You have Medicare but are able to sign up with a Medicare Advantage Plan such as Cigna Healthspring, Kaiser, Riverside, etc.
If you have Medicare as your primary insurance, here are important things to know.
Certain items require you to have a face to face with your physician or referring provider within 6 months of receiving equipment. If you do not have a face to face encounter that was specifically regarding your need for the equipment, Medicare will not cover your claim. A list of these items and more information regarding this policy can be found on Medicare’s website.
Medicare has policies called LCD’s (local coverage determination) for every item. Each LCD describes what must be addressed in chart notes from your face to face visit specifically regarding your need for the equipment. If these issues are not addressed in your chart notes, your device will not be covered. In addition to chart notes, a prescription must be provided that includes a length of need and a diagnosis. Per the LCD’s some items are only covered if you have a certain diagnosis.
Lastly, if a face to face is required for the item you desire, a “face to face evaluation form” is also required. This is just like a prescription having all the same elements (description of item, length of need, diagnosis) but also needs to indicate the date of your face to face exam (which must be within 6 months of receiving the DME you desire). Please note when a face to face is required for an item all 3 documents must be on file with the supplier before providing your equipment (1. prescription 2. face to face form 3. chart notes addressing required information from Medicare’s LCD).
Medicare Same and Similar
Another factor that could stop you from obtaining your DME is Medicare’s same or similar information on file. Medicare keeps on file every piece of equipment you have received and when. You are only allowed an item once every 5 years. Medicare considers canes and walkers similar items. You cannot obtain a rollator walker and then a year later try to obtain a cane. Even though they are technically different devices, Medicare considers them similar because they are both walking aids. Be sure to check with your provider that you are eligible for the equipment you desire based on any same or similar information on file with Medicare.
Discharging From Rehab
If you are discharging from a hospital, skilled nursing center or rehabilitation center their policy states that if they recommend equipment for you, that they are legally not allowed to discharge you without this equipment as it would be unsafe. However, you would still have to qualify for the equipment. If you do not qualify your only option would have to pay out of pocket to obtain the equipment in order to discharge.
For example, they may recommend a rollator walker but Medicare has on file they already paid for a walker within 5 years, but you disposed of it after your fracture healed, now you have a new injury. Medicare will only pay for a piece of equipment once every 5 years. It would be your responsibility to purchase another walker in order to be discharged.
Medicare In Network Providers
Medicare as your primary insurance has in-network suppliers that “Accept Assignment” as well as non-participating suppliers that are on file but “Do not Accept Assignment”.
There is another aspect that you need to know about regarding DME which is called competitive bid items. In network suppliers would be the only ones who could possibly assist you with DME that is considered to be competitive bid. Patients that Medicare considers to live in a rural area are not subject to the competitive bid. To find out if you are subject to the competitive bid and what suppliers can assist you. Remember, this is based on the zip code Medicare has on file for your remittances (if your physical address is different, you cannot use your physical address to determine what DME supplier you can use).
The costs associated with regular Medicare? Medicare has a yearly part B deductible of $166.00 that must be met before any DME claims are paid. This deductible is subject to change and increase year to year. Once your deductible is met, Medicare will then pay claims at 80% leaving you with a responsibility of 20%. If you have a secondary insurance, coverage would have to be verified by the provider to tell you if you have any share.
There are also items that may not be completely covered and have upgrade charges that you would have to pay out of pocket such as Rollator Walkers. Only the seat and frame portion are billable to insurance and providers are able to bill you for the basket, color and brakes. There are instances where you may want a certain item such as a heavy duty scooter which you may not qualify for based on your weight, the provider can only bill for a standard scooter that you may qualify for based on your weight and you can pay an upgrade charge out of pocket as well in this instance to receive the heavy duty scooter you want. Your provider should go over with you all of this information about your costs on items before providing you with any DME.
If you have an Advantage Plan providing payment for your DME here are things to know:
You will need to make sure you go to a provider that is in-network with your Medicare Advantage Plan. Although they follow Medicare guidelines, they also have different guidelines of their own. For example, most items may require authorization to obtain where regular Medicare doesn’t have an authorization process for items other than power wheelchairs and specialty manual wheelchairs.
Medicare advantage plans also may have different deductible amounts although they still pay 80% of DME claims. For example, the part B deductible for patients with Cigna Healthspring is $156.00 which is cheaper than original Medicare however you would still have to pay this each year before any DME claims are paid. A deductible will be payable to whichever provider or claims your insurance company states it is applied to. This will be noted on any EOB (explanation of benefits) to whom you owe the deductible to (Note: it may carry over many claims until the total amount is met).
With regular Medicare and Advantage Plans a provider does not have to supply you with the exact name brand piece of equipment you desire. This will be something you will need to discuss with your provider if you want something particular. They only have to supply you with an item that meets Medicare requirements to be billable as that item. For example, a scooter is coded K0800. A provider is responsible for providing you with a scooter that was approved to be billed with that code. They do not have to provide you with any scooter you desire that is coded as K0800. There may be extra accessories on the scooter you desire that aren’t billable to insurance where a provider may give you an option to pay an upgrade charge for the accessories not billable if they are able to provide this product.
Do you want to know how to use Medicare to get Durable Medical Equipment DME? Medicare pays for DME, except scooters and wheelchairs, through two procedures.. In this guide, we take a look at these two methods that you should use to get Medicare to pay for your DME.They Are:
Current Procedure• The first method you should use starts with your care provider or doctor. You either let the doctor recommend DME to you or ask them about it, for example; they may urge Medicare to provide you with DME when leaving the hospital or during routine medical visits.• Medicare only pays for DME after your primary care provider submits an order, prescription or certificate that you need it, for example, in the case of injuries or medical conditions. They must also mention that you will only use this equipment at home.• Another requirement is that you must pay office visits to your heath care provider or doctor before Medicare accepts to cover these costs for DME. The purpose of these visits is to state the reason why you need to get the equipment.• Make sure you pay these visits 6 months or less before you order for the machine. Remember you need a doctor’s note to confirm that you paid these visits.• Use the right supplier or vendor. That ensures that you get coverage for your equipment. They must have approval from your Medicare Advantage plan or original Medicare plan. You should also present them with the doctor’s note or prescription.
Original Medicare• If you have original Medicare plan, use suppliers that have approval from Medicare. That’s because of the methods that Medicare uses to pay for the DME and which brand you need.• Medicare uses two primary methods to pay suppliers: that’s through contract suppliers or vendors who have signed to bill Medicare.• If you have diabetic conditions, you should be careful who you select as your equipment provider. That’s because Medicare uses a competitive program in bidding for diabetic supplies’. That’s for those from Mail orders.• Contract suppliers are therefore ideal for those who get diabetic supplies through Mail orders. If you get them from your local pharmacy, use stores that accept consignments from Medicare.
What to Do• Contact Medicare through their customer care numbers or website to ensure you get the full list of suppliers that Medicare has approved for your area.• Ask about the competitive bidding process. That’s because it affects the type of vendor that you will use and the costs. If you live in a non-competitive bidding area, remember that you may have to rely on different vendors.
Medicare Advantage Plan• This plan requires you to get its approval before accessing DME. You may also have to use vendors that use its program. That means you may not get coverage if you use other suppliers.• Another requirement is that you may need to list your DME preferred brands. Choose brands that suit your budget needs.
ConclusionGetting Medicare to pay for your DME should be easier using the above guide. The key points to remember are following the above guidelines and checking your budget needs.Medicare is useful in helping patients acquire a Durable Medical Equipment (DME) such as a manual wheelchair. There are a number of steps that you need to take to obtain Medicare coverage for a manual wheelchair.
Procedure for Acquiring a Manual WheelchairOne of the measures is to start by consulting with your doctor, who will recommend a Manual Wheelchair. It is vital that you have an office visit with your physician to point our medical reasons that shows why you require a wheelchair.To acquire a wheelchair quickly through Medicare, it’s necessary to fill in either a prescription or a certificate from the doctor. The order must stipulate that the patient in question has difficulty walking around making it impossible to carry out his or her daily activities. . This prescription or certificate must be signed stating that the patient in question requires a manual wheelchair to help move aroundOnce you have a written order from your doctor, ensure that you get the right kind of supplier who is approved by either your Medicare Advantage Plan (MAP) or Original Medicare.
Original MedicareIf you are using Original Medicare as your primary insurance, you must be aware that the type of supplier who has been approved by Medicare will rely on how Medicare pays for your wheelchair. Therefore, the cost of your manual wheelchair will be determined through the competitive bidding demonstration.
Medicare Advantage PlanOn the other hand, if you are using the Medicare Advantage Plan, it will necessitate that you join a plan’s network to get a supplier.You are required to identify the preferred brands of manual wheelchairs since they cost differently. The benefit with the Medicare advantage Plans is that the involved patients are not affected by the competitive bidding demonstration.
The Bottom LineAcquiring a manual wheelchair through Medicare has become a lot easier thus benefiting patients. Patients are first advised to consult with their doctors in their quest to acquire a wheelchair. With the approval of a doctor, a patient can either use the Original Medicare or the MAP to get a manual wheelchair.