Medicare Coverage Policy
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, or
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, accessories, and oxygen contents.
Beyond the 36 months, Medicare will limit payments to replacement of accessories, and allows a small fee for monthly content and to check the equipment every six months.
After an item has been purchased for you, you will be responsible for calling your provider any time 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.
What Can You Expect to Pay?
Every year, in addition to your monthly premium, you will have to pay the first $135 of covered expenses out of pocket and then 20 percent of all approved charges if the provider agrees to accept Medicare payments.
Unfortunately, your medical equipment provider cannot automatically waive this 20 percent or your deductible without suffering penalties from Medicare. Your provider 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 suffer from qualifying financial hardships.
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 provider 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.
Other possible costs:
Medicare will pay only for items that meet your basic needs. Oftentimes you will find that your provider 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 provider 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 patients to upgrade to a piece of equipment that they like better than other standard options for which they may otherwise qualify.
The Advance Beneficiary Notice, or ABN, must detail how the products differ, and requires a signature to indicate that you agree to pay the difference in the retail costs between two similar items. Your provider 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.