Part B provides coverage for Durable Medical Equipment (DME). DME includes items such as: wheelchairs, walkers, oxygen therapy, prosthetics and orthotics and compression devices. Coverage for these items is strictly limited to those cases that meet the coverage criteria defined in the Local Medical Review Policy (LMRP) for the applicable Durable Medical Equipment Regional Carrier (DMERC).

Medicare pays for Durable Medical Equipment in different ways, depending on the item or service and whether you buy or rent the equipment. Medicare pays the same amount whether the supplier “takes assignment” or not. If the supplier takes assignment and if you have already met your deductible for the year, Medicare pays 80 percent of the Medicare approved charge and you’re responsible for the remaining 20 percent. You may pay more if the supplier does not take assignment.Assignment means that the supplier agrees to accept the Medicare-approved amount as payment in full. If you buy equipment from a supplier who does not take assignment, Medicare will still pay only 80 percent of the Medicare-approved amount. You are responsible for the difference between what Medicare pays and what the supplier charges.Whether the supplier takes assignment or not, the supplier is still required by law to bill Medicare. To keep your cost to a minimum, ask the supplier if it accepts Medicare assignment.

Medicare Does Not Cover All Medical Products

Medicare pays for lymphedema compression treatment items. The items and services included in this benefit category are defined in section 1861(s)(2)(JJ) of the Social Security Act (the Act), and further defined in Medicare regulations at 42 Code of Federal Regulations (CFR) 410.36(a)(4).

The benefit includes medically necessary treatment items for each affected body part, including:

• Standard and custom fitted, gradient compression garments, including those for daytime and nighttime, which offer different levels of compression
• Compression bandaging systems and supplies provided during the initial decongestion phase and maintenance phases of treatment
• Gradient compression wraps with adjustable straps
• Necessary accessories for gradient compression garments and wraps, including:
  • Aids for putting on and taking off (donning and doffing) items for different body parts, like lower limb butlers or foot slippers that help patients put on compression stockings
  • Fillers
  • Lining
  • Padding
  • Zippers

Medicare pays for both standard and custom fitted gradient compression garments. Custom fitted compression garments are garments that are uniquely sized and shaped to fit the exact dimensions of the affected extremity or part of the body of an individual, to provide accurate gradient compression to treat lymphedema. This is defined in section 145 of chapter 15 of the Medicare Benefit Policy Manual (CMS Pub. 100-2).

Certain laws, regulations, and Medicare program manuals are often mentioned on this page, and you can locate them by going to the “Related Links” section.

You Must Pay Medicare Copayments

After you have met your deductible, you’re still responsible for paying directly, or through supplemental insurance, at least 20 percent of the Medicare approved amount. This copayment may not be dropped by the supplier except in very special hardship situations and only on a case-by-case basis.Offers by suppliers to drop copayments or deductibles or to give discounts, coupons, rebates, or other “special offers” — eliminating the need for copayments on Medicare-approved items — are illegal. Report such offers to your Medicare carrier.Special “offers” may seem like a good idea at the time because they appear to be saving you money. But such practices lead to increases in your Medicare Part B premiums and deductibles and unwarranted increased costs to the Medicare program. Reputable suppliers do not resort to these kinds of incentives. They will provide a reliable product at a reasonable cost to you and the Medicare program.

In the past 20 years, so many insurance plans have evolved that it is difficult to draw a dividing line between them anymore. Rather, it is helpful to see them as two ends of a continuum of options: On one end of this continuum is traditional indemnity insurance (fee-for-service), or unmanaged care. On the opposite end are the most managed types of organizations, called Health Maintenance Organizations (HMOs).

Traditional indemnity insurance was common before the advent of Managed care and the drive to control healthcare costs. Indemnity plans are as simple as they sound. They reimburse medical providers for each service you receive on a case-by-case basis. With an indemnity plan, you can use any medical provider (such as a doctor and hospital). You or they send the bill to the insurance company, which pays part of it. Usually, you have a deductible, the amount of the covered expenses you must pay each year before the insurer starts to reimburse you.

Once you meet the deductible, most indemnity plans pay a percentage of what they consider the cost of covered services. The insurer generally pays 80 percent of the usual and customary costs and you pay the other 20 percent, which is known as coinsurance. If the provider charges more than the usual and customary rates, you will have to pay both the coinsurance and the excess charges.

As you move along the continuum from indemnity insurance plans to Health Maintenance Organizations (HMOs), you find that organizations have progressively greater control over the delivery of care. A parallel continuum goes in the same direction – more control usually limits the choices that providers and members are able to make. Providers are subject to utilization management policies and members are more limited in their choice of providers.

When managed care organizations began, their approach was to managing both the financing and delivery of healthcare. This was very different than that of traditional indemnity insurers, which only handled the financing of healthcare. In these organizations, physicians of the managed care organization work closely with other physicians to control healthcare delivery decisions. In an HMO, utilization management becomes a global, organizational concern, which starts the minute the member enrolls in the plan.

In between these extremes are many other types of insurance plans and managed care organizations. The following is a brief description of the typical managed care plans found today.