FAQs

Medicare FAQs

Please refer to the CMS website www.cms.gov or medicare.gov for additional information.

What are the different types of Medicare and what do they cover?

The Medicare program consists of two separate but complementary divisions: Medicare Part A and Medicare Part B.

Medicare Part A, or Medicare Hospital Insurance, covers medically necessary inpatient hospital care, skilled nursing facility services, hospice, and some home health care. Most people do not pay a monthly payment (premium) for Part A.

Medicare Part B covers most equipment you use in your home. Medicare Part B covers medically necessary Durable Medical Equipment, Prosthetics, and Orthotics (DMEPOS), physician services, ambulance services, outpatient physical therapy, speech pathology services, and other healthcare services, including patients with End Stage Renal Disease (ESRD). Beneficiaries enrolled in Medicare Part B normally pay a monthly premium.

Medicare Part C consists of Medicare Advantage Plans and is a choice offered in some areas of the country by private insurance companies that are contracted with Medicare.  There are usually multiple choices for the type of plan such as; HMO (Health Maintenance Organization), PPO (Preferred Provider Organization), PFFS (Private Fee-for-Service) or SNP (Special Needs Plan). Beneficiaries enrolled in a Medicare Part C Advantage Plan normally pay a monthly premium.

What part of Medicare covers Durable Medical Equipment (DME) and Supplies?

Medicare Part B covers most equipment for home use.  Part B covers medically necessary durable medical equipment and supplies prescribed by a Medicare enrolled physician.  Medicare has specific coverage criteria and documentation requirements that must be met in order for the equipment, supplies or services to qualify for payment.

In addition, most Medicare Advantage Plans will cover DME and supplies. However; some require the beneficiary to use a network supplier and/or to obtain authorization prior to obtaining the equipment or service.

What are the requirements for equipment used in the home?

Durable Medical Equipment is defined as equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, and is generally not useful to a person in the absence of an illness or injury. Medicare has very specific restrictions on the types of equipment and supplies that it will pay for.  All of the following requirements of this definition must be met before an item can be considered durable medical equipment:

• The equipment is prescribed by a Medicare-enrolled physician
• The equipment meets the definition of medical equipment
• The equipment is necessary and reasonable for the treatment of the patient’s illness or injury, or to improve the functioning of a malformed body member
• There is documentation available in the medical records to support that there was a face-to-face evaluation and/or treatment for a condition that supports the need for the equipment.
• The equipment is used in the beneficiary’s home

Medicare helps pay for most DME used in the home, such as oxygen, continuous positive airway pressure (CPAP), respiratory assist devices (RAD), ventilators, nebulizers, wheelchairs, hospital beds, and more.

What does Medicare define as a “home”?

Home medical equipment must be appropriate for use in the home. A “home” can be a:

• house
• an apartment or condo
• a relative’s house
• a home for the aged or
• institutions that are not primarily engaged in providing skilled nursing care

Who can write a prescription for a Medicare beneficiary?

Only healthcare practitioners, such as a physician (MD or DO), nurse practitioner (NP), physician assistant (PA) or clinical nurse specialist (CNS) who are enrolled in Medicare can order equipment on your behalf.

What documentation is required by Medicare?

Medicare has strict rules regarding the documentation to be collected before an item can be ordered and covered. The first step in the process is to visit your physician.  Your physician will complete an evaluation, determine a diagnosis and write a prescription for the equipment he/she feels is medically necessary. 

Each item ordered requires specific documentation in your medical records that support the medical need for the equipment.   The prescription (order) also must meet Medicare’s requirements and must be obtained prior to delivery. 

Types of documentation required by Medicare:

• Dispensing Order – Used for equipment and supplies that do not need a Written Order Prior to Delivery (WOPD).  A dispensing order requires the following information:
  • Description of the item
  • Name of beneficiary
  • Name of the physician
  • Start date of the order
• Written Order Prior to Delivery – Required for items such as portable oxygen, hospital beds, wheelchairs, nebulizers, TENS units, alternating pressure pads, and other items listed in MM8304 from the Affordable Care Act (ACA).The minimum requirements elements in a WOPD are:
  • Date of the order
  • Start date, if different than the order date
  • Detailed description of the item
  • Name of beneficiary (patient)
  • Printed name of the physician and the physician’s National Provider Identifier (NPI)
  • Physician’s signature and signature date

Preferred Homecare | LifeCare Solutions must obtain a WOPD prior to the delivery of the equipment. For a complete list of items that require a WOPD click here.

• Medical Documentation – These are your chart notes, therapy notes and test results that help support the medical need for the equipment and supplies that have been ordered.

Obtaining all the documentation required by Medicare can take time.  Preferred Homecare | LifeCare Solutions will work with your physician to gather all the necessary medical information and documentation required by Medicare.    

How does Medicare decide if they will cover a DME item?

Medicare reviews two critical elements in order to decide if they will provide equipment:

1) is it medically necessary

2) does it meet the patients functional need

Medicare requires that there be proof that the equipment ordered is medically necessary for the patient and that the equipment provided meets the patient’s functional needs. 

What are my costs under Medicare Part B?

Under the current Medicare Part B plan, most people pay a monthly premium and must meet an annual deductible each year. A deductible is the amount you must pay before Medicare begins paying its portion of your medical bill.

For durable medical equipment, Medicare has certain allowable amounts it will pay for different types of equipment. Medicare will pay 80% of the allowable amount after your deductible has been met; you are responsible for the other 20%. The 20% balance of the allowable charge is referred to as the co-payment.  You may have a supplemental policy that will pay the Medicare deductible and co-payment.

What durable medical equipment is not covered by Medicare?

Some equipment that patients may find useful and even necessary may not be covered by Medicare. For example, bathroom safety items such as a shower bench are not covered because they are not primarily medical in nature.  Your physician and Preferred Homecare | LifeCare Solutions can help determine if a particular DME item is covered by Medicare.  If you want to obtain items that are not covered by Medicare an Advanced Beneficiary Notice (ABN) is required.

What is the Advanced Beneficiary Notice (ABN)?

Medicare requires that equipment be medically necessary, restricts how long  equipment can be rented, and limits how often equipment can be purchased. If the equipment ordered does not meet Medicare’s requirements or if Medicare denies payment for equipment it becomes your obligation to pay for the item.

In these cases, Preferred Homecare | LifeCare Solutions is obligated to notify you that the equipment ordered may not be covered. This notice is given through an Advanced Beneficiary Notice. An ABN is a form that you will be asked to sign confirming that you are aware that Medicare may not pay for the item ordered and that you will be responsible for the cost of the item(s) if payment is not made by Medicare.

Situations where you may be asked to sign an ABN

• You may have rented the same type of equipment before
• The item or service is expected to be denied as not reasonable or necessary, i.e. lack of medical necessity
• You are requesting a medically unnecessary upgrade
  • An example of an upgrade – your physician orders a lightweight wheelchair, you only qualify for a standard wheelchair under Medicare guidelines, and you choose to pay for an upgrade. In this example you would sign an Advanced Beneficiary Notice that states you agree to pay the additional costs for an upgrade.