units are covered for the treatment of chronic intractable pain that has been present for at least three months or more, and in some cases for acute post-operative pain.
  • Not all types of pains can be treated with a TENS unit. TENS units have proven ineffective in treating headaches, visceral abdominal pains, pelvic pains, and TMJ pains, and therefore Medicare will not pay for the device when used to treat these conditions.
  • For chronic pain sufferers, Medicare will pay for a one or two month trial rental to determine if this device will alleviate the chronic pain. You must return to your physician exactly 30-60 days after initial evaluation to authorize the purchase of this equipment.
  • For acute post-operative pain sufferers, Medicare will consider rental payment for a maximum of 30 days. Any duration longer than that will require individual consideration.

Non-covered items (partial listing):

  • Van Lifts or Ramps
  • Stair Lifts

III. Medicare Supplier Standards

Below is a summary of the standards Medicare requires of home medical equipment providers. Our company meets or exceeds all of these standards.

  1. A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements.
  2. A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days.
  3. An authorized individual (one whose signature is binding) must sign the application for billing privileges.
  4. A supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or from any other Federal procurement or non-procurement programs.
  5. A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment.
  6. A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty.
  7. A supplier must maintain a physical facility on an appropriate site.
  8. A supplier must permit CMS (formerly HCFA), or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these standards. The supplier location must be accessible to beneficiaries during reasonable business hours, and must maintain a visible sign and posted hours of operation.
  9. A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a beeper, answering machine or cell phone is prohibited.
  10. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier’s place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations.
  11. A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from calling beneficiaries in order to solicit new business.
  12. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items, and maintain proof of delivery.
  13. A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.
  14. A supplier must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicare-covered items it has rented to beneficiaries.
  15. A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.
  16. A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item.
  17. A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier.
  18. A supplier must not convey or reassign a supplier number, i.e., the supplier may not sell or allow another entity to use its Medicare billing number.
  19. A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility.
  20. Complaint records must include: the name, address, telephone number, and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it.
  21. A supplier must agree to furnish CMS (formerly HCFA) any information required by the Medicare statute and implementing regulations.
  22. All suppliers of DMEPOS and other items and services must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services, for which the supplier is accredited in order for the supplier to receive payment for those specific products and services.
  23. All DMEPOS suppliers must notify their accreditation organization when a new DMEPOS location is opened. The accreditation organization may accredit the supplier location for three months after it is operational without requiring a new site visit.
  24. All DMEPOS supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill the Medicare. An accredited supplier may be denied enrollment or their enrollment may be revoked, if CMS determines that they are not in compliance with the DMEPOS quality standards.
  25. All DMEPOS suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation. If a new product line is added after enrollment, the DMEPOS supplier will be responsible for notifying the accrediting body of the new product so that the DMEPOS supplier can be re-surveyed and accredited for these new products.
  26. All DMEPOS suppliers must obtain a surety bond in order to receive and retain a supplier billing number.

What our patients are saying…
“Aeroflow was wonderful when it came to helping us with our wheelchairs and lift-even showed us how to use the lift. We were very thankful for the friendly and knowledgeable service.”
WHAT OUR PATIENTS ARE SAYING...
“I was looking for a power wheelchair for my wife. Aeroflow had a great selection and they were very kind and helpful on the phone. Great people to do business with!”
WHAT OUR PATIENTS ARE SAYING...
“I recently bought a Go-GoPower Scooter from Aeroflow and couldn't be happier with its mobility and compact design.The chair is amazing and goes anywhere I want.It was a great experience!”
WHAT OUR PATIENTS ARE SAYING...
“My doc referred me to Aeroflow when I needed a sleep test, and I went back when I needed a wheelchair.The service was exceptional! Aeroflow really cares about their customers.”