Who qualifies for Medicare benefits?

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

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, the Part B program requires a monthly premium to stay enrolled. In 2008 that premium will range between $96.40 and 238.40 per month depending on your income. Typically, this amount will be taken from your Social Security check.

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.

Purpose of ABN

• The Advance Beneficiary Notice also will 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.

Understanding Assignment (a claim-by-claim contract)

• When providers accept assignment, they are agreeing to accept Medicare’s approved amount as payment in full.
• You will be responsible for 20 percent of that approved amount. This is called your coinsurance.
• You also will be responsible for the annual deductible, which is $135.00 for 2008.
• If a provider does not accept assignment with Medicare, you will be responsible for paying the full amount upfront. The provider will still file a claim on your behalf and any reimbursement made by Medicare will be paid to you directly. (Providers must still notify you in advance, using the Advance Beneficiary Notice, if they do not believe Medicare will pay for your claim.)

Mandatory Submission of Claims

• Every provider is required to submit a claim for covered services within one year from the date of service

Prescriptions Before Delivery:

• For some items, Medicare requires your provider to have completed documentation (which is more than just a call-in order or a prescription from your doctor) before these items can be delivered to you:
• Decubitus care (wheelchair cushions and pressure-relieving surfaces placed on a hospital bed)
• Seat lift mechanisms
• TENS Units (for pain management)
• Power Operated Vehicles/Scooters
• Electric or Power Wheelchairs
• Negative Pressure Wound Therapy  (wound vacs)

• As of February, 2001, all providers of Medicare-covered drugs are required to accept assignment on these items.
• Traditional Medicare Part B insurance will cover some nebulizer drugs, some infused drugs using a pump, specific immunosuppressive drugs, select oral anti-cancer medications and most parenteral nutrition.
• The Medicare Part D plans may provide additional coverage of other oral medications, inhalers and similar drugs.

Mobility Products: Canes, Walkers, Wheelchairs, and Scooters

• Essentially the new Mobility Assistive Equipment regulations will ensure that Medicare funds are used to pay for:
  • Mobility needs for daily activities within the home
  • Least costly alternative/lowest level of equipment to accomplish these tasks.
  • Most medically appropriate equipment (to meet the needs, not the wants)
• Medicare requires that your physician and provider evaluate your needs and expected use of the mobility product you will qualify for.
• They must determine which is the least level of equipment needed to help you be mobile within your home to accomplish daily activities by asking the following questions:
  • Will a cane or crutches allow you to perform these activities in the home?
  • If not, will a walker allow you to accomplish these activities in the home?
  • If not, is there any type of manual wheelchair that will allow you to accomplish these activities in the home?
  • If not, will a scooter allow you to accomplish these activities in the home?
  • If not, will a power chair allow you to accomplish these activities in the home?
• Keep in mind if you have another higher level product in mind that will allow you to do more beyond the confines of the home setting, you can discuss with your provider the option to upgrade to a higher level or more comfortable product by paying an additional out of pocket fee using the Advance Beneficiary Notice (ABN) to select the product you like best.
• A face-to-face examination with your physician is required prior to the initial setup of a power chair or scooter.
• Your home must be evaluated to ensure it will accommodate the use of any mobility product.

Nebulizers

• Nebulizer machines, medications, and related accessories are usually covered for patients with obstructive pulmonary disease, but can also be covered to deliver specific medications to patients with HIV, CF, brochiectasis, pneumocystosis, complications of organ transplants, or for persistent thick or tenacious pulmonary secretions.
• Patients can obtain up to a three month’s supply of nebulizer medications and accessories at a time.

Non-covered items (partial listing):

• Adult diapers
• Bathroom safety equipment
• Hearing aids
• Syringes/needles
• Van lifts or ramps
• Exercise equipment
• Humidifiers/Air Purifiers
• Raised toilet seats
• Massage devices
• Stair lifts
• Emergency communicators
• Low Vision aids
• Grab bars

TENS Units

• TENS units are covered for the treatment of chronic intractable pain that has been present for at least three months or more, and in some cases for acute post-operative pain.
• Not all types of pains can be treated with a TENS unit. TENS units have proven ineffective in treating headaches, visceral abdominal pains, pelvic pains, and TMJ pains, and therefore Medicare will not pay for the device when used to treat these conditions.
• For chronic pain sufferers, Medicare will pay for a one or two month trial rental to determine if this device will alleviate the chronic pain. You must return to your physician exactly 30-60 days after initial evaluation to authorize the purchase of this equipment.
• For acute post-operative pain sufferers, Medicare will consider rental payment for a maximum of 30 days. Any duration longer than that will require individual consideration.

Below is a summary of the standards Medicare requires of home medical equipment providers. Our company meets or exceeds all of these standards.

1.   A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements.
2.   A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days.
3.   An authorized individual (one whose signature is binding) must sign the application for billing privileges.
4.   A supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or from any other Federal procurement or non-procurement programs.
5.   A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment.
6.   A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty.
7.   A supplier must maintain a physical facility on an appropriate site.
8.   A supplier must permit CMS (formerly HCFA), or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these standards. The supplier location must be accessible to beneficiaries during reasonable business hours, and must maintain a visible sign and posted hours of operation.
9.   A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a beeper, answering machine or cell phone is prohibited.
10.    A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier’s place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations.
11.    A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from calling beneficiaries in order to solicit new business.
12.    A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items, and maintain proof of delivery.
13.    A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.
14.    A supplier must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicare-covered items it has rented to beneficiaries.
15.    A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.
16.    A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item.
17.    A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier.
18.    A supplier must not convey or reassign a supplier number, i.e., the supplier may not sell or allow another entity to use its Medicare billing number.
19.    A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility.
20.    Complaint records must include: the name, address, telephone number, and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it.
21.    A supplier must agree to furnish CMS (formerly HCFA) any information required by the Medicare statute and implementing regulations.
22.    All suppliers of DMEPOS and other items and services must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services, for which the supplier is accredited in order for the supplier to receive payment for those specific products and services.
23.    All DMEPOS suppliers must notify their accreditation organization when a new DMEPOS location is opened. The accreditation organization may accredit the supplier location for three months after it is operational without requiring a new site visit.
24.    All DMEPOS supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill the Medicare. An accredited supplier may be denied enrollment or their enrollment may be revoked, if CMS determines that they are not in compliance with the DMEPOS quality standards.
25.    All DMEPOS suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation. If a new product line is added after enrollment, the DMEPOS supplier will be responsible for notifying the accrediting body of the new product so that the DMEPOS supplier can be re-surveyed and accredited for these new products.

     

26. .  Must meet the surety bond requirements specified in 42 C.F.R. 424.57(c). Implementation date- May 4, 2009

27.    A supplier must obtain oxygen from a state- licensed oxygen supplier.

28.    A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F.R. 424.516(f).

29.    DMEPOS suppliers are prohibited from sharing a practice location with certain other Medicare providers and suppliers.

30.    DMEPOS suppliers must remain open to the public for a minimum of 30 hours per week with certain exceptions.