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MEDICARE

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Medicare is a health insurance program for:

• people age 65 or older,
  
• people under age 65 with certain disabilities, and
  
• people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).

Medicare covers durable medical equipment (DME) that your doctor prescribes for use in your home. Only your own doctor can prescribe medical equipment for you.

Canes, crutches, walkers, wheelchairs, and scooters (POVs) are called medically assistive devices. The primary consideration for approval of a medically assistive device is to determine what equipment will help restore the beneficiary’s ability to participate in mobility-related activities of daily living like using the bathroom, feeding, dressing and grooming oneself and bathing in customary locations in the home.

Durable Medical Equipment is:

• Durable (is long lasting)
• Used for a medical reason
  
• Not usually useful to someone who isn’t sick or injured
  
• Used in your home

The amount you pay varies. Call your Durable Medical Equipment Regional Carrier (DMERC) for more information. To get their telephone number, call 1-800-MEDICARE (1-800-633-4227). Medicare pays for different kinds of DME in different ways; some equipment must be rented, other equipment must be purchased, and for some equipment you may choose rental or purchase.

While some equipment may be important to you, it may not be "medically necessary" by Medicare or your insurance's guidelines. Click here to see what portion Medicare will cover in your state of residence.

MEDICARE INFORMATION FOR YOUR DOCTOR OR SPECIALIST
A new Center for Medicare & Medicaid Services (CMS) rule, effective for services on or after Oct. 25, streamlines access for people with Medicare to power-operated vehicles (“scooters”) and power wheelchairs, and gives physicians greater certainty regarding Medicare payment.

The rule also applies to physician assistants, nurse practitioners, or clinical nurse specialists. Highlights include:

Face-to-face exams. You must conduct a face-to-face examination of the patient before prescribing a power wheelchair or power scooter. When discussing power mobility device (PMD) options with a patient, be aware of the Medicare coverage policies that will apply to the claim for the equipment; they take into account the patient’s medical history, elements of a physical assessment such as strength and range of motion, a functional needs assessment as documented in the medical record, and the availability of other types of devices.

Written prescriptions. You must submit a written prescription for the PMD to the supplier, who must receive it within 30 days of the face-to-face evaluation, or in the case of a recently hospitalized patient, within 30 days of discharge from the hospital.

The written prescription must include the beneficiary’s name, the date of the face-to-face exam, the diagnoses and conditions that support the claim for the PMD, a description of the specific type of PMD required, and the expected length of time the patient will need the equipment.
The rule no longer allows only specialists in physical medicine, orthopedic surgery, neurology or rheumatology to prescribe a power scooter. Now, other physicians or practitioners can prescribe one.
Supporting documentation. Along with a prescription, the physician who performed the face-to-face exam must submit to the PMD supplier copies of relevant, existing documentation from the beneficiary’s medical record before the supplier can deliver a power wheelchair or scooter to the patient.

The documentation must clearly support the medical necessity for the PMD in the patient’s home and may include the history, physical examination, diagnostic tests, summary of findings, diagnoses, and treatment plans. It also may include information from other examinations, as well as relevant reports from other consultants and practitioners.
This combination of a written prescription and supporting clinical information replaces the Certificate of Medical Necessity (CMN) that prescribing physicians previously had to submit to the equipment supplier.
Billing and payment. Medicare will make an additional payment to physicians for preparing and providing the required documentation to the equipment supplier. To receive this payment, you will include an add-on G code for the face-to-face exam on your claim for the office or hospital visit. The payment amount for this new G code for 2005 is $21.60, adjusted by the geographic area where the service is provided.

For more information, including a copy of the rules, Q&A, and an algorithm for determining what type of equipment is reasonable and necessary, go to Medicare’s Mobility Assistive Equipment page.

Note: CMS is accepting comments on the interim rule until Nov. 25, and a final rule will be published at a later date.)

Power mobility devices (PMDs) include power operated vehicles (also referred to as scooters or POVs) and power wheelchairs (PWCs).

INSURANCE
If we are able, we will be glad to work with your insurance company, workman's compensation, Office of Vocational Rehabilatation (OVR) or other society, group or private organization.

We cannot submit to ANY H.M.O. insurances.

If you have a private insurance carrier as your primary insurance, contact them to see if your policy includes coverage for the item you are interested in obtaining.