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Medical Necessities will ensure that you receive the best possible outcome when purchasing the equipment you need by working closely with your insurance company while providing you with personalized solutions.

Owners David and Niki Baxter work with Medicare, Medicaid, and most other commercial insurances so that you can get the quality respiratory care, rehabilitation equipment, and speech assistive solutions that you need.

Contact us today by visiting one of our locations or by filling out our easy online contact form to find out how Medical Necessities works closely with your insurance.

Guide to Medicare Coverage

Medicare coverage for specific types of home medical equipment

Medicare and Insurance Guide

Both Medicare and private health insurance plans pay for a large portion or sometimes even all costs associated with many types of medical equipment used in the home. This type of equipment is referred to as durable medical equipment or home medical equipment. The guide below will help you understand the Medicare guidelines related to home medical equipment. Most health insurance plans have similar rules to Medicare, but you should know that all private health insurance plans vary and the specific rules of your plan may differ from these Medicare guidelines. We accept most of the major health insurance plans. We would be happy to work with you and your insurance company to help you understand how your plan works as it relates to home medical equipment needed by you or a loved one.

List of Insurance we work with on a daily basis:

Guide to Medicare Coverage

 

 Who qualifies for Medicare coverage?

  • Individuals 65 years of age or older
  • Individuals under 65 with permanent kidney failure (beginning three months after dialysis begins)
  • Individuals under 65, permanently disabled and entitled to Social Security benefits (beginning 24 months after the start of disability benefits)

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The different benefits of traditional Medicare

  • Medicare Part A benefits cover hospital stays, home health care, and hospice services
  • Medicare Part B benefits cover physician visits, laboratory tests, ambulance services and home medical equipment
  • While oftentimes you do not have to pay a monthly fee to have Part A benefits (you only have to pay money when you use the services), the Part B program requires a monthly premium to stay enrolled (even if you do not use the services). That premium will be set annually by Medicare
  • Typically, this amount will be taken from your Social Security check
  • Medicare Part D offers optional program benefits that cover prescription drugs
  • For more information about your benefits or making coverage decisions, you can visit the official website for Medicare benefits at www.medicare.gov

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What can you expect to pay?

  • Going forward, your premium is set annually by Medicare
  • Unfortunately, your medical equipment supplier cannot automatically waive this 20 percent or your deductible without suffering penalties from Medicare. They must attempt to collect the coinsurance and deductible if those charges are not covered by another insurance plan; however, certain exceptions can be made if you meet qualifying financial hardships established by your supplier
  • If you have a supplemental insurance policy, that plan may pick up this portion of your responsibility after your supplemental plan’s deductible has been satisfied
  • If your medical equipment supplier does not accept assignment with Medicare you may be asked to pay the full price up front, but they will file a claim on your behalf to Medicare. In turn, Medicare will process the claim and mail you a check to cover a portion of your expenses if the charges are approved

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Other possible costs

  • Medicare will pay only for items that meet your basic needs. Oftentimes you will find that your supplier offers a wide selection of products that vary slightly in appearance or features. You may decide that you prefer the products that offer these additional features. Your supplier should give you the option to allow you to privately pay a little extra money to get the product that you really want
  • To take advantage of this opportunity, a new form has been approved by the Centers for Medicare and Medicaid Services (CMS) that allows you to upgrade to a piece of equipment that you like better than the other standard option you may otherwise qualify for. This form is known as the Advance Beneficiary Notice or ABN
  • The ABN your supplier completes for you must detail how the products differ and require a signature to indicate that you agree to pay the difference in the retail costs between two similar items. Your supplier will typically accept assignment on the standard product and apply that cost toward the purchase of the fancier item, thus requiring less money out of your pocket

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Purpose of ABN

  • The Advance Beneficiary Notice of Non-Coverage will also be used to notify you ahead of time that Medicare will probably not pay for a certain item or service in a specific situation, even if Medicare might pay under different circumstances. The form should be detailed enough that you understand why Medicare will probably not pay for the item you are requesting
  • The purpose of the form is to allow you to make an informed decision about whether or not to receive the item or service knowing that you may have additional out-of-pocket expenses

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Durable medical equipment (DME) defined

In order for any item to be covered under Medicare, it typically has to meet the test of durability. Medicare will pay for medical equipment when the item:

  • Withstands repeated use (which excludes many disposable items such as underpads)
  • Is used for a medical purpose (meaning there is an underlying condition which the item should improve)
  • Is useless in the absence of illness or injury (which excludes any item that is preventative in nature such as bathroom safety items used to prevent injuries)
  • Used in the home (which excludes all items that are needed only when leaving the confines of the home setting)

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Mandatory submission of claims

  • Every supplier is required to submit a claim for covered services within one year from the date of service. However, if the item is never covered by Medicare, your supplier is not obligated to submit a claim

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The role of the physician with respect to home medical equipment

  • Every item billed to Medicare requires a physician’s order or a special form called a Certificate of Medical Necessity (CMN), and sometimes additional documentation will be required such as copies of office visit notes from prior visits with your physician or healthcare provider or copies of test results relevant to the prescription of your medical equipment
  • Nurse Practitioners, Physician Assistants, Interns, Residents and Clinical Nurse Specialists can also order medical equipment and sign CMNs when they are treating you
  • All physicians and healthcare providers have the right to refuse to complete documentation for equipment they did not order, so make sure you consult with your physician or healthcare provider about your need for medical equipment or supplies before requesting an item from a supplier
  • For every new item prescribed by your physician or healthcare provider, you should have a recent office visit that documents the reasons for ordering the equipment and products. Many items will now require you to have an in-person office visit with your doctor or healthcare provider to discuss the need and justification for the prescription of medical equipment before a supplier can fill those orders

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Prescriptions before delivery

For some items, Medicare requires your supplier to have completed documentation (which is more than just a call-in order or a prescription from your doctor or healthcare provider) before they can deliver these items to you:

  • Decubitus care (wheelchair cushions, pressure-relieving surfaces placed on a hospital bed and air-fluidized beds) 
  • Seat lift mechanisms
  • TENS units (for pain management
  • Power operated vehicles/scooters
  • Electric or power wheelchairs and related options and accessories
  • Negative pressure wound therapy (wound vacs)

The list of items that require an office visit and written order before delivery has been expanded due to new provisions of the Affordable Care Act to include all items that cost more than $1000, and commonly prescribed items such as oxygen, hospital beds, wheelchairs and more.

There are over 150 products across multiple product categories that are affected. Your supplier will be able to tell you if the item ordered by your doctor or healthcare provider is subject to these additional requirements:

  • Your supplier cannot deliver these products to you without a written order from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider

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How does Medicare pay for and allow you to use the equipment?

Typically, there are four ways Medicare will pay for a covered item:

  • Purchase it outright, then the equipment belongs to you
  • Rent it continuously until it is no longer needed
  • Consider it a "capped" rental in which Medicare will rent the item for a total of 13 months and consider the item purchased after having made 13 payments
  • Medicare will not allow you to purchase these items outright (even if you think you will need it for a long period of time)
  • This is to allow you to spread out your coinsurance instead of paying in one lump sum
  • It also protects the Medicare program from paying too much should your needs change earlier than expected
  • If you have oxygen therapy, Medicare will make rental payments for a total of 36 months during which time this fee covers all service and accessories
  • Beyond the 36 months (for a period of two additional years), Medicare will limit payments to a small fee for monthly gas or liquid contents, where applicable, and a limited service fee to check the equipment every six months

After an item has been purchased for you, you will be responsible for calling your supplier anytime that item needs to be serviced or repaired. When necessary, Medicare will pay for a portion of repairs, labor, replacement parts, and for temporary loaner equipment to use during the time your product is in for servicing. All of this is contingent on the fact that you still need the item at the time of repair and continue to meet Medicare’s coverage criteria for the item being repaired

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What is competitive bidding?

In many parts of the country, a new program called Competitive Bidding will require you to obtain certain medical equipment from specific, Medicare-contracted suppliers in order for Medicare to pay. Not all products are subject to competitive bidding in the same area. If you are located in a city where the program is in effect, you will need to obtain some or all of the following items from a contracted supplier:

  • Oxygen, oxygen equipment, and supplies
  • Standard power wheelchairs, scooters, and related accessories
  • Enteral nutrition, equipment, and supplies
  • Continuous Positive Airway Pressure (CPAP) devices and Respiratory Assist Devices (RADs), and related supplies and accessories
  • Hospital beds and related accessories
  • Walkers and related accessories
  • Support surfaces (Group 1 and Group 2 mattresses and overlays)
  • Manual wheelchairs and accessories
  • Mail-order and direct delivery of diabetic supplies
  • Nebulizers
  • Home infusion therapy including insulin pumps and supplies
  • TENS Units and supplies
  • Patient lifts
  • Commodes
  • Seat lifts
  • Negative pressure wound therapy devices and related supplies and accessories

Competitive Bidding areas are designated based on the zip code of your permanent residence on file with Social Security. To find out if your zip code is affected by Competitive Bidding, call 1-800-MEDICARE (1-800-4227). You may also visit Medicare.gov and lookup suppliers in your area by zip code (a notice will appear if your area is subject to Competitive Bidding). If medical equipment is marked with an orange star, it will need to be provided by a contracted supplier (also marked with an orange star). Throughout this guide, products that are potentially impacted by the competitive bidding program will be designated with a double asterisk **. Your provider can assist you with answering your questions about competitive bidding and can address whether or not they have been contracted to provide the services you need if subject to competitive bid.

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Medicare coverage for specific types of home medical equipment

 

BiLevel devices/respiratory assistive devices

For a respiratory assist device to be covered, the treating physician or healthcare provider must fully document in your medical record symptoms characteristic of sleep-associated hypoventilation, such as daytime hypersomnolence, excessive fatigue, morning headaches, cognitive dysfunction, dyspnea, etc.

A respiratory assist device is covered if you have a clinical disorder characterized as:

  • Restrictive thoracic disorders (i.e., progressive neuromuscular diseases or severe thoracic cage abnormalities
  • Severe chronic obstructive pulmonary disease (COPD)
  • Central sleep apnea (CSA) or complex sleep apnea (CompSA)
  • Hypoventilation syndrome

If you're diagnosed with obstructive sleep apnea, see the coverage criteria for positive airway pressure devices below:

  • Various tests may need to be performed to establish one of the above diagnosis groups
  • Three months after starting your therapy you must return to your doctor or healthcare provider for a follow-up to confirm the machine is benefiting you and that you're regularly using the device
  • This must be documented in your doctor or healthcare provider's notes from that office visit. Your physician or healthcare provider will be required to respond in writing to questions regarding your continued use along with how well the machine is treating your condition
  • If you're not using your machine for an average of four hours per night per 24-hour period at the time you meet with your doctor or healthcare provider, then you may be held responsible (via an Advance Beneficiary Notice) to pay for the rental until you meet this requirement
  • BiLevel devices are considered to be capped rental items, which means they cannot be purchased outright. You will own the equipment after Medicare makes 13 payments towards the purchase of the equipment
  • Depending on which product is ordered, your supplier may not be able to deliver this product to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider

Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your supplier for more details.

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Nebulizers

  • Nebulizer machines, medications, and related accessories are usually covered if you have obstructive pulmonary disease, but can also be covered to deliver specific medications if you have HIV, Cystic Fibrosis, bronchiectasis, pneumocystosis, complications of organ transplants, or for persistent thick or tenacious pulmonary secretions
  • You may obtain up to a three month's supply of nebulizer medications and accessories at a time as long as you continue to regularly use the medications through your machine
  • If at any time you stop using your medications, please notify your supplier
  • Nebulizer machines are considered to be capped rental items, and that means they cannot be purchased outright. You will own the equipment after Medicare makes 13 payments toward the purchase of the equipment
  • Depending on which product is ordered, your supplier may not be able to deliver this product to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider

*Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your suppliers for details.

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Oxygen

Your doctor or healthcare provider must start with an office visit to discuss your symptoms before ordering any testing. If your symptoms are indicative of a chronic lung condition or other diseases that require long-term oxygen therapy, Medicare will likely cover oxygen when the test results meet the coverage criteria outlined below.

Oxygen is covered if you have significant hypoxemia in a chronic stable state when:

  • You have a severe lung disease or hypoxemia that might be expected to improve with oxygen therapy
  • Your blood gas levels or oxygen saturation levels indicate the need for oxygen therapy
  • Your oxygen study was performed by a physician, qualified lab, another qualified provider
  • Alternative treatments have been tried or deemed clinically ineffective

Categories/Groups of oxygen therapy are based on the test results to measure your oxygen. There are two types of tests that can be used for this purpose. An Arterial Blood Gas (ABG) test is an invasive procedure which provides detailed information and a direct measurement of oxygen in arterial blood (from an artery). ABG test results are reported in millimeters of mercury (mmHg). A saturation test (SAT) is a non-invasive procedure that indirectly measures oxygen saturation using a sensor typically placed on the ear or finger. SAT test results are reported in percentages (%).

  • Group 1 Criteria: mmHg = 55, or saturation = 88% - For these results, you must return to your physician or healthcare provider between 9-12 months after the initial visit to discuss whether your oxygen therapy should continue for lifetime or for a shorter period if the need is expected to end. Typically, you will not have to be retested when you return to your physician or healthcare provider for the follow-up visit
  • Group 2 Criteria: 56-59 mmHg, or 89% saturation - For these results, you must return for another office visit with your physician or healthcare provider to discuss your oxygen therapy and for these borderline results you will also have to be retested within 3 months of the first test to continue therapy for lifetime or until the need is expected to end

Note on nocturnal oxygen therapy: 

  • If you only require the use of oxygen during the nighttime, your doctor should rule out obstructive sleep apnea as a cause for the hypoxemia symptoms you may be experiencing. If obstructive sleep apnea is a potential factor, Medicare will not cover oxygen therapy until you have officially had the sleep apnea diagnosed and treated. When obstructive sleep apnea is a factor, testing for oxygen needs can only begin after the apneas are controlled with appropriate positive airway therapy using a CPAP or Bi-PAP
  • Oxygen will be paid as a rental for the first 36 months. After that time, if you still need the equipment, Medicare will no longer make rental payments on the equipment. However, if the equipment is still necessary, your supplier will continue to provide the equipment to you for an additional 24 months. During this two-year service period, Medicare will pay your supplier for refilling your oxygen cylinders and for a semi-annual maintenance fee
  • After 60 months of service through Medicare, you may choose to receive new equipment
  • Depending on which product is ordered, your supplier may not be able to deliver this product to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider

*Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your supplier for details.

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