Medicare FAQ
Who is eligible for Medicare?
Medicare is a federal health insurance program for people 65 years old and older. Some people are eligible before the age of 65 due to long term disabilities and/or if they have end stage kidney disease.
Will Medicare pay for my medical equipment?
Medicare has several parts. Medicare Part B covers selected home medical equipment. However, Medicare Part B does have some restrictions:
- Deductibles ($124.00 for 2006)
- Co-payments (for Part B this is 20 percent of the Medicare allowable)
Co-payments frequently are covered by a patient’s supplemental insurance.
What is a Medicare allowable?
Medicare has set reimbursement amounts for products. Medicare will reimburse 80 percent of that amount. The remaining 20 percent is the responsibility of the patient. Medicare sets the purchase price and the terms of the sale.
Does Medicare purchase or rent home medical equipment?
Medicare does pay for the purchase of some products, such as walkers, commodes and glucometers. On some products like hospital beds, manual wheelchairs and patient lifts, Medicare rents the product for up to 15 months. However, the product converts to a sale or in some cases becomes a capped rental, depending on the decision the patient makes after the tenth month of rental. If the patient made the rental decision, the product remains the property of the provider and the provider will receive a service and maintenance fee to maintain the equipment. If the patient chooses the purchase option, the equipment becomes theirs and they are responsible for non-warranty repair work.
(Congress passed a bill removing the maintenance and service feature. In the near future, all equipment will be the property of the beneficiary once Medicare has made 13 rental month payments.)
How about respiratory products?
At this time, oxygen is a continuous rental due to the high maintenance of the system. However, Congress recently passed new legislations that caps the rental at 36 months, allowing the patient to own the equipment. Nebulizers, CPAP machines and respiratory assist devices (BIPAP) will be capped at a 13 month rental, then converted to a sale.
Unless the patient lives in the metro Detroit area, Henry Ford Health Products reserves the right to not provide RENTED items to patients. Because of the nature of the rental, Henry Ford Health Products restricts its rental business to the metro Detroit area.
If I have a prescription from my doctor, will Medicare cover my medical equipment?
A prescription is required, of course. However, sometimes even with the prescription, Medicare might not cover the cost of the product. Depending upon the equipment or supplies, Medicare has specific requirements or criterion that must be met. For example:
A commode:
A commode is covered when the patient is physically incapable of utilizing regular toilet facilities. This would occur in the following situations:
- The patient is confined to a single room, or
- The patient is confined to one level of the home environment, and there is no toilet on that level, or
- The patient is confined to the home and there are no toilet facilities in the home.
A walker:
The patient has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL) in the home.
A mobility limitation is one that:
- Prevents the patient from accomplishing the MRADL entirely, or
- Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform the MRADL, or
- Prevents the patient from completing the MRADL within a reasonable time frame; and
- The patient is able to safely use the walker; and
- The functional mobility deficit can be sufficiently resolved with the use of a walker.
Will Henry Ford Health Products submit a claim for me to Medicare?
Yes, Henry Ford Health Products is a Medicare provider. We will submit Medicare claims for our internet customers. We will bill either an assigned claim or an unassigned claim for our customers.
Assigned claims: we bill Medicare the Medicare allowable. Medicare will reimburse Henry Ford Health Products 80 percent of that allowable, and the patient is responsible for the remaining 20 percent of the allowable.
Non-assigned claims: The customer pays Henry Ford Health Products up front for purchases made on henryford.com. For Medicare approved purchases, Henry Ford Health Products will file a claim on the patient’s behalf. If the purchase is approved by Medicare, Medicare will make payment directly to the patient.
How long does it take for Medicare to pay on a claim?
Once the claim is submitted to Medicare, payment may be made within 14 days. Delays in payment might be due to Medicare’s need to review the claim for medical necessity.
Is my Medicare Part B always the primary payer for my medical claims?
No, Medicare is not always the primary payer. If you are covered by another health plan, if you are still working or if the illness or injury is due to an automobile accident or work injury, Medicare could be secondary.
What would be some reasons Medicare might deny my claim?
Some of the reasons might be:
- If you have had the same or similar product before and Medicare has made payment.
- If you are in the hospital or a skilled nursing facility during the time of purchase.
- If you do not meet Medicare’s medical criteria for the product.
- If you do not have Part B coverage
- If the item is covered by another payer