Medicare and Insurance Coverage of Medical Equipment used in the Home

The medical equipment used by patients in the home – such as oxygen assistance devices, wheelchairs, scooters, specialty beds, etc. – is known as “durable medical equipment” (DME) or “home medical equipment” (HME) by Medicare and most insurance companies. Medicare provides benefits for DME under its Medicare Part B. Virtually all private medical insurance plans cover medical equipment, subject to deductibles applicable to the insured and sometimes subject to annual dollar limits and a specified network of providers.

Find Out if You Are Eligible for Medicare and When You Can Enroll
Find Out What Medicare Covers
Medicare Supplier Standards
Medicare - Background
Medicare Part A: Hospital Insurance
Medicare Part B: Medical and Home Medical Equipment Insurance
Does your medical equipment supplier accept assignment?
Medicare Supplement
For more information on Medicare

Medicare Supplier Standards:
Note: This is an abbreviated version of the application certificate standards, which every Medicare supplier must meet in order to obtain and retain their billing privileges. These standards, in their entirety, are listed in 42 C.F.R. pt. 424, sec 424.57(c) and are effective on December 11, 2000. A supplier must disclose these standards to all customers/patients who are Medicare beneficiaries (standard 16). 

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 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 customer 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 that 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 statue and implementing regulations.

Medicare - Background:
Medicare is a federal health insurance program designed to make health care affordable and available to all elderly and certain chronically disabled persons. It's divided into two parts. Part A is hospital insurance that is available without a premium to anyone eligible for Social Security; otherwise it can be purchased for a monthly premium. Part B is an optional medical insurance that is available for a monthly premium, regardless of Social Security status.

What documentation does Medicare require of my doctor?
Medicare requires a physician to fill out a Certificate of Medical Necessity (CMN), which indicates the patient's diagnosis, prognosis and status – as well as indicating the estimated amount of time the equipment will be needed.

Medicare components

Part A: Hospital Insurance
Most people do not pay a monthly premium for Part A because they or a spouse have 40 or more quarters of Medicare covered employment. Those with fewer than 40 quarters of employment pay a monthly premium.

Medicare pays all covered costs except the Medicare Part A annual deductible (2005 = $912) during the first 60 days. Part A pays coinsurance amounts for hospital stays that last beyond 60 days and no more than 150 days.

For each annual benefit period you pay:

- A total of $912 for a hospital stay of 1-60 days.
- $228 per day for days 61-90 of a hospital stay.
- $456 per day for days 91-150 of a hospital stay. (Reserve Days).
- All costs for each day beyond 150 days.

- If approved you pay nothing for the first 20 days.
- You pay $114.00 per day for days 21-100.
- You pay all charges beyond 100 days.

Home Health Care (Medically necessary skilled care therapy)

If approved you pay nothing for part time care.

Hospice Care (For the terminally ill)

As long as doctor certifies need, Medicare pays all but limited costs of drugs and respite care. You pay limited costs of drugs and respite care.

Part B: Medical Insurance

Part B is available to those eligible for Medicare. It requires a separate monthly premium ($66.60 per month for 2004.)

Covered Services under Part B

Part B covers physician services, outpatient hospital services, certain home health services and durable medical equipment, as follows:

Medical services in and out of the hospital: Medicare pays 80% (after deductible* ) of approved charges. You pay 20% (after deductible*) of approved charges, plus any excess charges levied by the physician or provider.

Home Health Care (Medically necessary skilled care therapy) -

Part time care: Medicare pays 100% if approved. You pay nothing.

Durable Medical Equipment (DME)
Prescribed by your doctor for use at home: Medicare pays 80% (after deductible*) of approved amounts. You pay 20% (after deductible*) of approved amounts. Medicare B pays only for durable medical equipment that a doctor prescribes for use in your home. There are certain items that require a written order before delivery. For these items, Medicare will not pay if the written order is obtained after delivery.

Outpatient Hospital Treatment
Unlimited if medically necessary: Medicare pays a fee schedule amount (after deductible*). You pay coinsurance or fixed copayment amount, which varies according to the service (after deductible*)

* Part B has a single yearly deductible of $110 and for most services there is a 20% coinsurance for approved services.
Physicians and providers who don't accept the amount Medicare approves may charge more than the Medicare approved amount.

Medicare does not cover all health care expenses.
It does not pay for outpatient prescription drugs, yearly physical exams, long-term care at home or in a nursing home, routine eye exams, eyeglasses, hearing aids, or dental care. It generally doesn't pay for care provided outside the U.S.

Does your medical equipment supplier accept assignment?
Most, but not all physicians and medical equipment providers accept assignment of Medicare. Our company accepts assignment for all Medicare patients. As such, we are agreeing to accept the Medicare approved amount as total payment for Medicare covered services. We bill Medicare and Medicare pays us directly. The patient is still responsible for his or her deductible and co-insurance (20%).

Medicare supplement:
“Medigap” or “Medsup” is insurance designed to fill in the gaps in Medicare coverage. (It's not sold or serviced by the gov't) Insurance companies can sell ten standard Medicare supplement plans, identified by the letters A – J. Companies are not allowed to add or subtract benefits from any of the plans. Your state's supplement premium comparison guide lists the companies that are licensed to sell Medicare supplement insurance. These guides will help you compare the various premiums and other features offered.

Ten Standard Medicare Supplement Plans: Basic Benefits

Medicare supplement plans A-J cover the following:

Medicare supplement plans A-J pays coinsurance for days 61-90.

Medicare supplement plans A-J pays coinsurance for days 91-150.

Medicare supplement plans A-J pays 100% for 365 more days.

Part B – Medical - Coinsurance/Co-pay

Parts A & B Blood

Additional Benefits

Skilled Nursing Facility - Coinsurance days 21-100 are covered by Medicare supplement plans: C, D, E, F, G, H, I, J

Part A Deductible – covered by Medicare supplement plans: B, C, D, E, F, G, H, I, J

Part B Deductible – covered by Medicare supplement plans: C, F, J

Part B Excess – covered by Medicare supplement plans: F, I, J, supplement plan G covers 80%

Foreign Travel Emergency – covered by Medicare supplement plans: C, D, E, F, G, H, I, J

At Home Recovery – covered by Medicare supplement plans: D, G, I, J

Basic Prescription Drugs – covered by Medicare supplement plans: H, I

Extended Prescription Drugs – covered by Medicare supplement plan: J

Preventive Medical Care – covered by Medicare supplement plans: E, J

For more information on Medicare:

Medicare & Medicaid info - http://www.medicare.gov/

Health and Human Services - http://www.hhs.gov/news/

Social Security Online - http://www.ssa.gov/