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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
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:
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Able
to withstand repeated use
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Primarily
used for a medical purpose
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Generally
useful only in the presence of illness or injury
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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.
Equipment is 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.
Equipment is 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.
Medical 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:
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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.
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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.
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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
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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
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