What is the difference between Medicare A, B and D?

Medicare Part A is primarily for hospital, home health nursing, and skilled nursing services. Medicare Part B will cover physician services and durable medical equipment and supplies. Medicare Part D is the newest part of Medicare. This part is for prescription drugs.

Medicare often refers to DME. What does DME mean?

DME stands for Durable Medical Equipment. This is special medical equipment used to aid patient’s movement and/or give specific therapy to a patient. It is equipment that is meant to withstand repeated use. There are many examples of DME including: wheelchairs, walkers, hospital beds, and canes.

I received a bill for a deductible. What are deductibles?

A deductible is a specific amount of an out-of-pocket expense paid by the patient at the first of the insurance year. The amount varies by insurance company and by the particular insurance policy.

I received a bill for my equipment. I thought Medicare paid 100%. Don’t they pay 100%?I received a bill for my equipment. I thought Medicare paid 100%. Don’t they pay 100%?

There is some confusion on this.  For Part B, Medicare has a yearly deductible and co-pay. Many people do not realize that Part B Medicare has a yearly deductible. For 2014, it is $147.00 per calendar year and it is deducted from the amount that Medicare allows for payment for a particular item. Also, Medicare does not pay 100% of the charges after the deductible; they pay 80%.  It is illegal to routinely waive the 20% balance. However, if you have a supplemental insurance, the supplement usually picks up the 20% balance.

I have a prescription for a wheelchair. Will Medicare buy it for me?

Many people think that Medicare buys equipment for them, but in many cases, they rent to purchase. Medicare calls that capped rental equipment. Capped rental equipment costs more than $150.00 and is not routinely purchased. It is not service-intensive and not customized for a particular patient.

If Medicare rents the equipment to the purchase price, how long is capped rental equipment rented?

For DME items other than oxygen, rental payment can be made for up to 13 months. After 13 months, the patient will own the equipment. Oxygen is handled differently, and is based on a 5 year cycle.  Medicare will pay rental for 36 months.  Then, for the next 24 months, Medicare will not pay rental, but will pay a set amount for portable oxygen contents.  After 60 months, the cycle will begin again.  The patient will never “own” oxygen equipment.

My provider talks about accepting assignment. What does “assignment” mean?

Assignment is an agreement by a medical provider to accept the insurance’s allowed charges as payment in full and therefore, only bill the patient for the amount of any unmet deductible and coinsurance. The insurance actually sets the price of the service, and the medical provider agrees to their price. When a provider accepts assignment, the insurance company sends payment to the medical provider instead of the patient.

Then, what does “non-assignment” mean?

If a provider does not accept assignment on a particular claim, then the provider files the claim on “non-assignment.”  This means that the supplier does not agree to accept the insurance’s allowed charges.  The supplier can bill the beneficiary for all charges up front. When the insurance company pays the claim, the insurance company will send payment to the patient.

If I have a prescription, does that mean Medicare will cover my equipment?

A prescription is the first step. However, just because you have a prescription doesn’t mean Medicare will cover the product. Medicare requires that the equipment is “medically necessary” which means that the level of services and supplies is adequate for the diagnosis and treatment of an illness or injury. Medicare may require a face to face visit with the doctor. Medicare may require a particular diagnosis for coverage. They may require certain test results or a specific treatment plan to verify the medical necessity. They usually require that the physician forward copies of the patient’s medical record to the equipment supplier before the claim is filed. The rules can be complicated.  At Home Health Products, our billing staff is always willing to research the rules and explain them. We will do our best to bill within the limits of the law. 

If a patient has a piece of medical equipment that is over five years old, will Medicare rent or purchase another piece of equipment because of the age of the equipment?

No, not simply based on the age of equipment.  The useful lifetime of DME is not less than five years.  If the equipment cannot be repaired after five years, Medicare will individually consider another piece of equipment as long as it is still medically necessary. You can bill Medicare for necessary parts and repairs if the equipment can be repaired.

I have a prescription for a raised toilet seat. Does Medicare pay for that?

There is an old saying that says, “Medicare stops at the bathroom door.”  Medicare doesn’t pay for raised toilet seats, shower chairs, grab bars, or commode safety rails.  The patient must pay for these items out of their own pocket.

I haven’t heard anything from Medicare and it has been several weeks. Does that mean you have not filed the claim like you should have?

As the years have passed, Medicare has increased the documentation requirements for filing claims.  It is not uncommon to wait several weeks to file the claim if we do not have all the documents required by Medicare.  Remember, we have to obtain a fully completed detail written order, physician’s chart notes, and sometimes other documents depending on the product.  The process of obtaining the correct documents might take several weeks. We cannot file the claim until we receive the correct documents.