How do I obtain Medicare coverage for medical equipment I need in the home?
A Dispensing Order written by the treating physician must be sent to us before an item can be supplied. Some items require a Detailed Written Order (DWO) prior to delivery or a Certificate of Medical Necessity (CMN).
A Dispensing Order (prescription) must include:
- A description of the item
- The beneficiary's full name
- The date of order, and
- Physician's signature and date
A Written Order must include:
- Detailed description of the item and accessories
- The beneficiary's full name
- An ICD-9-CM diagnosis code
- Start date of the order
- The length of need, and
- Physician's signature and date
What is covered by Medicare?
Medicare Part B helps pay for durable medical equipment, including:
- manual wheelchairs (capped rental item)
- power wheelchairs
- nebulizers (capped rental item)
- walkers, rollators, canes, crutches
- scooters (POV's)
- seat-lift mechanisms for lift-chairs
- mattress over-lays (capped rental item)
- hospital beds, semi-electric type only (capped rental item)
- patient lifts (capped rental item)
- CPAP & BiPAP therapy
- oxygen equipment (capped rental item)
Durable medical equipment, such as wheelchairs, are covered only when prescribed by a doctor and the coverage criteria is meet. For most of the above equipment there are specific criteria that must be met. Please call to understand the criteria for Medicare coverage.
What does capped rental mean?
Medicare will pay for the rental of the equipment for 13 continuous months of use with the exclusion of oxygen equipment which rents for 36 months. After Medicare has paid for 13 months of continuous use on capped rental equipment, the supplier shall transfer the title to the beneficiary. Oxygen equipment does not transfer title to the beneficiary and the supplier is required to maintain the equipment until the 60th month under Medicare guidelines. After the 60th month the beneficiary can opt for new equipment and a new 36 month rental period begins.
Does Medicare pay or reimburse for hospital beds?
Medicare considers hospital beds as a "capped rental" item. This means that Medicare will rent the bed for 13 monthly payments after which it will "cap out" and the beneficiary will own the bed. Medicare does not consider a full-electric hospital bed, deluxe bed, or a luxury bed to be medically necessary. If your physician feels a hospital bed is medically necessary, they must chart in the patient notes that they feel it is necessary and the reason why it is necessary verses a traditional bed.
Are manual wheelchairs covered by Medicare?
Medicare considers wheelchairs as a "capped rental" item. This means that Medicare will rent the wheelchair for 13 monthly payments after which it will "cap out" and the beneficiary will own the wheelchair. Medicare does not consider a lightweight, ultra-lightweight, heavy duty, or modified chair medically necessary without doctors notes that support the medical need for such add-ons. If your physician feels a wheelchair is medically necessary, they must chart in the patient notes that they feel it is necessary and the reason why it is necessary verses a cane, walker or crutch.
Is respiratory equipment covered by Medicare?
Oxygen Concentrators, CPAP and other respiratory products are Capped Rentals thru Medicare. These items are also considered capped rental items and have specific criteria for coverage:
- Home oxygen - Must have a saturation test showing that your oxygen levels are 89% or lower or an arterial PO 2 at or below 55 mm Hg
- CPAP - A continuous positive airway pressure (CPAP) device is covered if the patient has a diagnosis of obstructive sleep apnea (OSA) documented by an attended, facility-based polysomnogram and it confirms that significant apneas & hypopneas are occurring.
Medicare covers equipment for "home use." What is considered "home?"
Home medical equipment must be appropriate for use in the home. Your "home" is your house, assisted living facility, apartment, a relative's home, or a group home in which you live. However, certain facility's are not considered home: a hospital, skilled nursing facility, or nursing facility.
Are walkers and rollators covered?
Medicare will allow a walker/rollator every 5 years with documentation that the current walker is unusable.
What is Medicare's coverage criteria for motorized or power wheelchairs?
A power wheelchair may be covered when all of the following criteria are met:
- The patient's condition is such that without the use of a wheelchair the patient would otherwise be bed or chair confined.
- The patient's condition is such that a wheelchair is medically necessary and the patient is unable to operate a scooter (POV), wheelchair, walker, cane or crutch in their home.
- The patient is capable of safely operating the controls for the power wheelchair.
A patient who requires a power wheelchair usually is totally non-ambulatory and has severe weakness of the upper extremities due to a neurological or muscular disease/condition. If the documentation does not support the medical necessity of a power wheelchair it will be denied as not medically necessary. For the correct steps to see if you qualify a power wheelchair please call us for a free guide.
What is Medicare's coverage of power operated vehicles (POVs) or scooters?
A power operated vehicle (POV) or scooter is covered when all of the following criteria are met:
- The patient's condition is such that a wheelchair is required for the patient to get around in the home.
- The patient is unable to operate a manual wheelchair, walker, cane or crutch.
- The patient is capable of safely operating the controls for the POV.
- The patient can transfer safely in and out of the POV and has adequate trunk stability to be able to safely ride in the POV.
Most POVs are ordered for patients who are capable of ambulation within the home but require a power vehicle for movement outside the home. POVs will be denied as not medically necessary in these circumstances. A POV that is beneficial primarily in allowing the patient to perform leisure or recreational activities will be denied as not medically necessary.
Does Medicare cover lift chairs?
Only the seat lift mechanism on a lift chair could be considered medically necessary if all of the following coverage criteria are met:
- The patient must have severe arthritis of the hip or knee or have a severe neuromuscular disease.
- The seat lift mechanism must be a part of the physician's course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in the patient's condition.
- The patient must be completely incapable of standing up from a regular armchair or any chair in their home. (The fact that a patient has difficulty or is even incapable of getting up from a chair, particularly a low chair, is not sufficient justification for a seat lift mechanism. Almost all patients who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.)
- Once standing, the patient must have the ability to ambulate (walk).
Coverage is limited to the seat lift mechanism, even if it is incorporated into a chair. The Medicare allowable for a Seat-lift Mechanism is approximately $340.00
Does Medicare cover wheelchair lifts and ramps?
Medicare does not reimburse nor authorize the purchase of a lift for a wheelchair or scooter at this time. Such items are typically not considered a medical necessity because they can also be used by persons without a medical condition. Don't forget, Medicare covers items needed "inside" the residence.
Do I have to pay the 20% co-payment to Medicare?
After you have met your deductible, you're still responsible for paying directly, or through supplemental insurance, at least 20 percent of the Medicare approved amount. This co-payment may not be dropped by the supplier except in hardship situations and only on a case-by-case basis. A supplier who routinely drops the co-payment may be violating federal law.
Does Medicare cover bath safety items such as shower chairs, transfer benches, grab bars, raised toilet seats, etc.?
Medicare does NOT cover bath safety items. Medicare coverage stops at the bathroom door.
