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Home Modification Guide

Medicare & Insurance

General Coverage Information

Individuals 65 years of age or older qualify for Medicare, as do people under 65 with permanent kidney failure (beginning three months after dialysis starts), and people under 65, permanently disabled and entitled to Social Security benefits (beginning 24 months after the start of disability benefits).

Medicare Part A benefits cover hospital stays, home health care and hospice services. Medicare Part B benefits cover physician visits, laboratory tests and home medical equipment. Medicare Part D benefits cover prescription drugs. Under Medicare Part B, you can expect to pay the following: (a) a monthly premium, (b) an annual deductible, and (c) a 20 percent co-pay on most approved charges. Your medical equipment provider is prohibited by law from waiving your co-pay under Medicare. Medicare generally covers the basic level of equipment. For Medicare to cover medical equipment in the home, it must be considered a covered item and it must be prescribed by your physician.

Covered items under Medicare must:

(a) withstand repeated use (excludes many disposable items), (b) be used for a medical purpose (meaning there is a condition the item will improve), (c) be useless in the absence of illness or injury (thus excluding any item preventive in nature), and (d) be used in the home (which excludes all items that are needed only when leaving the confines of the home setting). When a medical equipment provider "accepts assignment," he or she agrees to accept Medicare’s approved amount as payment in full. In these cases, you will be responsible for 20 percent of that approved amount.

This is called your coinsurance. You also will be responsible for the annual deductible. There are some items billed to Medicare that require a physician’s order on a special form called a Certificate of Medical Necessity (CMN), and sometimes additional documentation will be required. For some items, Medicare requires your provider to have completed documentation (which is more than just a prescription from your doctor) before they can be provided to you. For most types of equipment, there are options and upgraded features available, and you can elect to purchase the equipment with the upgraded features you desire. In those cases, you have the option to pay a little extra money to get a product that you really want. This upgrading is done via the Advance Beneficiary Notice, or ABN. The ABN details how the products differ, and requires a signature to indicate that you agree to pay the difference in the retail costs between two similar items. Normally when you upgrade through use of an ABN, Medicare pays the cost of basic equipment and you pay the difference between the basic and upgraded equipment.