Medicare Durable Medical Equipment Coverage

From wheelchairs to hospital beds, power scooters to portable oxygen equipment, Medicare’s DME coverage spans a broad variety of items essential for managing various health conditions, including medicare covered equipment.

However, to tap into this benefit, certain criteria must be met. The item must be prescribed by a healthcare provider, intended for use at home, and acquired from a Medicare-approved supplier, among other conditions.

Following surgery, Medicare also provides coverage for DME, including prosthetic devices, under certain conditions. The usage of the device must start within 2 days post-surgery, and the coverage extends for the 3-week period following the procedure.

These conditions ensure that Medicare beneficiaries receive the necessary support to aid their recovery process.

Eligible DME Items: What Medicare Approves

An item must meet certain conditions to be considered as durable medical equipment under Medicare; it should be medically necessary and commonly used for medical purposes. This includes items like hospital beds, oxygen, pumps, canes, power wheelchairs, and more.

Additionally, Medicare limits coverage to items that are specifically provided for use in the patient’s home and can withstand repeated use, ensuring that beneficiaries receive durable and reliable equipment.

However, not all DME items are created equal in the eyes of Medicare. The program has an extensive list of approved items, with specific types of DME and supplies that are not covered, such as disposable items.

Beneficiaries must keep themselves informed and verify the eligibility of an item prior to purchasing or renting.

Exclusions in DME Coverage: Understanding the Limits

Despite the extensive coverage of DME by Medicare, one must realize that not every item is covered. Medicare classifies items as ‘not medically necessary’ if they are personal comfort items and not primarily medical in nature.

Furthermore, the suitability of a DME item for home use is a key determinant of Medicare coverage. This includes items like diabetes self-testing equipment, oxygen, and power wheelchairs that assist individuals in performing daily activities at home.

Specific DME items that are excluded from Medicare coverage include:

• Stairway elevators

• Grab bars

• Air conditioners

• Bathtub and toilet seats

• Incontinence pads

• Catheters

• Surgical facemasks

• Compression leggings

While these items may be useful, they do not meet the strict criteria set for Medicare DME coverage. Hence, beneficiaries should familiarize themselves with these exclusions to prevent unforeseen out-of-pocket costs.

The Role of Your Primary Care Provider in DME Coverage

Your primary care provider is your key ally in securing DME coverage under Medicare for a medical purpose. Their main role is to prescribe the DME, indicating its medical necessity for home use.

This entails providing a signed order, prescription, or certificate explicitly indicating the need for DME coverage under Medicare.

In addition to prescribing the necessary equipment, your healthcare provider can assist in advocating for your DME coverage. They can do this by ensuring that your medical records provide comprehensive documentation to substantiate the medical necessity of the DME.

This is especially important in cases where the need for the equipment may not be immediately apparent to others.

Securing Medicare Coverage for Your Medical Equipment Needs

Acquiring Medicare coverage for your DME needs involves several steps, necessitating meticulous documentation and adherence to Medicare regulations. From obtaining a valid prescription from your primary care provider to choosing a Medicare-approved DME supplier, every step plays a crucial role in ensuring your equipment is covered.

You may also need to complete specific forms and paperwork when seeking coverage for Durable Medical Equipment through Medicare. One such form is the CMS-855S form, which serves as the Medicare enrollment application for DMEPOS suppliers.

While this process may seem cumbersome, it is a necessary part of ensuring that your medical equipment needs are met without causing a significant financial burden.

Prescription & Documentation: Starting the Process

The process to obtain DME coverage commences with securing a prescription from your primary care provider. This prescription needs to be issued for equipment covered by Medicare Part B, following a face-to-face visit within six months prior to writing the prescription.

This rule ensures that the prescription is based on a recent evaluation of your medical needs, including the consideration of prescription medications.

The required documentation for Medicare DME coverage includes:

• Maintaining medical records and documents for a period of seven years from the Date of Service (DOS)

• A standardized prescription containing your name or Medicare Beneficiary Identifier (MBI) Number

• A comprehensive description of the needed item

It’s important to retain these records as they may be needed for future references or in case of any disputes regarding your DME coverage.

Selecting the Right DME Supplier: Ensuring Compliance

Selecting a Medicare-approved DME supplier is a vital step towards ensuring coverage for your medical equipment needs. A Medicare-approved DME supplier is an entity that has obtained DMEPOS accreditation and holds an NPI for each practice location.

You can use the official Medicare tool to identify these suppliers and ensure that the supplier you choose is compliant with Medicare rules.

However, it’s also important to be aware that a DME supplier can lose Medicare approval if it fails to fulfill the DMEPOS accreditation requirements or if CMS suspends its prior authorization requirement.

Hence, aside from price, other factors such as customer service, commitment to providing effective care, and financial stability should be taken into account when choosing a supplier.

Prior Authorization and Approval: Navigating the Formalities

Certain DME items require prior authorization from Medicare. This is a process aimed at achieving cost savings by ensuring that Medicare only disburses benefits for pre-approved medical care.

The process of obtaining prior authorization requires the following:

• Submission of a request to the Durable Medical Equipment Medicare Administrative Contractor (DME MAC).

• A complete written order from the treating practitioner.

• Documentation supporting medical necessity.

• Compliance with requirements to ensure proper utilization.

Failing to obtain prior authorization can lead to benefit denial and significant adverse impacts, especially for those enrolled in various types of Medicare Advantage plans. Your DME supplier can help you navigate this process by ensuring compliance with Medicare coverage criteria and completing the Prior Authorization Request form for submission.

This collaboration can be crucial in securing the necessary approval for your DME needs.

Frequently Asked Questions

What medical devices are covered by Medicare?

Medicare covers a range of durable medical equipment, such as wheelchairs and hospital beds.

What qualifies as DME under Medicare?

DME under Medicare includes equipment such as wheelchairs, walkers, hospital beds, power scooters, and portable oxygen equipment, which are covered by both Original Medicare and Medicare Advantage Plans, ensuring consistency across plans.

How do I bill my DME claim to Medicare?

To bill your DME claim to Medicare, you should use the CMS-1500 form and submit the claim electronically to Medicare through CEDI.

What is the cost-sharing policy for DME under Medicare?

You will be responsible for a 20% coinsurance of the Medicare-approved amount for DME, while Medicare covers the remaining 80%.

How do I secure Medicare coverage for my DME needs?

To secure Medicare coverage for your DME needs, you’ll need a valid prescription from your healthcare provider, select a Medicare-approved DME supplier, and complete required paperwork, like the CMS-855S form.