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.
- Medicare Part C is coverage offered through private insurance companies as an alternative to Medicare Part B.
- Medicare Part D offers optional program benefits that cover prescription drugs.
- For more details, visit Medicare.gov for coverage options and enrollment periods.
What Can You Expect to Pay for Medicare Part B Services?
For Part B services, you are typically responsible for:
- 20% of Medicare-approved charges if the supplier agrees to accept Medicare payments.
- If the supplier does not accept Medicare assignment, you may need to pay the full price upfront, but they will file a claim on your behalf.
- If you have supplemental insurance, it may cover the coinsurance and deductible after the plan’s deductible is met.
Durable Medical Equipment (DME) Defined
Medicare typically covers DME items that meet the following criteria:
- Durability: Items that can withstand repeated use.
- Medical Purpose: Items that are used to improve health.
- Home Use: Items that are intended for home use.
Understanding Assignment (A Claim-by-Claim Contract)
When a supplier accepts Medicare assignment, they agree to accept Medicare’s approved amount as payment in full. You’ll be responsible for:
- 20% Coinsurance of the approved amount.
- The annual deductible (for 2019, this was $185).
Medicare's Coverage for DME
Medicare may cover DME through:
- Purchase: Pay for it outright, and the equipment is yours.
- Rental: Rent until the item is no longer needed.
- Capped Rental: Medicare rents the item for 13 months, after which you own the equipment.
- Oxygen Therapy: Medicare pays for oxygen equipment rental for 36 months, then a small fee for the gas or liquid contents.
Mandatory Submission of Claims
Medicare requires suppliers to submit claims within one year from the date of service. If the item is not covered, your supplier is not obligated to submit a claim.
The Role of Physicians in DME
For any DME item billed to Medicare, a physician's order or a Certificate of Medical Necessity (CMN) is required.
Prescriptions Before Delivery
For certain items, including wheelchairs, oxygen, and TENS units, Medicare requires:
- A recent office visit with your doctor or healthcare provider.
- A written order or prescription for the equipment.
How Does Medicare Pay for and Allow You to Use the Equipment?
Medicare may cover DME in four ways:
- Purchase: Medicare pays for the item outright.
- Rental: Medicare covers the rental until the item is no longer needed.
- Capped Rental: Medicare rents the item for 13 months, and it becomes yours after that.
- Oxygen Therapy: Medicare pays for oxygen equipment rental for 36 months, after which a small fee is paid for gas or liquid contents.
Competitive Bidding Program
The Competitive Bidding Program requires you to obtain specific medical equipment from Medicare-contracted suppliers in certain areas. This program limits suppliers and will be effective starting in 2021.