Q. How do I obtain Medicare coverage for medical equipment I need in the home?

A. Prescription. Your physician must write a prescription. The physician must then complete and sign a Certificate of Medical Necessity (CMN), or a form that describes the nature of your condition, this is called a Written Confirmation of Verbal Order (WCVO).

Q. Who initiates the necessary paperwork?

A. We do. We forward the Certificate of Medical Necessity (CMN) or Written Confirmation of Verbal Order (WCVO) to the physician. The physician completes these forms and returns them to us for submission.

Q. What do we need to begin processing your Medicare claim?

A. 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.

You can FAX this information to us at 818-752-9753, or mail it to us at:

Total Health Care Plus
10851 Burbank Blvd.
North Hollywood, CA. 91601

Q. What does “assigned” and “non-assigned” mean?

A. “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 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. We submit claims for Internet purchases to Medicare on a “non-assignment” basis only. We can help determine if you qualify for benefits.

Q. What is Covered by Medicare?

A. Medicare Part B helps pay for durable medical equipment, including;

• manual wheelchairs (capped rental item) see rental equipment below
• power wheelchairs (reimbursable item)
• some positioning devices
• walkers (some heavy duty rollators)
• scooters
• seat-lift mechanisms for lift-chairs
• mattress over-lays
• hospital beds (semi-electric only)
• oxygen equipment
• artificial limbs
• orthotics (splints)

Durable medical equipment such as wheelchairs are covered only when meeting the correct criteria, prescribed by a doctor and when provided by a supplier approved by Medicare. You can find out what equipment is covered, and whether a supplier is approved, by calling Medicare’s durable medical equipment (DMERC) regional carrier for your area.

Q. What is NOT covered by Medicare?

A. Equipment not covered by Medicare includes; adaptive daily living aids such as: reachers, sock-aids, utensils, transfer benches, shower chairs, raised toilet seats, and grab bars. Basically, Medicare stops at the bathroom door. For more detailed information regarding coverage, call us.

Q. What is covered in a nursing home?

A. Under Part A, orthotics and durable medical equipment are not covered. Under Part B, orthotics can be covered but not durable medical equipment. If you are about to be discharged from a hospital, a discharge planner should follow your physician’s instructions about your particular equipment needs and refer you to one or more suppliers who can meet those medical equipment needs. The discharge planner will usually contact the supplier you choose for yourself. The supplier then will contact your personal physician or the doctor who took care of you in the hospital to make sure he or she has all the medical information needed. Two days prior to discharge the medical equipment can be delivered to allow the staff and family to learn how to use the equipment.

Q. What is considered, Home?

A. Home medical equipment must be appropriate for use in the home. Your “home” is your house, (including assisted living), apartment, a relative’s home, a home for the aged, or some other type of institution in which you live. However, an institution IS NOT CONSIDERED YOUR HOME if it is: a hospital or primarily engaged in providing skilled or non skilled nursing care (this does not apply to certain supplies and equipment that are prosthetics, orthotics, and medical supplies).

Q. Can I rent medical equipment?

A. Medicare will allow you to rent durable medical equipment for 15 months. They are done as a capped rental item and include wheelchairs, semi electric beds and a few other products. Medicare pays rental for no more than 15 months though. (The supplier will still rent the equipment to you for as long as your doctor says you need it.) Suppliers who have received 10 months of rental payments from Medicare must offer you the option to buy the equipment. If you decide to purchase the item, the supplier must transfer title for the item to you following the 13th rental month. The decision to buy the equipment changes the rental payments to installment payments. Remember, if you decide to continue renting the equipment, Medicare will stop paying for the equipment following the 15th month, except for certain service and maintenance.

Q. What is Medicare’s coverage criteria for motorized or power wheelchairs?

A. Medicare does rent and will pay for a manual wheelchair, Medicare will on occasion, pay for a motorized unit as well. 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. Options that are beneficial primarily in allowing the patient to perform leisure or recreational activities are non-covered.

Q. What is Medicare’s coverage of power operated Vehicles (POVs) or scooters?

A. 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 POV is covered, a wheelchair provided at the same time or subsequently will usually be denied as not medically necessary.

Q. Does Medicare cover Lift Chairs?

A. 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).

Coverage of 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. Excluded from coverage is the type of lift which operates by spring release mechanism with a sudden, catapult-like motion and jolts the patient from a seated to a standing position. Coverage is limited to the seat lift mechanism, even if it is incorporated into a chair.

Q. Does Medicare cover Wheelchair Lifts and Ramps?

A. Medicare does not reimburse nor authorize the purchase of a lift 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. Don’t forget, Medicare covers items needed “inside” the residence.

Q. Do I have to pay the 20% co-payment to Medicare?

A. 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 very special hardship situations and only on a case-by-case basis. A supplier who routinely drops the co-payment may be violating federal law.