Medicare Coverage

Medicare Coverage

If you are looking for a powered mobility device, Medicare may be able to assist you with the cost. However, there are a few things you should know about Medicare coverage before this is possible.

Who qualifies for Medicare benefits?

  • Individuals 65 yeas of age or older qualify to receive Medicare benefits.
  • Those under the age of 65 with permanent kidney failure (beginning three months after dialysis begins.
  • Those under 65 who are permanently disabled and entitled to Social Security benefits (beginning 24 months after the start of disability benefits).

What Can You Expect to Pay?

Just because you have Medicare insurance does not mean the services requested will be covered. Every year, in addition to your monthly premium, you will have to pay a deductible before Medicare will reimburse the covered items. Once that is met, you will be responsible for 20 percent of all approved charges if the provider agrees to accept Medicare payments. If you have a supplemental or secondary insurance policy, it may cover the remaining portion not covered by Medicare after your deductible has been met.

Medicare will only pay for items or equipment considered medically necessary to meet your basic needs. Any additions or special features desired for a powered mobility device may not be considered medically necessary to assist in improving your mobility needs. If they are not considered medically necessary, there is a high probability that you will have to pay for these additional items or equipment out of pocket. For this reason, you will be required to read, understand and complete the Advance Beneficiary Notice, or ABN.

Purpose of ABN

The Advance Beneficiary Notice will also  be used to notify you ahead of time that Medicare will probably not pay for a certain item or service in a specific situation, even if Medicare might pay under different circumstances. The form should be detailed enough that you understand why Medicare will probably not pay for the item you are requesting. You will have the option of whether or not you will agree to receive and pay out-of-pocket for products and services not covered under Medicare.

How does Medicare pay for and allow you to use the equipment?

  1. Medicare pays in full for the item or equipment and it belongs to you.
  2. Rent continuously until the equipment is no longer necessary.
  3. Issue a ‘capped’ rental, in which case Medicare will rent the item for a total of 13 months. After this point the item is considered purchased and it will belong to you.
  4. Medicare sometimes will not allow you to purchase these items outright so the entire copay amount is not your responsibility in one lump sum but over an extended period of time. This will also protect Medicare from overpaying in the instance your medical needs change.

It will be your responsibility to ensure your equipment is taken care of after it is considered a purchase. If any repairs are needed be sure to call the Provider so any concerns are addressed in a timely fashion. When necessary, Medicare will pay for a portion of repairs, labor, replacement parts, and for temporary loaner equipment to use during the time your product is in for servicing. All of this is contingent on the fact that you still need the item at the time of repair and continue to meet Medicare’s coverage criteria for the item being repaired.

Medicare Coverage for Specific Types of Home Medical Equipment

Medicare requires that your physician and provider evaluate your needs and expected use of the mobility product you will qualify for. They must determine which is the least level of equipment needed to help you be mobile within your home to accomplish daily activities by asking the following questions:

  1. Will a cane or crutches allow you to perform these activities in the home?
    • If not, will a walker allow you to accomplish these activities in the home?
    • If not, is there any type of manual wheelchair that will allow you to accomplish these activities in the home?
    • If not, will a scooter allow you to accomplish these activities in the home?
    • If not, will a power chair allow you to accomplish these activities in the home?
  1. A face-to-face examination with your physician is required prior to the initial setup of a power chair or scooter.
  2. Your home must be evaluated to ensure it will accommodate the use of any mobility product.

If you have questions regarding your Medicare coverage and/or powered mobility devices, feel free to contact one of our mobility specialists.  We can be reached immediately at 888-345-1780 or you can fill out a Qualify Through Insurance form and we will be in touch shortly.  We look forward to hearing from you!

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