Third-party payers, including Medicare and Medicaid programs, cover Home Medical Equipment and Wellness products in some cases. Coverage guidelines and processes vary by payer and by state and reimbursement is often determined on a case-by-case basis. Most often medical necessity criteria must be met. Medical necessity is determined by your doctor who then produces a Certificate of Medical Necessity (CMN). This is a document she produces and signs that describes what product is required.
Although we encourage you to contact your insurance company directly for specific coverage and policy information, here is some additional information that will help you understand the steps.
Medicare pays for different kinds of durable medical equipment in different ways. Some equipment must be rented, other equipment must be purchased. If the item is covered by Medicare as a rental item, it may be “capped”. Capped rentals are items such as hospital beds, patient lifts, manual wheelchairs, oxygen concentrators, nebulizers and CPAP machines. These items are rented on a monthly basis and maintained by the supplier as a 13 month lease. Then the title is transferred to the beneficiary.
Medicare will also purchase equipment on behalf of a beneficiary if medical necessity criteria has been met. Items in this category include walkers/rollators (once every 5 years), arm ,leg, back and neck braces, medical supplies such as ostomy bags, surgical dressings, splints and casts,scooters, seat lift mechanisms for lift chairs, cushions, artificial limbs, orthotics, splints and transfer boards. Coverage of these items is determined based on medical necessary as it relates to Medicare guidelines. Medicare normally pays 80% of an allowable amount, which varies by state and product category. You are responsible for the other 20%.
In other instances items may not be reimbursable at all. These items are often referred to as “non-covered” by Medicare. Items in this category include non-medical equipment like overbed tables or adjustable beds. Lift chairs, except for the lift mechanism, diabetic shoes unless fitted by a podiatrist, lifts and ramps, compression stockings, ADL equipment like reachers, sock aides, long handled sponge and automobile lifts, bath assistance devices like bath and transfer benches, raised toilet seats and grab bars as well as all items where the medical necessity criteria has not been met.
Managed Medicare
Medicare Advantage, formerly known as Medicare + Choice is a group of Medicare Managed Care Plans offered through commercial insurance companies that are contracted by Medicare. They offer the same benefits provided by traditional Medicare and depending on the plan, may provide additional benefits. Contact your Medicare Managed Care plan for specific coverage policies and guidelines. Reimbursement rates vary by company and patient plan.
Other important numbers:
Medicare: (800) MEDICARE, TTY users call (877) 486-2048
Frequently asked questions
Q. Will VidaCura contact my insurance carrier on my behalf?
Our customer care representatives will gladly place a call to your insurance carrier on your behalf. In order to act as your agent, we will need the following:
A prescription from your physician stating the type of equipment needed and the condition for which it is being prescribed. If a specific brand is recommended it must also be stated.
A signed HIPPA release form which will allow us to obtain information from your physician and speak directly to your carrier.
The name and telephone number of the carrier (located on the back of your card)
Insured’s Name/Subscriber ID # /Group #
Insured’s Date of Birth
Patient’s Name and Date of Birth
VidaCura is a contracted medical equipment provider for many insurance companies. We will contact your insurance carrier to determine your coverage and eligibility before processing your order. We will obtain prior authorization when necessary and let you know what your co-payment amount will be. In some cases, VidaCura will be paid directly minimizing or even eliminating your contribution.
Q.Will VidaCura bill Medicare on my behalf?
VidaCura Inc. is a retailer not a healthcare provider. We do not bill third party insurance, Medicare or Medicaid. Our Home Delivery program is a direct purchase consumer program set up for your convenience. We can take Visa, Master Card, Discover, Pay Pal, google check out and Bill Me Later. You may also mail your order along with a check or money order
Q. When will Medicare cover wheelchairs and scooters?
Medicare will help pay for a powered wheelchair or a scooter if it is medically necessary based on Medicare requirements. Medicare won’t cover a power wheelchair or scooter if you only need it for your convenience or for leisure or recreational activities.
In most cases, Medicare will cover a power wheelchair if your physician states that you need it for your medical condition and:
You can’t walk on your own.
You have severe weakness in your upper body caused by a brain, spinal, or muscle condition.
Your upper body weakness prevents you from using a manual wheelchair.
You spend most of your time in bed or in a chair when you are not in your wheelchair.
You are able to work the controls of a power wheelchair or scooter.
Medicare will cover a scooter if:
You have a condition that makes you unable to move around your house without the use of a wheelchair.
You are unable to operate a manual wheelchair.
You can safely get in and out of a scooter.
Your Durable Medical Equipment Regional Carrier can tell you if you qualify for this coverage
If you are in the Traditional Medicare Plan, you pay 20 percent of the Medicare-approved purchase amount, after you pay your $135 Part B deductible for the year. If you are in a Medicare Managed Care Plan your costs may be different. Check your member contract for more information. If you have another insurance policy besides Medicare that usually pays your Medicare deductibles and copayments, your costs may also be different.
Q.Does Medicare cover power wheelchair and scooter accessories?
Medicare will cover accessories for your power wheelchair or scooter if the accessories help you function in your home and perform activities of daily living such as bathing, dressing, and eating. Adjustable arm heights, headrest extensions, and leg rests are examples of accessories you may need. Medicare won’t cover an accessory if it will be used only to help you with leisure or recreational activities.
Q. If I meet the conditions for home healthcare that Medicare sets forth what durable medical equipment will be covered?
If you have Medicare, you can use your home health care benefits if you meet all the following conditions.
Your doctor must decide that you need medical care at home, and make a plan for your care at home.
You must need at least one of the following: intermittent skilled nursing care, or physical therapy, or speech-language therapy, or continue to need occupational therapy.
The home health agency caring for you must be approved by the Medicare program (Medicare-certified).
You must be homebound, or normally unable to leave home unassisted. To be homebound means that leaving home takes considerable and taxing effort. A person may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as a trip to the barber or to attend religious service. A need for adult day care doesn’t keep you from getting home health care.
If you meet all four of the conditions above for home health care, Medicare will cover:
certain medical supplies like wound dressings, but not prescription drugs or biologicals.
Durable medical equipment such as a wheelchair or walker.
Q. When will Medicare cover Lift Chairs?
Medicare will only cover the seat lifting mechanism in a lift chair ($200-$300) if the chair is considered medically necessary. Just because an individual may have difficulty getting out of a chair they will not automatically qualify to have a lift chair covered by Medicare. A lift chair would 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 attending or consulting physician’s course of treatment and be prescribed to arrest or retard deterioration in the patient’s condition or to improve upon it.
The patient must be completely incapable of standing up from a regular armchair or any chair in their home.
Once standing, the patient must have the ability to walk.
Q. Will VidaCura contact a non-Medicare insurance carrier on my behalf?
Our customer care representatives will gladly place a call to your insurance carrier on your behalf. VidaCura is a contracted medical equipment provider for many insurance companies. We will contact your insurance carrier to determine your coverage and eligibility before processing your order. We will obtain prior authorization when necessary and let you know what your co-payment amount will be. In some cases, VidaCura will be paid directly minimizing or even eliminating your contribution. In order to act as your agent, we will need the following:
A prescription from your physician stating the type of equipment needed and the condition for which it is being prescribed. If a specific brand is recommended it must also be stated.
A signed HIPPA release form which will allow us to obtain information from your physician and speak directly to your carrier.
The name and telephone number of the carrier (located on the back of your card)
Insured’s Name/Subscriber ID # /Group #
Insured’s Date of Birth
Patient’s Name and Date of Birth
Information Disclaimer: Information contained in this section is taken from a variety of sources including, but not limited to insurance company policies and guidelines and official government documents . Information is provided to our customers from information correct at the time of publication. VidaCura Inc. assumes no responsibility for errors, omissions or policy changes contained herein. The information provided is meant to be a guide for your information only.
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