Ok. Now that you are 65, you are probably carrying that red, white and blue card in your pocket. It’s official. You now have Medicare.
So, fast forward 10 years. Your legs are getting weaker and you’re having a harder time getting around. Your doctor sends you for some physical therapy. And, the therapist says it’s time to think about a mobility aid like a cane or walker.
Now is a good time to be thankful you have that little card because Medicare Part B includes a pretty good benefit for durable medical equipment like this. But there will be some paperwork to get through.
What is Durable Medical Equipment?
Before we get into the specifics of your Medicare Part B, here is a quick definition of Durable Medical Equipment (DME). To meet the Medicare definition of durable medical equipment, the following criteria must be met:
- Must withstand repeated uses
- Must be used for a medical reason
- Isn’t usually helpful to someone who isn’t sick or injured
- Is suitable for use in the home
- Will generally last 3 years or more
Common examples of this type of equipment are oxygen machines, hospital beds, and mobility aids like canes, walkers, and rollators.
How Much Will Medicare Pay for DME?
Medicare has established limits to what it will pay based on the item being requested. These are called “allowables”. Medicare will pay for 80% of this allowed amount and the beneficiary (i.e., you) pays the other 20% unless they have a secondary (additional) insurance policy. For example, if the allowable on a cane is $10.00, Medicare will pay $8.00 and the beneficiary pays $2.00.
Also, Medicare may either rent or purchase the item for you. As a general rule of thumb, inexpensive routine items like canes and walkers are purchased by Medicare. This means they belong to you, the beneficiary, at the time Medicare pays for the item.
However, Medicare will typically rent more expensive items like wheelchairs and hospital beds from a home medical equipment company. This rental period is typically 13 months from the date of the initial delivery of the item to you. After 13 months, the item becomes yours – kind of like a rent to own program. But, if you no longer need the item during the 13 month period – or you pass away – the equipment will go back the medical equipment company.
The company providing your equipment should explain all of this to you. If they don’t, ask them. It is very important that you understand if the equipment belongs to you or is being rented.
What Paperwork is Required Before Medicare Will Pay for Medical Equipment?
It depends really. Some items will only require a prescription from your doctor. Others will require a physical exam by your doctor. Some will even require evaluations by therapists. As a general rule, the more expensive the item, the more hoops there will be to jump through.
A Prescription from Your Doctor
Inexpensive items like canes, walkers, and rollators are pretty routine for someone with mobility problems and only a prescription from a doctor is needed. To get the cane or walker, take a copy of your prescription along with your Medicare card to a home medical equipment company that participates in Medicare. You can use this online supplier directory to help you find one near you.
A Face to Face Visit with Your Doctor
More expensive items are going to require you go see your doctor in person. Medicare calls this the “Face to Face Encounter.” Examples of items that require a face to face visit are hospital beds, wheelchairs, and oxygen equipment.
The purpose of this visit is to prove that your physician has evaluated you and your need for the equipment. Your doctor will keep a record of the visit where he or she will discuss why you need the equipment, what other treatments have been tried, and why less costly equipment will not solve the problem. These statements will be backed up by objective measurements like your oxygen saturation levels or the strength level of your legs.
The DME supplier will need a copy of these notes for their file too. The doctor’s office usually sends these automatically. If not, the DME supplier will usually call and get a copy. In most cases, though, you cannot get the equipment until the proper paperwork is complete.
Some items are going to require even more documentation of your condition. Power wheelchairs and mobility scooters, for example, will usually require an evaluation with a physical or occupational therapist. Oxygen equipment may require further documentation from a pulmonologist or a respiratory therapist. An overnight sleep study is generally needed for CPAP and BIPAP machines.
Medicare Competitive Bidding
A quick word should be said here about the Medicare Competitive Bidding program. Several years ago Medicare bid out the contracts to supply common DME items to patients in certain geographical areas. In those areas, only those companies can bill Medicare for the most commonly prescribed pieces of medical equipment.
So, what does this mean for you? It means the local medical equipment store down the street may not be able to give you a walker and bill Medicare for you. Your choice will be limited to only those suppliers who are contracted with Medicare. You can find out if you are part of this program by clicking here to visit the Medicare Competitive Bidding information page.
Is There Someone Who Can Help?
I know this seems very confusing. But there is help out there. Here are places to call or visit for more information:
- Medicare. Call the Medicare Customer Line at 1-800-MEDICARE. This is an interactive voice number and will ask you to state the reason for your call. Say “Coverage and Benefits” at the prompt. You can also say “Representative” at any time and get transferred to a customer service agent.
- Your Doctor’s Office. Many doctor’s offices are up to date on Medicare requirements and will help you get the documentation you need. Give them a call or stop by and ask for their help.
- The Local Medical Equipment Store. Also, your local home medical equipment company is a good place to check also. These companies must stay up to date on all the latest Medicare requirements because this is such a large part of their business.
There are lots of people willing to help. Just reach out, make a phone call, and ask.
If you think you need medical equipment and want Medicare to pay for it, the best place to start is with your doctor. Chances are they will need to be part of the process at some point anyway. They can also refer you to other providers to assist with any other testing or evaluations you may need.
Scott Grant, ATP, CRTS® is a certified Assistive Technology Professional, custom wheelchair specialist at a home medical equipment company, and father of 4 beautiful girls. He is also the founder and editor of Graying With Grace where he helps seniors and caregivers find the best products to make their lives easier.