How does Medicare Cover Durable Medical Equipment?

Durable medical equipment (DME)

 

Medicare covers items like oxygen equipment and supplies, wheelchairs, walkers, and hospital beds ordered by a doctor or other health care provider enrolled in Medicare for use in the home. Some items must be rented.  You pay 20% of the Medicare-approved amount, and the Part B deductible applies. If you have a Medi Gap plan, that should pay the 20%!   Medicare Advantage, check the summary of benefits or EOC Evidence of Coverage.

Make sure your doctors and DME suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If your doctors or suppliers aren’t enrolled, Medicare won’t pay the claims they submit. It’s also important to ask your suppliers if they participate in Medicare before you get DME. If suppliers are participating suppliers, they must accept assignment (that is, they’re limited to charging you only coinsurance and the Part B deductible for the Medicare-approved amount). If suppliers aren’t participating and don’t accept assignment, there’s no limit on the amount they can charge you.

To find suppliers who accept assignment, visit Medicare.gov/supplierdirectory or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. You can also call 1-800-MEDICARE if you’re having problems with your DME supplier, or you need to file a complaint. Copied from Medicare & You – see link in side panel

What about Stair Lifts?

acorn stair lifts.com

Medical Necessity of Stair Lifts & Lifting devices Clinical Bulletin?

Durable Medical Equipment

Seat Life Mechanisms

Do Condominiums have to provide stair lifts, under ADA?

Pride Mobility.com Steps to get Medicare to pay

Law Dictionary.com Does Insurance Cover Stair Lift?

hhs.gov research 1989

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Anthem Medicare Supplement

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Coverage for #Orthotics

 

All health plans and insurers to are now required to offer (make something available for those who want it) coverage for orthotic and prosthetic devices

and services as follows:

  • Annual and lifetime maximums for orthotic and prosthetic devices and services cannot be lower than the maximums applicable to other plan benefits; and
  • Copayments, coinsurance, deductibles, and maximum out-of-pocket amounts cannot be higher than the most common amounts on the benefit plan.  AB 2012  Health and Safety Code §1367.18 Insurance Code §10123.7

What is an Orthotic?

 

A removable shoe insert, otherwise known as a foot orthoses, accomplishes many number of purposes, including daily wear comfort, foot and joint pain relief from arthritis, overuse, injuries, and other causes such as orthopedic correction, smell reduction and athletic performance. wikipedia.org/Shoe_insert

Foot orthoses comprise a custom made insert or footbed fitted into a shoe. Commonly referred to as “orthotics” these orthoses provide support for the foot by redistributing ground reaction forces as well as realigning foot joints while standing, walking or running. A great body of information exists within the orthotic literature describing the sciences that might be used to aid people with foot problems as well as the impact “orthotics” can have on foot, knee, hip, and spine deformities. They are used by everyone from athletes to the elderly to accommodate biomechanical deformities and a variety of soft tissue inflammatory conditions such as plantar fasciitis.[8]   wikipedia.org/Orthotics#Foot_orthoses

Medical Necessity

 

When Medically Necessary, benefits are available for:

  • Orthotics (braces, boots, splints) for foot disfigurements resulting from bone deformity, motor impairment, paralysis, or amputation. This includes but is not limited to, disfigurement caused by cerebral palsy, arthritis, polio, spina bifida, diabetes, accident, injury, or developmental disability, and
  • Podiatric devices, such as therapeutic shoes and shoe inserts, to prevent or treat diabetes-related complications

Covered Services include determining if You need the device, initial purchase, fitting, adjustment, and repair of a custom made rigid or semi-rigid supportive device  Sample ACA/Obamacare Policy Page 77 

Clinical Policy Rules to get coverage

Aetna

Medicare

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies

 

Consumer Resources

 

San Pedro Shoes
Excellent Orthotics

spenco.com/ insoles

Video Istep digital foot analysis
vimeo.com

thorlo.com  Socks

Before AB 2012, health plans and insurers were required to offer group coverage for orthotic and prosthetic devices under terms agreed upon between the employer and the health plan or insurer. AB 2012 revised the existing “mandate to offer” to stipulate that this coverage may be subject only to maximums and limitations on coverage that apply to the plan’s basic health care services. The new provision is effective July 1, 2007.

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