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Medicare and Durable Medical Equipment Buying Equipment for Someone on Medicare
 Can be Tricky Business
The following is extracted from an issue brief intended for professionals who work with Medicare recipients.  It is an excellent explanation for anyone who might have a need for medical equipment.  Reprinted with permission of the Center for Medicare Education, www.MedicareEd.org  

Medicare coverage of wheelchairs, hospital beds and other durable medical equipment (DME) is a major source of confusion for people with Medicare, their families and the professionals who work with them.  Yet, consumer publications rarely touch on it.  In this brief we offer an overview of DME coverage issues and payment policies.  Many people with Medicare and their families mistakenly think getting home medical equipment is as easy as going to their local medical equipment supplier and bringing the equipment home, or calling up a company that advertises on television and having the equipment delivered right to their door.  For example, there are commercials on TV that show older people riding scooters at the grocery store, the mall or the park; these often lead people to believe that almost anyone can get Medicare to pay for a scooter to run errands and perform other activities. Unfortunately, it's not usually that easy.  Medicare's coverage requirements and related rules for getting medical equipment are complex and often confusing.  It's crucial for you and your clients to understand that durable medical equipment is primarily medical, and the entire process of acquiring Medicare-covered  equipment starts with your client's physician.  It's also important to understand that each Medicare-covered piece of equipment has specific requirements that your client must meet to ensure Medicare payment.  For example, the commercials mentioned above do not tell people that they must be unable to walk to get a Medicare-covered scooter.

The Centers for Medicare and Medicaid Services, the federal agency that oversees Medicare and Medicaid, contracts with four companies, known as Durable Medical Equipment Regional Carriers, or DMERDs, to process Medicare DME claims.  Each DMERC handles a specific geographic region of the country.  DMERCs also provide information and assistance to providers, suppliers and people with Medicare who have questions about DME coverage.  (To find the DMERC for your state, see the chart at the bottom of the page.  

When Does Medicare Pay for Durable Medical Equipment? The entire class of DME items includes prosthetics, orthotics and supplies (sometimes abbreviated as DMEPOS), giving us these three major three DME categories
  • Durable medical equipment, or DME
  • Prosthetics and orthotics
  • Supplies
In this brief, we will refer to all of these items as DME. Medicare pays for DME if your clients require the assistance or use of the equipment to function at their best and their physician orders it.  The equipment itself must meet certain requirements for Medicare coverage.  It must be:
  • Able to withstand repeated use
  • Primarily used for a medical purpose
  • Generally useful only in the presence of illness or injury
  • Appropriate for use in someone's home
We'll describe these in more detail in the next few sections Physician Order/Certificate of Medical Necessity Medicare requires a physician's order, or prescription, for DME.  A certificate of medical necessity (CMN) supporting the prescription is also often required.  A CMN is a special form authorizing the use of certain physician-prescribed equipment, such as hospital beds, oxygen and wheelchairs.  The Medicare-certified supplier should know which items need a CMN and work with your client's physician to submit all required documentation to Medicare. Durable Medicare pays for equipment that is durable, meaning that it can withstand repeated use.  Expendable items such as incontinence pads, bandages and surgical stockings are not covered under the DME benefit.  However, certain items such as lancets and test strips used by people with diabetes to check their blood sugar levels, while used once and then discarded thereafter, are covered. Primarily Used for Medical Purpose and Useful Only When Ill or Injured Medicare pays for equipment that is primarily and customarily used for a medical purpose and generally only useful when your client has an illness or injury.  Canes, walkers, hospital beds and respirators are common examples of these types of equipment. However, Medicare does not cover some devices that your client might need to recover from illness or injury. For example, while air conditioning may be useful for your clients with certain cardiac or respiratory illnesses, Medicare will not cover it because air conditioning is not primarily used for a medical purpose.  In addition, Medicare will not cover equipment used primarily for your client's convenience or that of his or her caregivers, such as elevators or stair lifts. For Use in the Home Medicare pays for equipment that is mainly for use inside your clients' homes, whether that is their own home, an apartment, the home of a relative, or an assisted living facility or other type of institution. However, this institution cannot be a hospital or skilled nursing facility, as such facilities are required to provide necessary equipment to residents. For example, Medicare will cover a power-operated vehicle, or scooter, when your client requires it to get around inside his or her home.  Medicare will not cover it if your client primarily needs it to get around outside the house, such as going to the grocery store. Prosthetics and Orthotics Medicare covers prosthetic devices that replace all or part of an internal body organ or its function and orthotics devices that support weak or deformed body parts.  Prosthetics include artificial limbs, eyes and lenses, and orthotics consist of leg, arm, back and neck braces.  Medicare also covers enteral and parenteral nutrition therapy supplies (such as food pumps and intravenous poles) as prosthetics.  However, Medicare generally doesn't cover dental devices such as dentures. Supplies Certain supplies, even though generally disposable in nature, fall under Medicare's coverage of DME, including testing items used by people with diabetes, as well as catheters and ostomy supplies. DME: Renting or Purchasing? Medicare approves some DME items for purchase, others for rent and others for either purchase or rent.  Your Medicare-certified supplier should know and explain whether Medicare requires purchase or rental of your client's physician-ordered DME.  In general:
  •  
DME for purchase:  Equipment that is a customized device 

If your clients want to buy a customized device ordered by their physician (such as a narrow or other specially-constructed wheelchair to accommodate their condition), Medicare and your clients pay their portions of the cost in respective lump sum payments.  Your clients then own the equipment.  If the cost of the equipment is high and the supplier is willing, the one-time lump sum payment may be divided into monthly payments, with Medicare and your clients still paying their respective portions of each month's payment.   

  •  
DME for rent: Equipment that needs to be serviced often, such as oxygen equipment and some ventilators and aspirators Medicare and your client pay their respective portions of the monthly rental payments.  

  •  
DME that is a "capped rental item": Equipment that must be rented for a period of time before the individual has a choice to buy it or continue renting it Capped rental items, such as wheelchairs and hospital beds, must be rented for nine months in a row.  Medicare and your client pay their respective portions of the monthly rental payments. In the 10th rental month, the supplier must offer your client the option to buy the equipment. If your client chooses to buy the equipment, Medicare will pay an additional three months of rent, after which the supplier must transfer ownership of the equipment to your client. The supplier may be allowed to charge your client an additional monthly amount on top of each of these final rental payments.  Thereafter, Medicare covers necessary repair or replacement of the equipment.  If your client chooses to rent the equipment, Medicare makes rental payments for an additional five months only.  After that, the supplier must continue to provide the equipment to your client free of charge and can only charge for service and maintenance. The supplier, however, owns the equipment

NOTE:  A supplier that accepts Medicare does not necessarily accept Medicare assignment.  Before getting any medical equipment, your clients should call their DMERC for a list of participating suppliers.  They can also find a supplier that takes assignment by calling 1-800-MEDICARE or by going to the Medicare Web site at www.medicare.gov

Durable Medical Equipment Regional Carriers
Region A Region C
CT, DE, ME, MA, NH, NJ, NY, PA, RI, VT AL, AR, CO, FL, FA, KY, LA, MS, NM, NC, OK, SC, TN, TX, PR, Virgin Islands
Health Now Upstate Medicare Division
1 (800) 842-2052
www.umd.nycpic.com
Palmetto GBA
1 (866) 238-9650
www.pgba.com
 
Region B Region D
DC, IN, IL, MD, MI, MN, OH, WI, WV, VA AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY, American Samoa, Guam, Mariana Island
AdminiStar Federal
1 (800) 622-4792
www.administar.com

CIGNA Healthcare
1 (800) 899-7995
www.cignamedicare.com

 By Molly 'Shomer of The Eldercare Team.  Please visit Molly's web site at http://www.eldercareteam.com for more elder care articles and important resources for those who are caring for aging adults.

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