Navigating Medicare – Understanding Medical Supplies vs. Durable Medical Equipment A Guest Post by Rodger Sims
Medicare is a health insurance program that covers people who are over 65 and can cover younger people with disabilities and people suffering from kidney failure, known as end-stage renal disease (ESRD). With over 71.3 million people enrolled, Medicare is one of the largest insurance providers for seniors in the United States. If your loved ones are enrolled in Medicare, it is important to know how to navigate your options.
There are four different parts to Medicare:
Medicare Part A
Part A covers your hospital insurance. This coverage includes inpatient hospital stays, care in a nursing facility, hospital care and even some home health care. If you’ve worked over ten years and have paid into social security taxes, this coverage is free to you. In 2015, Medicare Part A had served 7.7 million patients.
Medicare Part B
Part B covers medical insurance and includes certain doctor’s services, outpatient care, medical supplies and preventative services. In 2015, Medicare Part B had served over 33.8 million seniors.
Medicare Part C
Part C is a health care plan offered by a private company that can help you with both Part A and B benefits. Known as a Medicare Advantage (MA) Plan, services offered include health maintenance organizations (HMO), preferred provider organizations (PPO), private fee-for-service plans, special needs plans and Medicare Health Savings Account (HSA) plans. Most of the Medicare Advantage Plans offer coverage for prescription drugs.
Medicare Part D
Part D of Medicare adds prescription coverage to the original Medicare, as well as to some Medicare cost plans, Medicare HSA and some private fee-for-service plans. In 2015, 38.9 million Americans utilized Part D of Medicare. Original Medicare is the tradition fee-for-service Medicare. The government pays directly for the health care services the patient receives.
Durable Medical Equipment vs. Medical Supplies
With all that in mind, it is also important to know that there are two main types of products: medical supplies and durable medical equipment (DME). Both DME and medical supplies are used to make meeting the basic needs of the elderly, ill or disabled patients at home.
Durable Medical Equipment
As suggested by the name, durable medical equipment is meant for long-term use. Medicare defines DME by the following criteria: durability, ability to be used in the home, not usually useful to someone who isn’t sick and must have a life span of three years of use. Examples of DME include hospital beds, mobility aids, prostheses (artificial limbs), orthotics (therapeutic footwear) and other supplies. Medicare pays for DME partially under Part A if the patient qualifies for home health benefit.
To qualify for home health benefit, the patient must be unable to leave his/her home, require care from a skilled nurse and does not require custodial care, such as bathing and toilet-usage. If the patient is eligible for home health benefit, Medicare will cover 80% of the allowable amount for DME.
An example of the allowable amount is the following: a patient needs a walker that costs $200. The allowable amount for the walker in that state is $100. Since Medicare will cover 80% of the allowable amount, the patient will then have to pay $120 for the walker. Under Medicare’s Part B coverage, the co-pay is the same at 20% of the allowable amount and any other additional expense after that.
For Medicare Part B, the patient does not need to qualify for home health benefit to be eligible for coverage. If a doctor or medical professional considers the product medically necessary, Medicare will partially reimburse the patient for it. One benefit of this is the ability to rent the product being needed and still be eligible for reimbursement.
Some DME products that are not covered by Medicare include hearing aids and home adaptation items like bathroom safety and ramps. Additionally, to be reimbursed, your product supplier must be enrolled in Medicare and adhere to their guidelines. If they are not, Medicare can refuse their claims.
Make sure your providers are eligible before purchasing any products.
Medical supplies are made for short-term use. They are typically used once then thrown away. Examples of medical supplies include diabetic sugar testing strips, incontinence products (diapers, catheters, etc.) and items like bandages and protective gloves. Generally, medical supplies are not covered by Medicare, though there are a few exceptions for patients with diabetes, ostomy patients and those currently using feeding tubes. These items, however, are limited.
Ostomy products can be limited to a certain number a month. If necessary, a patient can appeal to increase the number of products received a month but must go through a process to do so. This process includes re-approval through Medicare and by a doctor.
If you can provide insurance for your loved ones and cost isn’t a large factor, it is useful to know that Medicare can be paired up with other private insurance companies. Doing so can help get over some of the limitations that are imposed by Medicare and ensure your senior has an overall health coverage. If this is not an option, then medical supplemental health insurance, known as Medigap, can help provide funds for expenses Medicare doesn’t cover.
To qualify for the Medigap program, you must be enrolled in both Medicare Part A and Medicare Part B. Medigap can cover excess costs, like co-insurance costs such as stays in the hospital or nursing home, and deductibles in Part A and Part B plans. Costs will vary according to coverage.
Medigap is available through private insurances or organizations that cater to the elderly.
Medicare covers durable medical equipment primarily under Part B, but also for DME for people under Part A with the home health benefit plan. Most medical supplies are not commonly covered by Medicare, and those that are covered tend to have limitations. Other options to ensure your senior has all their needs covered including pairing Medicare with a private insurance company or enrolling them in medical supplemental health insurance to help cover excess costs.
With the introduction and popularity of the internet, finding the supplies you need at the right cost is easier than ever before. Different websites offer low-cost medical supplies to help ensure the basic needs of your seniors are met. It is also easier to find the right insurance company for them with all the information available online.
For more information about Medicare and what it covers, got the Medicare website at Medicare.gov.