Guide to Medicare Coverage

• Are you 65 years of age or older?
• Are you under 65 with permanent kidney failure?
• Are you under 65, permanently disabled and entitled to Social Security benefits?

If you answered yes to any of these questions you may qualify for 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 Medicare Part D offers optional program benefits that cover prescription drugs. If you have questions about your benefits or making coverage decisions, you can visit the Medicare Website at www.medicare.gov.  

In addition to your monthly premium, you will have to pay the first $147 of covered expenses out of pocket for Part B services, this is your annual deductible. Then 20 percent of all approved charges if the supplier agrees to accept Medicare payments. The medical equipment supplier cannot automatically waive this 20 percent or your deductible. They 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 meet the criteria for financial hardship established by the supplier. If you have a secondary insurance plan, it may pick up this portion of your responsibility. Medicare will only pay for items that are medically necessary to meet your basic needs. The supplier may offer additional products or features and you may decide that you prefer one of these items. The supplier can give you the option to pay an out of pocket expense to get the product that you really want. In order for you to do this, the Centers for Medicare and Medicaid Services (CMS) have approved a new form that allows you to upgrade to a piece of equipment that you like better than the other standard option you may qualify for. This form is known as the Advance Beneficiary Notice or ABN. The ABN your supplier completes for you 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.  

In order for any item to be covered under Medicare, it typically has to meet the test of durability. Medicare will pay for medical equipment when the item:

• Withstands repeated use.
• Is used for a medical purpose and there is a condition that can be improved
• Is useless in the absence of illness or injury
• Used in the home

When a supplier accepts 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 will be responsible for the annual deductible of $147.00, this could vary from year to year. If you have chosen to receive an upgraded product, other than what Medicare typically covers, you will be responsible for any additional amounts disclosed on the Advance Beneficiary Notice that identifies the additional features and fees that you have approved.  

Every supplier is required to submit a claim for covered items and/or services within one year from the date of service. If the item and/or service is not covered by Medicare the supplier is not required to submit a claim.  

Medicare considers 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 this items outright. 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. After an item has been purchased for you, you will be responsible for calling your supplier anytime that item needs to be serviced or repaired. 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 service.