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
The Social Security Act that established Medicare specifically extended coverage only to those items that meet the definition of Durable Medical Equipment. Part of that definition included the requirement that it “can withstand repeated use; i.e., be rented and used by successive patients.” Elastic compression garments do not meet this requirement and are therefore deemed a “non-covered item” by Medicare. Medicare does not offer a benefit for elastic compression garments (Compression stockings or ARM sleeves), specialty compression garments (such as JoVi Paks, CircAids or Reid Sleeves), or non-elastic compression garments. (See the Useful Links side bar for Medicare Coverage Database – Indications and Limitations of Coverage (see “elastic stockings”)However, a recent exception has been made for elastic compression knee-high stockings, but they are only covered for the treatment of venous stasis ulcers secondary to venous disease. (See the Useful Links side bar for Coverage Criteria for Elastic Knee High Garments
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.