Both Medicare and private health insurance plans pay for a majority of costs associated with medical equipment used in the home. Some types of equipment and assistive devices are not covered by Medicare or insurance and require you to bear the cost. This guide can help you understand the Medicare guidelines as they relate to home medical equipment. Most health insurance plans have similar rules, but be aware that all private health insurance plans vary and the specific rules of an individual’s plan may differ from these Medicare guidelines.

Terms Defined | General Information | Product Coverage Guide

Terms Defined

Deductible
The amount that must be paid annually, out-of-pocket by the beneficiary before coverage of costs begin. Defined under Medicare or each health insurance policy.

Co-pay
The portion of each approved, covered charge which is the responsibility of the patient. Usually expressed as a percentage of covered charges. Applies over and above the deductible.

Lifetime maximum
A limitation on benefits offered under the insurance coverage, which can apply to all covered costs or specifically to the durable medical equipment portion of costs.

Covered charges
The charges for medical services and equipment that are acceptable to the health plan or Medicare. These form the basis for what the provider is paid and what the patient pays, usually an 80/20 split.

CMN
A Certificate of Medical Necessity. Similar to a prescription, a CMN is required to be signed by your physician before medical equipment can be dispensed or paid for by the program.

ABN
Advanced Beneficiary Notice. This is a document required by Medicare in cases where the beneficiary wants to have a higher level of medical equipment than is medically necessary and agrees to pay a portion of the cost personally.

We accept most major health insurance plans. Feel free to ask us questions. We are here to help you.

General Information on Medicare & Insurance Coverage

Individuals 65 years of age or older qualify for Medicare, as do people under 65 with permanent kidney failure (beginning three months after dialysis begins), 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. In order for Medicare to cover medical equipment in the home, it must be considered a covered item and it must be prescribed by your physcian.

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 requires a signature to indicate that you agree to pay the difference in the retail costs between two similar items. Normally when you upgrade through use of an ABN, Medicare pays the cost of basic equipment and you pay the difference between the basic and upgraded equipment.

We are available to answer any questions you have on Medicare and insurance coverage. We accept most 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.

Product Coverage Guide

There are many home medical products covered by Medicare. Often, what Medicare does not cover, secondary insurance will. Use the table below as a guide. Generally you pay 20 percent of the Medicare-approved amount. However, the amount you pay may vary because Medicare pays differently on different items. In some cases you may be able to rent the equipment.

Epuipment/ Item	Covered*	Normal Coverage Requirements
Bathroom Safety Equipment	No
BiPAP	Yes	Testing and physician documentation of sleep disorder.
Breast Prosthesis	Yes	Breast prosthesis (one per two years), mastectomy forms (one every six months) and mastectomy bras covered.
Canes, Walkers	Yes	Mobility limitations, please call us for specifics.
Cervical Traction	Yes	Patient has impairment and home traction has proven effective.
Commode	Rarely	Only if patient is confined to an area with no toilet facility.
Compression Stockings	Sometimes	Covered when used to treat open venous ulcers. Otherwise, not covered.
CPAP	Yes	Covered upon sleep study results and physician order.
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 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.
Lymphedema Pumps	Yes	Covered for treatment of true lymphedema and chronic venus insufficiency.
Manual Wheelchairs	Yes	Usually covered. We can help assess patient needs.
Mobility Equipment	See Detail Below	Covers the least level of equipment needed to help 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 physician and home evaluation.
Nebulizer	Yes	Covered for patients with medical need, as are some medications and accessories.
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 assistance of more than one person and 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 modification covered for diabetic patients with specific foot conditions.
Urological Supplies	Yes	Covered for pemanent urinary incontinence.

*For items that are covered by Medicare, Medicare pays 80 percent, patient is responsible for 20 percent. For private insurance, percentage of coverage varies by plan.

More specific information can be obtained by calling our store.