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Everything You Need to Know About Medicare Open Enrollment: Medical Equipment Benefits

Making sense of Medicare isn’t easy. But like they always said in G.I. Joe, knowing is half the battle, so to make sure you’re getting the most out of your coverage, read on and learn the ABCs in time for open enrollment, coming this Fall.

What is Medicare?

Let’s start with the basics: Medicare is a government-run health-insurance plan for people age 65 and older, people under 65 with disabilities, and people with End-Stage Renal Disease (ESRD).

There are four main parts to Medicare:

Part A: Hospital Insurance

Part A covers inpatient hospital stays, hospice care, care in a skilled nursing facility, and some home health care.

Part B: Medical Insurance

Part B covers medical supplies, certain doctors' services, outpatient care, and preventive services.

Together, Part A & Part B are often referred to as “Original Medicare.”

Part C: Medicare Advantage Plans

Part C is a plan offered by a third-party private company that, in cooperation with Medicare, covers all the benefits of Part A and Part B. Some Part C plans also offer prescription drug coverage.

Part D: Prescription Drug Coverage

Part D plans cover the cost of prescription drugs not covered by the Original Medicare. These plans are offered through private Medicare-approved insurance companies.

How do I sign up for Medicare?

For a step-by-step guide to signing up for Medicare Parts A & B, visit medicare.gov. For Parts C & D, there’s open enrollment.

What is open enrollment?

Open enrollment is the period of time when you have the chance to enroll you can then switch to, drop, add, or amend Parts C & D of your coverage. 

(shortened from the original 3 months down to 45 days)

Any changes take effect at the start of the new year. For example, this year, any changes you make during open enrollment will take effect as of January 1, 2018.

Why should I re-evaluate my Medicare coverage?

Reviewing your options is never a bad idea, especially since a lack of action now might end up costing you down the road. Why? Every year, insurance companies are allowed to make changes to their Medicare plans that can impact how much you end up paying “out-of-pocket” throughout the year. For instance, a recent study found that average premiums for drug plans are expected to rise by 6% this year, with some plans raising costs by more than 20%. Research from PlanPrescriber.com found that individuals can save, on average, more than $654 per year just by changing to a different prescription-drug plan. So how do you know if the juice is worth the squeeze?

There are a number of online tools designed to help you sort through the different Medicare plans. The Plan Finder tool at Medicare.gov is a great place to start. There are also State Health Insurance Assistance Programs for free, unbiased help.”

What kind of Durable Medical Equipment (DME) is covered under Medicare?

The coverage for durable medical equipment (DME) can be complicated and confusing, so it’s important to be aware of the rules and understand your coverage so you can learn how to get Medicare to pay for the items you need.

Medicare covers medically necessary durable medical equipment that meets the following criteria:

  • Is durable (i.e. you can use it over and over again)
  • Has been prescribed by a doctor or treating practitioner for a medical reason
  • Is used in your home (for instance, Medicare will help pay for a walker if you need it to get around inside your home, but not if you only need it when you go outside.)
  • Has an expected lifetime of at least 3 years

Types of equipment that may be covered include:

This list is not comprehensive. For questions about whether Medicare covers a particular item, visit Medicare.gov, or call 1-800-MEDICARE.

Can I purchase a piece of equipment and then bill it back to Medicare?

Billing for durable medical equipment is extremely specific and Medicare pays for different kinds of DME in different ways (rentals or ownership for starters) so please don’t go out and purchase a piece of equipment before understanding whether it’s covered by your plan.

To qualify for coverage your equipment must be prescribed by a Medicare-enrolled doctor, and you must order the equipment from a Medicare (or Medicare Advantage Plan) approved supplier who is “participating” in Medicare. Sound complicated? It is. But not impossible. For a list of terms and definitions that can help, check out the glossary in this report. And if you’re still confused, visit Medicare.gov and select “Find suppliers of medical equipment & supplies” for a list of participating suppliers or call 1-800-MEDICARE.

A few things to watch out for.

  • A supplier enrolled in Medicare must meet strict standards to qualify for a Medicare supplier number. If your supplier doesn’t have a supplier number, Medicare won’t pay your claim, so be sure that your supplier is a Medicare- participating supplier that has agreed to accept “assignment” and has a valid Medicare supplier number before making a purchase.
  • DME must be prescribed due to necessity inside your home. A hospital or nursing home that’s providing you with Medicare-covered care does not qualify as your “home,” however, a long-term care facility can.
  • If you’re in a Medicare Advantage Plan (e.g. Medicare Part C) and you need DME, call your plan to find out if the equipment is covered and how much you’ll have to pay.
  • Generally, Medicare will cover 80% of the allowable purchase price and you, or your supplemental insurance, will be responsible for the remaining 20% and any amount over the allowable limit. Contact your plan to confirm exactly how much you will be required to pay.

If you, or someone you know, could benefit from durable medical equipment, contact Wound Care Solutions today. We offer a variety of equipment and products to keep patients safe and comfortable on their road to optimum health.