Medicare FAQ

Quick answers to frequently asked Medicare questions

We assist you in filing your Medicare Claim. We assemble and mail you a package with everything you’ll need to submit it yourself. All you have to do is mail it!
Assigned vs. non-assigned claims: Assigned means no out of pocket, non-assigned means you pay up-front (reimbursement for purchase). More on Medicare Assignment and Non-Assignment.
Capped-Rental: Paid as a monthly rental and not as a reimbursable purchase. More on Medicare Capped Rentals.
Compression Hose: At this time Compression Hose are not covered by Medicare.
Diabetic Shoes and inserts: In order for Medicare to cover Diabetic Shoes they must be fit to your feet by a local foot specialist. We do not bill for shoes sold over the Internet. More on Diabetic Shoes Medicare Coverage.
Hospital Beds, Adjustable Beds: Hospital Beds are Capped-Rentals, Adjustable beds are not covered. More on Medicare and Hospital Beds.
Lift Chairs: The lift-mechanism is covered, about $280 reimbursement. Files as non-assigned claim, meaning you pay up front. More on Medicare Coverage of Lift Chairs.
Patient Lifts: Patient Lifts are a capped-rental item. More on Medicare Coverage of Patient Lifts and Hoyer Lifts.
Manual Wheelchairs: Capped-rental. All manual wheelchairs are covered by Medicare as rental only. More on Medicare Coverage of Wheelchairs.
Oxygen Concentrators, Nebulizers, CPAP: Capped Rental items. For products such as Oxygen Concentrators, CPAP, Nebulizer and related supplies are covered as a capped-rental. Visit a local supplier that rents these products and bills Medicare. More on Medicare Coverage of Respiratory Products.
Power Wheelchairs: Filed as non-assigned claim for power wheelchairs purchased over the Internet. More on Medicare Coverage of Power Wheelchairs.
Power Scooters (POVs): File non-assigned claims for power scooters purchased over the Internet. More on Medicare Coverage of Power Scooters.
Walkers and Rollators: File non-assigned claims for walkers and rollators purchased over the Internet. More on Medicare Coverage of Ambulatory Aids.

How to Obtain Medicare Coverage

Q How do I obtain Medicare coverage for medical equipment I need in the home?
In most cases a Doctor’s written prescription (Rx) is all that is required, or Dispensing Order written by the treating physician must be sent to us before an item can be shipped. Some items require a Detailed Written Order (DWO) prior to delivery or a Certificate of Medical Necessity (CMN). You can view or Download Medicare Forms here.

Dispensing Order (prescription) must include:

A description of the item
The beneficiary’s full name
The date of order; and
Physician’s signature and date

Written Order must include:

Detailed description of the item and accessories
The beneficiary’s full name
An ICD-9-CM diagnosis code
Start date of the order
The length of need
Physician’s signature and date

Q What you need to begin processing your Medicare claim?
Once you have placed your order you can fax or email us the following information:

Full legal name of patient, address, phone number.
Full name, FAX number and UPIN of prescribing doctor. (Ask doctor for their UPIN number)
Doctor’s prescription for desired equipment, which must include patient’s diagnosis.
Patient’s Medicare number, which must include the alpha character after the number (A, B, D, etc).
Patient’s date of birth.
Patient’s height & weight

Medicare Assignment and Non-Assignment Billing

Q What does “assigned” and “non-assigned” mean?
“Assigned” means the supplier accepts the Medicare-approved fee for the equipment. Medicare pays for 80% of the approved fee. The beneficiary is responsible for the remaining 20%. “Non-assigned” means the beneficiary pays the supplier in full for the equipment and the supplier submits the claim to Medicare. If the item is covered, Medicare reimburses the beneficiary 80% of the approved fee. If this is not paid, it is the responsibility of the beneficiary. You may be asked to sign an ( ABN) Advanced beneficiary Notice to confirm you understand this ruling.

Q What is Covered by Medicare?
Medicare Part B helps pay for durable medical equipment, including;

manual wheelchairs (capped rental)
power wheelchairs
some positioning devices
walkers , rollators
scooters
seat-lift mechanisms for lift-chairs
mattress over-lays (capped rental)
hospital beds, semi-electric type only (capped rental)
patient lifts (capped rental)
oxygen equipment (capped rental)
artificial limbs
orthotics, splints

If you need one of the product types listed as capped rental please visit a local dealer that rents equipment and bills Medicare. Many people are surprised that Manual Wheelchairs and Hospital Beds fall under “capped rental” items. For these “capped rental” items, the dealer (provider) is required to maintain the equipment over the lease period (13 months).

Durable medical equipment, such as wheelchairs, are covered only when prescribed by a doctor and the coverage criteria is met. You can find out what equipment is covered, and whether a supplier is approved, by visiting medicare.gov and look for DME Medical equipment information for all equipment details.

Products Not Covered by Medicare

Q What is NOT covered by Medicare?
Equipment not covered by Medicare includes; adaptive daily living aids such as: full electric beds, bath safey equipment, ramps, automobile lifts, reachers, sock-aids, utensils, transfer benches, shower chairs, raised toilet seats, adjustable based beds , pulse oximeter and grab bars. Basically, Medicare stops at the bathroom door. For more detailed information regarding coverage, call 1-800-MEDICARE.

Q What is covered in a nursing home or skilled nursing facility?
Under Part A, orthotics and durable medical equipment are not covered. Under Part B, only orthotics can be covered. If you are about to be discharged from a nursing home or skilled nursing facility, medical equipment can be delivered two days prior to discharge to allow the staff and family to learn how to use the equipment.

Home Coverage

Q How do they consider it, Home?
Home medical equipment must be appropriate for use in the home. Your “home” is your house, assisted living facility, apartment, a relative’s home, or a group home in which you live. However, certain facility’s are NOT CONSIDERED YOUR HOME: a hospital, skilled nursing facility, or nursing facility.

What is a Capped Rental

Q What does capped rental mean?
For the majority of products covered by Medicare, 80% of the rental is covered for 13 continuous months of use. Most secondary insurers pick up the remaining 20%.
Products covered as capped rental of 13 months:

Hospital Beds.
Manual Wheelchairs.
Patient Lifts.
Some Support Surfaces such as Low-Air-Loss and Alternating Pressure mattress.

After Medicare has paid for 13 months of continuous use, the supplier may transfer the title to the beneficiary.
Respiratory Products: Some Respiratory products have longer rental periods. Oxygen Concentrator (Medicare) rentals may be covered for up to 36 months.

Manual Wheelchair Medicare Coverage

Q Are manual wheelchairs covered by Medicare?
In almost all cases, manual wheelchairs are covered by Medicare as a “Capped Rental.” This means that Medicare pays approx. 80% of the monthly rental and you are responsible for the remaining 20% or this may be covered by secondary insurance. You are also responsible for denials and non-reimbursed money that is billed for your rental period of 13 months. This includes stays in any skilled facility during your rental period. You must use a local dealer that rents chairs and bills Medicare for the monthly rental fees. Some Ultra-lightweight wheelchairs have a K0005 Billing code and can be billed as a purchase.

Rollator & Walker Coverage

Q Are walkers and rollators covered?
Medicare will allow a walker or rollator every 5 years. They cover 80% of the allowed amount set by Medicare. If you have a supplement insurance that covers the 20%, reimbursement is usually about $125.00.

Q What should the doctor’s prescriptions say?
Walker with 4 wheels, seat, and handbrakes.

Adjustable Bed Coverage

Q Does Medicare pay or reimburse for Adjustable Beds?
Medicare coverage for a bed is limited to a hospital bed and all hospital beds are covered as a capped rental only. Medicare does not cover Adjustable Beds.

Hospital Bed Coverage

Q Does Medicare pay or reimburse for Hospital Beds?
Medicare covers hospital beds as a Capped Rental item. This means that you must use a vendor in your local area that rents equipment and bills Medicare for the monthly fees. Your local dealer will install and maintain this “capped rental” equipment. Medicare does not consider a full-electric hospital bed, Adjustable Bed, or other Luxury beds to be medically necessary. Medicare coverage is for a Semi-electric twin-size hospital bed.

Overbed Tables

Q Are Overbed or Bedside Tables covered by Medicare?
Over-Bed Tables an Bedside Tables are not classified as a medical necessity and are not covered.

Respiratory Equipment Coverage

Q Are Oxygen Concentrators, CPAP and Nebulizers covered by Medicare?
Oxygen Concentrators, CPAP and other respiratory products such as Nebulizers are Capped Rentals thru Medicare. For these products you should seek a local dealer that rents equipment and bills Medicare.

All other respiratory products are for purchase only

Q If you purchase a Portable Oxygen Concentrators will Medicare reimburse me?
No. Medicare does not allow for, or provide, coverage for both a home oxygen concentrator and additional Portable Oxygen Concentrator.

Transfer Boards

Q Are Transfer Boards covered by Medicare?
Transfer boards may be considered medically necessary for patients with medical conditions that limit their ability to transfer from wheelchair to bed, chair, or toilet. We file Medicare claims for Transfer Boards on a non-assignment basis only.

Patient Lift Coverage

Q Are Patient Lifts covered by Medicare?
Patient Lifts are reimbursed as a capped rental item. This means that you must visit a local dealer/retailer that rents such equipment and bills Medicare for the monthly fees. Medicare reimburses 80% of rental for up to 13 months. We do not bill Medicare for Patient Lifts sold over the Internet. This capped-rental coverage is for a standard hydraulic-manual lift and sling. Power Lifts and Standing Lifts are not covered.

Q Are Stand-up Patient Lifts covered by Medicare?
No. Patient Lift coverage is for a Manual/Hydraulic Patient Lift only.

Power Wheelchair Coverage

Q What is Medicare’s coverage criteria for motorized or power wheelchairs?
Medicare may pay for a motorized wheelchair. Although it is not guaranteed that you will qualify or be reimbursed by Medicare, whether you personally lay out the price for one, or are looking for Medicare to purchase one for you, we can give you some guidelines to follow and the basic criteria that must be met in order for Medicare to either reimburse or authorize payment for a motorized unit. A power wheelchair is covered when all of the following criteria are met:

The patient’s condition is such that without the use of a wheelchair the patient
would otherwise be bed or chair confined.
The patient’s condition is such that a wheelchair is medically necessary and the
patient is unable to operate a wheelchair manually.
The patient is capable of safely operating the controls for the power wheelchair.

A patient who requires a power wheelchair usually is totally non-ambulatory and has severe weakness of the upper extremities due to a neurological or muscular disease/condition. If the documentation does not support the medical necessity of a power wheelchair but does support the medical necessity of a manual wheelchair, payment is based on the allowance for the least costly medically appropriate alternative. However, if the power wheelchair has been purchased, and the manual wheelchair on which payment is based is in the capped rental category, the power wheelchair will be denied as not medically necessary.

Power Scooter Coverage

Q What is Medicare’s coverage of power operated Vehicles (POVs) or scooters?
A power operated vehicle (POV) is covered when all of the following criteria are met:

The patient’s condition is such that a wheelchair is required for the patient to get around in the home.
The patient is unable to operate a manual wheelchair.
The patient is capable of safely operating the controls for the POV.
The patient can transfer safely in and out of the POV and has adequate trunk stability to be able to safely ride in the POV.

Most POVs are ordered for patients who are capable of ambulation within the home but require a power vehicle for movement outside the home. POVs will be denied as not medically necessary in these circumstances. A POV that is beneficial primarily in allowing the patient to perform leisure or recreational activities will be denied as not medically necessary. If a Mobility Scooter is covered, a wheelchair provided at the same time or subsequently will usually be denied as not medically necessary.

Lift Chair Coverage

Q Will Medicare pay for a Lift Chair?
Only the seat lift mechanism on a Lift Chair could be considered medically necessary if all of the following coverage criteria are met:

The patient must have severe arthritis of the hip or knee or have a severe neuromuscular disease.
The seat lift mechanism must be a part of the physician’s course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in the patient’s condition.
The patient must be completely incapable of standing up from a regular armchair or any chair in their home. (The fact that a patient has difficulty or is even incapable of getting up from a chair, particularly a low chair, is not sufficient justification for a seat lift mechanism. Almost all patients who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.)
Once standing, the patient must have the ability to ambulate (walk).

Medicare only covers the Motor that lifts the seat. Seat lift mechanisms is limited to those types which operate smoothly, can be controlled by the patient, and effectively assist a patient in standing up and sitting down without other assistance. The rest of the chair is the financial responsibility of the beneficiary. Only the lifting motor is 80% covered by the insurance if it meets all the Medicare criteria.

Diabetic Shoes

Q Does Medicare cover the cost of Diabetic Shoes?
Medicare does reimburse for, or authorize the coverage of Diabetic shoes, if the shoes are fitted to your feet by a Pedorthist. Most cases involve “heat molding” the shoe or insert to your feet such that the foot condition is treated properly. Even with this personal fitting, the shoes must be prescribed by a qualified physician treating a foot condition resulting from Diabetes. In addition, the person fitting and providing the shoes must be approved by Medicare and must be a Medicare provider in order to properly bill for the product. Medicare will cover 1 pair of shoes and 3 pairs of inserts per calendar year. Patients seeking Medicare coverage of shoes are usually diagnosed with peripheral neuropathy.

Ramps

Q Does Medicare cover Wheelchair Lifts and Ramps?
Medicare does not reimburse nor authorize the purchase of mobility lifts or ramps for a wheelchair or scooter at this time. Such items are typically not considered a medical necessity because they can also be used by persons without a medical condition. See all Wheelchair and Scooter Ramps

Medicare Co-payments

Q Do I have to pay the 20% co-payment to Medicare?
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 co-payment may not be dropped by the supplier except in hardship situations and only on a case-by-case basis. A supplier who routinely drops the co-payment may be violating federal law.