Insurance Guide

Medicare and most private health insurance plans pay for some costs associated with many items used for medical care in the home under certain conditions. 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. This information is to help you understand some of the complexities associated with getting Medicare Reimbursement.

If you are considering submitting your purchase for insurance reimbursement, please call your insurance company before making the purchase to determine whether they will reimburse you for your purchase. We do not accept assignment of health insurance plan payments at this time for consumer purchases. You as the consumer will be responsible for any purchases. The following information is to help you decide whether you could or should submit your bill to Medicare or your insurance company for reimbursement to you.

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 physician role 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.
* Nurse Practitioners, Physician Assistants, Interns, Residents and Clinical Nurse Specialists can also order medical equipment and sign CMNs when they are treating a patient.
* All physicians' have the right to refuse to complete documentation for equipment they did not order, so make sure you consult with your physician before requesting an item.

 
Mobility Products: Canes, Walkers, Wheelchairs, and Scooters
The new Mobility Assistive Equipment regulations help ensure that Medicare funds are used to pay for:

* Mobility needs for daily activities within the home
* The least costly alternative/lowest level of equipment to accomplish these tasks.
* The most medically appropriate equipment (to meet the needs, not the wants)

Medicare requires that your physician or medical 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.

 
Patient Transfer Aids
A lift is covered if the transfer between a bed and chair, wheelchair, or commode requires the assistance of more than one person and, without the use of a lift, the patient would be bed confined.

An electric lift mechanism is not covered because it is considered a convenience feature. If you prefer to have the electric lift mechanism, your provider can usually apply the cost of the manual lift toward the purchase price of the electric lift model by using an Advance Beneficiary Notice (ABN). You would be responsible to pay the difference in the retail charges between the two items.

 
Seat Assists
In order for Medicare to pay for a seat lift mechanism, patients must be suffering from severe arthritis of the hip or knee, or have a severe neuromuscular disease. In addition they must be completely incapable of standing up from any chair, but once standing they can walk either independently or with the aid of a walker or cane. The physician must believe that the mechanism will improve, slow down or stop the deterioration of the patient’s condition.

Transferring directly into a wheelchair will prevent Medicare from paying for the device.

Medicare will only pay for the lift mechanism portion. The chair portion of the package is not covered, and you will be responsible for paying the full amount for the furniture component of the chair.

 
Padding or Cushions
Products are designed to be placed on top of a standard hospital or home mattress. They can utilize gel, foam, water or air, and are covered for patients that are:

* Completely immobile

or have limited mobility with any stage ulcer on the trunk or pelvis (and one of the following):
* impaired nutritional status
* fecal or urinary incontinence
* altered sensory perception
* compromised circulatory status

 
Non-covered items:
This is not a complete list of non covered items.

* Adult diapers
* Bathroom safety equipment
* Hearing aides
* Van lifts or ramps
* Exercise equipment
* Humidifiers/Air Purifiers
* Raised toilet seats
* Massage devices
* Stair lifts
* Emergency communicators
* Low Vision Aides
* Grab bars

 
To offer you the best quality daily living aides at an affordable price we do not bill or accept Medicare or other third party insurance at this time. However, you can download a Medicare Medicare Reimbursement Form that you can send in to Medicare.

Call 1-800-MEDICARE for the address to submit your reimbursement form.

 
Go to the following link for additional Medicare Reimbursement Information