It is logical to assume that a large proportion of our country’s older residents will require home medical equipment and supplies at some point in their lives. But the need for home medical equipment and supplies is not limited to the elderly. Injuries, illness and disabilities can strike at any age.
Perhaps you or a loved one will require home medical equipment in the near future. If so, it is important to understand what you need to do in order for your insurance to help to cover the cost.
Medicare
Medicare is our country’s health insurance program for people age 65 or older. In certain cases, individuals younger than age 65 may be covered by Medicare if they have qualifying disabilities or diseases as designated by Medicare.
Medicare covers numerous types of medical equipment and supplies where there is a documented need for them. Often this documentation begins with a prescription by the attending physician followed by a Certificate of Medical Necessity.
People in the hospital, home health care, or a nursing home are covered by Medicare Part A. Otherwise, medical equipment and supplies may be covered by Medicare Part B.
Medical supplies and equipment that are covered by Medicare include:
- Some catheters
- Ostomy supplies, ostomy bags, and irrigation and flushing equipment, and supplies
- Supplies required for feeding tubs (such as catheters, filters, and nutrient solutions)
- Supplies for tracheotomy care
- Dressing required for treatment of a wound caused by a surgical procedure or after debridement (removing non-living tissue of a wound)
- Diabetic supplies, glucose monitors and Diabetic Shoes
- Respiratory supplies including home oxygen equipment & equipment for sleep apnea
- Vacuum devices for impotence treatment
- Manual wheelchairs, electric wheelchairs, and motorized scooters
- Augmentative communication devices
- Orthotics and prosthetics, when these devices are considered medically necessary or when they replace or support a body part
Other supplies and equipment may be covered if they can be shown to be medically necessary and your doctor has documented it in your medical records.
Not all medical equipment and supplies are covered by Medicare. Some are considered “personal convenience” items. Examples of items which are not covered include:
- Raised toilet seat
- Shower/commode wheelchair
- Grab bars and other safety equipment for the bathroom
- Hearing aids
- Examination gloves
- Some catheters
- Incontinence supplies such as briefs and underpads
Be sure to research the factors that affect how much Medicare coverage you will receive. Make sure all paperwork is completed correctly and that you buy your equipment through an approved supplier that accepts assignment.
Medicaid
Medicaid is a state-run insurance program and may differ from state to state. In most cases, you will need prior approval from Medicaid before ordering your medical equipment and supplies. Your doctor must explain in writing:
- Your diagnosis and prognosis
- How the equipment/supplies will aid recovery and/or daily life functions
- Expected consequences of no equipment/supplies or not using the recommended equipment/supplies.
- If substituting less expensive equipment is unacceptable, explain why.
- Length of time the items are needed
- You have been or will be instructed how to use the equipment properly and that you are able to do so.
Physician-prescribed home medical equipment covered by Medicaid may include:
- Hospital beds
- Wheelchairs
- Speech devices, computer screen readers for blind or visually impaired users, vocal amplifiers and similar communication augmentation
- Bath or shower chairs
- Dialysis equipment
- Oxygen equipment, tanks and supplies
- C-pap and bi-pap equipment and supplies
- Walkers, crutches, and canes
- Nebulizers and medication delivery devices
- Commodes, and elevated toilet sets
- Traction equipment.
Medicaid typically will not cover items like air conditioners or exercise equipment where there is no illness or injury involved, even if they are prescribed by a doctor.
Private and commercial health insurance
Private and commercial health insurance, including employer-sponsored group plans and individual plans vary widely. It is extremely important for you to diligently research eligibility, requirements and coverage criteria for your specific private health insurance. Be sure to check for specific forms and procedures for compliance with the preapproval process and the medical documentation. It’s also important to confirm that your insurance carrier is contracted with the specific Durable Medical Equipment supplier from which you plan to purchase the equipment or supplies.
