Skip to main content

Medicare Guide

Guide to Medicare Coverage

Who qualifies for Medicare benefits?

  • Individuals 65 years of age or older
  • Individuals under 65 with permanent kidney failure (beginning three months after dialysis begins), or
  • Individuals under 65, permanently disabled and entitled to Social Security benefits (beginning 24 months after the start of disability benefits)

The Different Benefits of Traditional Medicare

  • Medicare Part A benefits cover hospital stays, home health care and hospice services.
  • Medicare Part B benefits cover physician visits, laboratory tests, ambulance services and home medical equipment.
  • While oftentimes you do not have to pay a monthly fee to have Part A benefits (you only have to pay money when you use the services), the Part B program requires a monthly premium to stay enrolled (even if you do not use the services). In 2016 that premium will be between $121.80-389.80 per month (but could be less) depending on your income. Typically, this amount will be taken from your Social Security check.
  • Medicare Part C is coverage offered through various insurance companies that offer Medicare Advantage Plans.  These plans are offered as an alternative to Medicare Part B.  Medicare Advantage Plans cover the same benefits as your Part B plan but often have limited provider networks and may require authorization for services prior to making payment. Premiums and deductibles vary by plan. Some plans offer perks like gym memberships as a participation benefit.
  • Medicare Part D offers optional program benefits that cover prescription drugs.
  • For more information about your benefits or making coverage decisions, you can visit the official website for Medicare benefits at www.medicare.gov.

What Can You Expect to Pay?

  • In 2016, in addition to your monthly premium, you will have to pay the first $166 of covered expenses out-of-pocket for Part B services, and then 20 percent of all approved charges if the supplier agrees to accept Medicare payments.
  • Unfortunately, your medical equipment supplier cannot automatically waive this 20 percent or your deductible without suffering penalties from Medicare. They must attempt to collect the coinsurance and deductible if those charges are not covered by another insurance plan; however, certain exceptions can be made if you meet qualifying financial hardships established by your supplier.
  • If you have a supplemental insurance policy, that plan may pick up this portion of your responsibility after your supplemental plan’s deductible has been satisfied.
  • If your medical equipment supplier does not accept assignment with Medicare you may be asked to pay the full price up front, but they will file a claim on your behalf to Medicare. In turn, Medicare will process the claim and mail you a check to cover a portion of your expenses if the charges are approved.

Other possible costs:

  • Medicare will pay only for items that meet your basic needs. Oftentimes you will find that your supplier offers a wide selection of products that vary slightly in appearance or features. You may decide that you prefer the products that offer these additional features. Your supplier should give you the option to allow you to privately pay a little extra money to get the product that you really want.
  • To take advantage of this opportunity, a new form has been approved by the Centers for Medicare and Medicaid Services (CMS) that allows you to upgrade to a piece of equipment that you like better than the other standard option you may otherwise qualify for.  This form is known as the Advance Beneficiary Notice or ABN.
  • The ABN form that your supplier completes for you must detail 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. Your supplier will typically accept assignment on the standard product and apply that cost toward the purchase of the fancier item, thus requiring less money out of your pocket.

Purpose of ABN

  • The Advance Beneficiary Notice of Non Coverage will also be used to notify you ahead of time that Medicare will probably not pay for a certain item or service in a specific situation, even if Medicare might pay under different circumstances. The form should be detailed enough that you understand why Medicare will probably not pay for the item you are requesting.
  • The purpose of the form is to allow you to make an informed decision about whether or not to receive the item or service knowing that you may have additional out-of-pocket expenses.

Durable Medical Equipment (DME), Orthotics and Prosthetics Defined

  • In order for any item to be covered under Medicare, it typically has to meet the test of durability. Medicare will pay for medical equipment when the item:
    • Withstands repeated use (which excludes many disposable items such as underpads)
    • Is used for a medical purpose (meaning there is an underlying condition which the item should improve)
    • Is useless in the absence of illness or injury (which excludes any item that is preventive in nature such as bathroom safety items used to prevent injuries)
    • Used in the home (which excludes all items that are needed only when leaving the confines of the home setting)
  • An orthotic simply put is a brace. Covered Braces are defined as rigid or semi-rigid devices that are used to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body. There are many products that fall within this category including knee braces, ankle and foot braces (such as walking boots) and back braces just to name a few.
  • A prosthesis is a device that is intended to replace all or part of an internal body organ or to replace all or part of the function of a permanently immobile or malfunctioning internal body part.  There are a number of items that fall within the prosthetic category including: artificial arms and legs, breast prostheses, eye prostheses, parenteral and enteral nutrition, and ostomy supplies. Glasses and contacts for patients with aphakia or pseudophakia are also covered under this category.

Understanding Assignment (a claim-by-claim contract)

  • When a supplier accepts assignment, they are agreeing to accept Medicare’s approved amount as payment in full.
  • 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, which is $166.00 for 2016.
  • If you have chosen to receive an upgraded, fancier product than what Medicare typically covers, you will also be responsible for any additional amounts disclosed on the Advance Beneficiary Notice that identifies the additional features and fees that you have approved.
  • If a supplier does not accept assignment with Medicare, you will be responsible for paying the full amount upfront. The supplier will still file a claim on your behalf and any reimbursement made by Medicare will be paid to you directly. (Suppliers must still notify you in advance, using the Advance Beneficiary Notice, when they do not believe Medicare will pay for your claim.)

Mandatory Submission of Claims

  • Every supplier is required to submit a claim for covered services within one year from the date of service. However if the item is never covered by Medicare, your supplier is not obligated to submit a claim.

The role of the physician with respect to home medical equipment, prosthetics and orthotics:

  • Every item billed to Medicare requires a physician’s order or a special form called a Certificate of Medical Necessity (CMN), and sometimes additional documentation will be required such as copies of office visit notes from prior visits with your physician or healthcare provider or copies of test results relevant to the prescription of your medical equipment.
  • Nurse Practitioners, Physician Assistants, Interns, Residents and Clinical Nurse Specialists can also order medical equipment and sign CMNs when they are treating you.
  • All physicians and healthcare providers have the right to refuse to complete documentation for equipment they did not order, so make sure you consult with your physician or healthcare provider about your need for medical equipment or supplies before requesting an item from a supplier.
  • For every new item prescribed by your physician or healthcare provider, you should have a recent office visit that documents the reasons for ordering the equipment and products.  Most items require you to have an in-person office visit with your doctor or healthcare provider to discuss the need and justification for the prescription of medical equipment (and even replacement equipment) before a supplier can fill those orders.

Prescriptions before Delivery:

  • The list of items that require an office visit and written order before delivery has been expanded due to new provisions of the Affordable Care Act to include all items that cost more than $1000, and commonly prescribed items such as oxygen, hospital beds, wheelchairs and more. There are over 150 products across multiple product categories that are affected.   Your supplier will be able to tell you if the item ordered by your doctor or healthcare provider is subject to these additional requirements.
  • Your supplier cannot deliver these products to you without a compliant written order from your doctor or healthcare provider. They cannot provide services and get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier when a compliant order is not secured before delivery.  So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.
  • At this time Prosthetic and Orthotic items are not subject to the Face-to-Face rule that mandates a detailed written order prior to delivery, however every item does require a detailed written order from your doctor or healthcare provider prior to billing.

How does Medicare pay for and allow you to use the equipment?

  1. Typically there are four ways Medicare will pay for a covered item:
    • Purchase it outright, then the equipment belongs to you (generally orthotic and prosthetic items are purchased),
    • Rent it continuously until it is no longer needed, or
    • Consider it a “capped” rental in which Medicare will rent the item for a total of 13 months and consider the item purchased after having made 13 payments.
      • Medicare will not allow you to purchase these items outright (even if you think you will need it for a long period of time).
      • This is to allow you to spread out your coinsurance instead of paying in one lump sum.
      • It also protects the Medicare program from paying too much should your needs change earlier than expected.
    • If you have oxygen therapy, Medicare will make rental payments for a total of 36 months during which time this fee covers all service and accessories.
      • Beyond the 36 months (for a period of two additional years), Medicare will limit payments to a small fee for monthly gas or liquid contents, where applicable, and a limited service fee to check the equipment every six months.
  2. After an item has been purchased for you, you will be responsible for calling your supplier anytime that item needs to be serviced or repaired. When necessary, Medicare will pay for a portion of repairs, labor, replacement parts, and for temporary loaner equipment to use during the time your product is in for servicing. All of this is contingent on the fact that you still need the item at the time of repair and continue to meet Medicare’s coverage criteria for the item being repaired.

What is competitive bidding?

In many parts of the country, a new program called Competitive Bidding will require you to obtain certain medical equipment, product and supplies from specific, Medicare-contracted suppliers in order for Medicare to pay. Not all products are subject to competitive bidding in the same area.  If you are located in a city where the program is in effect, you will need to obtain some or all of the following items from a contracted supplier:

  • Oxygen, oxygen equipment, and supplies
  • Standard power wheelchairs, scooters, and related accessories
  • Enteral nutrition, equipment, and supplies
  • Continuous Positive Airway Pressure (CPAP) devices and Respiratory Assist Devices (RADs), and related supplies and accessories
  • Hospital beds and related accessories
  • Walkers and related accessories
  • Support surfaces (Group 1 and Group 2 mattresses and overlays)
  • Manual Wheelchairs and accessories
  • Mail-order and local home delivery of diabetic supplies
  • Nebulizers
  • Home infusion therapy including insulin pumps and supplies
  • TENS Units and supplies
  • Patient Lifts
  • Commodes
  • Seat Lift Chairs
  • Negative Pressure Wound Therapy Devices and related supplies and accessories

Competitive Bidding areas are designated based on the zip code of your permanent residence on file with Social Security. To find out if your zip code is affected by Competitive Bidding, call 1-800-MEDICARE (1-800-4227). You may also visit Medicare.gov and lookup suppliers in your area by zip code (a notice will appear if your area is subject to Competitive Bidding). If a product or item is marked with a yellow/orange star, it will need to be provided by a contracted supplier (also marked with an orange star).  Throughout this guide, products that are potentially impacted by the competitive bidding program will be designated with a double asterisk **.  Your provider can assist you with answering your questions about competitive bidding and can address whether or not they have been contracted to provide the services you need if subject to competitive bid.

Medicare Coverage for Prosthetics and Orthotics

Prosthetics:

Additional Prostheses other than those listed below may be covered by Medicare. Talk to your supplier for specific details or questions regarding those items.

Breast Prostheses

  • Breast Prostheses are covered after a radical mastectomy. Medicare will cover:
    • One silicone prosthesis every two years or a mastectomy form every six months.
    • As an alternative, Medicare can cover a nipple prosthesis every three months.
    • Mastectomy bras are covered as needed, but not on an automatic basis.
  • There is no coverage for replacement prostheses due to wear and tear before the specified time frames. However, Medicare will cover replacement of these items due to:
    • Loss
    • Irreparable damage, or
    • Change in medical condition (e.g. significant weight gain/loss)
  • You are allowed only one prosthesis per affected side, others will be denied as not medically necessary even if attempting asymmetry (an Advance Beneficiary Notice should be provided in this circumstance).
  • Mastectomy sleeves which are used to control swelling are not covered in the home setting because they do not meet Medicare’s definition of prosthesis; however, it is possible that they may be covered under the hospital per diem if you request one during your hospital stay.
  • A mastectomy bra is covered if the pocket of the bra is used to hold a covered prosthesis or mastectomy form.

Eye Prostheses

  • Eye prostheses are covered by Medicare if you have an absence or shrinkage of an eye due to birth defect, trauma or surgical removal.
  • Medicare will also cover polishing and resurfacing of the prosthesis twice annually.
  • Medicare will cover a one-time enlargement or reduction of your prosthesis when medically necessary.  Speak with your physician or healthcare provider if there is a medical need to have your prosthesis resized beyond the one time allowance.
  • Your prosthesis may be eligible for replacement after five years under the Medicare benefit, talk with your supplier for details
  • Your supplier cannot deliver this product to you without a written order from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare cannot make payment for those products to you or your supplier.  So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.

Facial Prostheses

  • Facial prostheses are covered by Medicare if you have a loss or absence of facial tissue due to disease, trauma, surgery or birth defect.
  • Facial prostheses can replace all or part of the face and can include:
    • Nasal prosthesis – removable superficial prosthesis which restores all or part of the nose and may include the nasal septum.
    • Mid-facial prosthesis – removable superficial prosthesis which restores part or all of the nose and significant adjacent facial tissue/structures, but does not include the eye orbit or any intraoral maxillary component. Adjacent facial tissue/structures include one or more of the following: soft tissue of the cheek, upper lip, or forehead.
    • Orbital prosthesis - removable superficial prosthesis, which restores the eyelids and the hard and soft tissue of the orbit. It may also include the eyebrow.
    • Upper facial prosthesis - removable superficial prosthesis, which restores the orbit and significant adjacent facial tissue/structures, but does not include the nose or any intraoral maxillary component. Adjacent facial tissue/structures include one or more of the following: soft tissue of the cheek or forehead. This code does not include the eye prosthesis. 
    • Hemi-facial prosthesis - removable superficial prosthesis, which restores part or all of the nose and the orbit plus significant adjacent facial tissue/structures, but does not include any intraoral maxillary component. This code does not include the eye prosthesis.
    • Auricular prosthesis - removable superficial prosthesis, which restores all or part of the ear.
    • Partial facial prosthesis - removable superficial prosthesis which restores a portion of the face but does not specifically involve the nose, orbit, or ear.
    • Nasal septal prosthesis - removable prosthesis, which occludes a hole in the nasal septum but does not include superficial nasal tissue.
  • Medicare will not cover skin care products that are related to the use of the prosthesis including cosmetics, skin cream, cleansers, etc.
  • Your supplier cannot deliver this product to you without a written order from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare cannot make payment for those products to you or your supplier.  So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.
  • Your physician and prosthetist will best determine the type of prosthesis that is necessary for your condition. If you would prefer a prosthesis that has features above and beyond what you medically need, you may be asked to complete an Advanced Beneficiary Notice and pay out-of-pocket for the item that you want.

Glasses

  • Medicare covers one complete pair of glasses, after the last cataract surgery with intra-ocular lens replacement. The Medicare benefit includes a frame and two lenses.  As an alternative, a pair of contact lenses can be covered in lieu of glasses.
  • Medicare beneficiaries that have a condition called aphakia (patients who are born without an intra-ocular lens, or who have had the lens removed and not replaced), are eligible for glasses, and/or contacts as often as is medically necessary.
  • When specifically prescribed for a medical condition documented in your medical chart, Medicare may also cover additional medically necessary features such as tint, anti-reflective coating, and/or UV.

Lower Limb Prostheses

  • Lower Limb Prostheses include those designed to replace feet, knees, ankles, hips or sockets and are covered when:
    • You will reach or maintain a desired functional state within a reasonable time frame; and
    • You are motivated to walk.
  • Medicare coverage is considered based on assessment of your potential functional abilities as determined by your physician and prosthetist. To determine your functional level, your physician and prosthetist will consider:
    • Your past history (including the use of prior prostheses, if applicable),
    • Your current condition including the status of the residual limb, as well as any other medical problems you may have, and
    • Your desire to walk.
  • Lower Limb Prostheses can be custom fabricated for you or provided off the shelf and custom fitted to address your individual needs. Custom fabricated items are created specifically to suit your individual needs and tend to be more expensive. Off the shelf prostheses can be bought “as is” and then customized for an individual fit. 
  • Your physician and prosthetist will best determine the type of prosthesis that is necessary for your condition. If you would prefer a prosthesis that has features above and beyond what you medically need, you may be asked to complete an Advanced Beneficiary Notice and pay out-of-pocket for the item that you want.

Non-covered items (partial listing)

  • Adult diapers
  • Bathroom safety equipment
  • Hearing aides
  • Syringes/needles
  • Van lifts or ramps
  • Exercise equipment
  • Humidifiers/Air Purifiers
  • Raised toilet seats
  • Massage devices
  • Stair lifts
  • Emergency communicators
  • Low vision aides
  • Grab bars
  • Elastic garments  

Ostomy Supplies

  • Ostomy supplies are covered for people with a:
    • colostomy,
    • ileostomy, or
    • urostomy
  • You may obtain up to a three month’s supply of wafers, pouches, paste and other necessary items as needed.
  • You must have nearly depleted the supplies on hand to be eligible for additional product.

Parenteral and Enteral Therapy**

  • Parenteral therapy requires all or part of the gastrointestinal tract to be missing. Nutritional formulas are delivered through a vein.
  • Enteral therapy is covered if you cannot swallow or take food orally. Nutrition must be delivered through a tube directly into the gastrointestinal tract.
  • Medicare will not pay for nutritional formulas that are taken orally.
  • Specialty nutrition/formulas can be covered if you have unique nutritional needs or specific disease conditions which are well documented in your physician’s or healthcare provider’s records.  In most cases, you may have to try standard formulas and document that they are unsuccessful before Medicare will consider the specialty nutrition.
  • You must have nearly depleted the supplies on hand to be eligible for additional product.

** Some or all of the products in this category may be subject to competitive bidding depending on where you live.  Ask your supplier for details.

Therapeutic Shoes

  • Special therapeutic shoes, inserts and modifications can be covered for diabetic patients with the following foot conditions:
    • previous amputation of a foot or partial foot
    • history of foot ulceration or pre-ulcerative calluses
    • peripheral neuropathy with callus formation
    • foot deformity
    • poor circulation in either foot
  • You must have an office visit with your physician or healthcare provider within six months of receiving new shoes to discuss and document your diabetes management and why you need these special shoes.  This office visit must be repeated each time you wish to obtain replacement shoes.
  • Only a physician treating your diabetes can certify your diabetic condition and complications that require specialty shoes. 
  • Your healthcare practitioner or a podiatrist may further evaluate your feet and order the shoes.
  • When providing you with shoes, your supplier must perform an in-person evaluation of your foot/feet, and they must verify that your shoes fit properly.
  • Newly established requirements of the Affordable Care Act require a specific office visit with your physician or healthcare practitioner to assess and document your need for this equipment take place and must then issue a compliant written order.
  • Your supplier cannot deliver this product to you without a written order from your doctor or healthcare provider. If the equipment is subject to these special rules, your supplier cannot get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier when a compliant order is not secured before delivery.  So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.

Urological Supplies

  • Urinary catheters and external urinary collection devices are covered to drain or collect urine if you have permanent urinary incontinence or permanent urinary retention. Permanent incontinence and retention are defined as a condition that is not expected to be medically or surgically corrected within 3 months.
  • A maximum of six catheters may be used per day (up to 200 per month), unless it is determined that a higher number is medically necessary by your physician or healthcare provider, and these unique circumstances are specifically documented in your medical records.
  • When at home, you may receive up to a 3-month supply at one time.
  • You must have nearly depleted the supplies on hand to be eligible for additional products.

Vacuum Erection Devices (VEDs)

  • Vacuum Erection Devices (VEDs) are no longer covered by Medicare for the treatment of erectile dysfunction.
  • As of July 1, 2015, the Achieving a Better Life Experience (ABLE) Act of 2014 mandated that Medicare discontinue coverage of these devices to mirror the non-coverage policies of the Medicare Part D program for erectile medication.

Orthotics:

Ankle-Foot Orthoses (Braces)

  • Ankle-Foot Braces are covered for patients that:
    • are able to walk,
    • need the ankle or foot to be stabilized due to a weakness or deformity, and
    • have the potential to benefit functionally from the use of the brace to do more than could be accomplished without a brace.
  • In order for Medicare to cover an ankle-foot brace, you must have one of the above conditions and also have undergone a face-to-face visit with your physician to examine your need for the brace.
  • Ankle-Foot Braces can be Custom Fitted or provided Off-the-Shelf.
    • Custom Fitted braces are manufactured devices that:
      • may be supplied as a kit that requires some assembly,
      • require fitting by a certified orthotist, and
      • require substantial modification at the time of the fitting to ensure a proper fit.
    • Off-the-Shelf braces are manufactured devices that:
      • may be supplied as a kit that requires some assembly,
      • require minimal adjustment by you as the beneficiary for a proper fit, and
      • do not require a certified orthotist to ensure the best possible fit.
  • Not all products that fall within this category are eligible for Medicare payment. For an Ankle-Foot Brace to be covered by Medicare, the condition/injury must also qualify. Medicare does not pay for braces used primarily for comfort or prevention purposes.
  •  Your physician will best determine the type of brace that is necessary to treat your condition.  If you would prefer a brace that has features above and beyond what you medically need, (such as warmth, circulation support, additional comfort features, etc.) you may be asked to complete an Advanced Beneficiary Notice and pay out of pocket for the brace that you want.

Arm Supports and Slings

  • Arm Support and Slings are generally made of cloth-like material and therefore do not meet the definition of a brace. These items are not payable under the Durable Medical Equipment benefit of your Medicare policy.  However, these items are billable by your physician when incident to an office visit and likely can be obtained directly from your physician.

Clavicle/Shoulder Orthoses (Braces)

  • Clavicle/Shoulder braces are covered for patients that need:
    • stabilization of the clavicle or shoulder because of a weakness or deformity,
    • to restrict movement of the clavicle or shoulder due to injury or disease, or
    • to limit movement during recovery from a surgical procedure on the clavicle or shoulder.
  • In order for Medicare to cover a clavicle/shoulder brace, you must meet one of the above criteria and also have undergone a face-to-face visit with your physician to examine and document your need for the brace and your ability to benefit from its use. 
  • Your physician will best determine the type of brace that is necessary to treat your condition. If you would prefer a brace that has features above and beyond what you medically need, you may be asked to complete an Advanced Beneficiary Notice and pay out-of-pocket for the brace that you want.
  • Clavicle/Shoulder braces can be Custom Fitted or provided Off-the-Shelf.
    • Custom Fitted braces are manufactured devices that:
      • may be supplied as a kit that requires some assembly,
      • require fitting by a certified orthotist, and
      • require substantial modification at the time of the fitting to ensure a proper fit.
    • Off-the-Shelf braces are manufactured devices that:
      • may be supplied as a kit that requires some assembly,
      • require minimal adjustment by you as the beneficiary for a proper fit, and
      • do not require a certified orthotist to ensure the best possible fit.

Elbow Orthoses (Braces)

  • Elbow braces are covered for patients that need:
    • Stabilization of the elbow because of a weakness or deformity,
    • To restrict movement of the elbow joint due to an injury or disease, or
    • to limit movement during recovery from a surgical procedure on the elbow.
  • In order for Medicare to cover an elbow brace, you must meet one of the above criteria and also have undergone a face-to-face visit with your physician to examine and document your need for the brace and your ability to benefit from its use. 
  • Elbow braces can be very basic or have additional features. Your physician will best determine the type of brace that is necessary to treat your condition. If you would prefer a brace that has features above and beyond what you medically need, you may be asked to complete an Advanced Beneficiary Notice and pay out-of-pocket for the brace that you want.
  • Elbow braces can be Custom Fitted or provided Off-the-Shelf.
    • Custom Fitted braces are manufactured devices that:
      • may be supplied as a kit that requires some assembly,
      • require fitting by a certified orthotist, and
      • require substantial modification at the time of the fitting to ensure a proper fit.
    • Off-the-Shelf braces are manufactured devices that:
      • may be supplied as a kit that requires some assembly,
      • require minimal adjustment by you as the beneficiary for a proper fit, and
      • do not require a certified orthotist to ensure the best possible fit.

Knee Orthoses (Braces)

  • Knee braces are covered for patients that:
    • are able to walk;
    • require the knee to be stabilized because of a weakness or deformity of the knee,
    • had a recent injury to the knee, or
    • had a recent surgical procedure on the knee such as a knee joint replacement.
  • In order for Medicare to cover payment for a knee brace, you must have one of the above conditions and also have undergone a face-to-face visit with your physician to examine your need for the brace.
  • Knee braces can be very basic or have additional features such as Velcro straps, flexible support joints or additional padding for comfort.
  • Your physician will best determine the type of brace that is necessary to treat your condition. If you would prefer a brace that has features above and beyond what you medically need, you may be asked to complete an Advanced Beneficiary Notice and pay out-of-pocket for the brace that you want.
  • Knee braces can be Custom Fitted or provided Off-the-Shelf.
    • Custom Fitted braces are manufactured devices that:
      • may be supplied as a kit that requires some assembly,
      • require fitting by a certified orthotist, and
      • require substantial modification at the time of the fitting to ensure a proper fit.
    • Off-the-Shelf braces are manufactured devices that:
      • may be supplied as a kit that requires some assembly,
      • require minimal adjustment by you as the beneficiary for a proper fit, and
      • do not require a certified orthotist to ensure the best possible fit.
  • Knee braces should be expected to last 1-2 years, depending on the type of brace being prescribed.

Knee-Ankle-Foot Orthoses (Braces)

  • Knee-Ankle-Foot Braces are covered for patients that:
    • are able to walk,
    • have a weakness or deformity of the foot and ankle and need additional stability for the knee, and
    • have the potential to benefit functionally from the use of the brace.
  • In order for Medicare to provide payment for a Knee-Ankle-Foot brace, you must have one of the above conditions and also have undergone a face-to-face visit with your physician to examine your need for the brace.
  • Knee-Ankle-Foot Braces can be Custom Fitted or provided Off-the-Shelf.
    • Custom Fitted braces are manufactured devices that:
      • may be supplied as a kit that requires some assembly,
      • require fitting by a certified orthotist, and
      • require substantial modification at the time of the fitting to ensure a proper fit.
    • Off-the-Shelf braces are manufactured devices that:
      • may be supplied as a kit that requires some assembly,
      • require minimal adjustment by you as the beneficiary for a proper fit, and
      • do not require a certified orthotist to ensure the best possible fit.
  • Not all products that fall within this category are eligible for Medicare payment. For a Knee- Ankle-Foot Brace to be covered by Medicare the condition it is being used to treat must qualify.
  • Your physician will best determine the type of brace that is necessary to treat your condition.  If you would prefer a brace that has features above and beyond what you medically need, (such as warmth, circulation support, additional comfort features, etc.) you may be asked to complete an Advanced Beneficiary Notice and pay out-of-pocket for the brace that you want.

Cervical  Orthoses (Neck Braces)

  • Neck braces are covered for patients that need:
    • stabilization because of a weakness or deformity of the neck,
    • to restrict movement of the neck due to an injury or disease, or
    • to limit movement during recovery from a surgical procedure on the neck.
  • In order for Medicare to cover payment for a neck brace you must meet one of the above criteria and also have undergone a face-to-face visit with your physician to examine and document your need for the brace and your ability to benefit functionally from its use.  
  • Neck braces can be very basic or have additional features.
  • Your physician will best determine the type of brace that is necessary to treat your condition. If you would prefer a brace that has features above and beyond what you medically need, you may be asked to complete an Advanced Beneficiary Notice and pay out-of-pocket for the brace that you want.
  • Neck braces can be Custom Fitted or provided Off-the-Shelf.
    • Custom Fitted braces are manufactured devices that:
      • may be supplied as a kit that requires some assembly,
      • require fitting by a certified orthotist, and
      • require substantial modification at the time of the fitting to ensure a proper fit.
    • Off-the-Shelf braces are manufactured devices that:
      • may be supplied as a kit that requires some assembly,
      • require minimal adjustment by you as the beneficiary for a proper fit, and
      • do not require a certified orthotist to ensure the best possible fit.

Orthopedic Shoes

  • Orthopedic shoes are covered when it is necessary to attach the shoe(s) to a leg brace.
  • Medicare will only pay for the shoe(s) attached to the leg brace(s).
  • Medicare will not pay for matching shoes or for shoes that are needed for purposes other than diabetes or leg braces.

Spinal Orthoses (Back Braces)

  • Back braces are covered:
    • When it is medically necessary to reduce pain by restricting upper body movement, or
    • to aid in the healing process after injury or a surgical procedure, or
    • to support weak, spinal muscles or a deformed spine
  • In order for Medicare to provide payment for a Back brace, you must have one of the above conditions and also have undergone a face-to-face visit with your physician to examine and document your need for the brace and your ability to benefit functionally from its use.
  • Your physician will best determine the type of brace that is necessary to treat your condition. If you would prefer a brace that has features above and beyond what you medically need, you may be asked to complete an Advanced Beneficiary Notice and pay out-of-pocket for the brace that you want.
  • In order for a back brace to be payable by Medicare it must be made primarily of non-elastic material such as canvas, cotton, nylon etc. or have a rigid posterior panel.
  • Back braces that are primarily made of elastic material will not be covered under the Medicare program. These items do not meet the definition of a brace as they are not rigid or semi-rigid and Medicare will not pay for these braces.

Wrist and Forearm Orthoses (Braces)

  • Wrist and Forearm braces are covered for patients that need:
    • stabilization of the wrist or forearm because of a weakness or deformity,
    • to restrict movement of the wrist or forearm due to an injury or disease, or
    • to limit movement during recovery from a surgical procedure on the wrist or forearm  (such as a joint replacement).
  • In order for Medicare to cover payment for a wrist or forearm brace, you must meet one of the above criteria and also have undergone a face-to-face visit with your physician to examine and document your need for the brace and your ability to benefit functionally from its use.
  • Wrist or forearm braces can be very basic or have additional features.
  • Your physician will best determine the type of brace that is necessary to treat your condition. If you would prefer a brace that has features above and beyond what you medically need, you may be asked to complete an Advanced Beneficiary Notice and pay out-of-pocket for the brace that you want.
  • Wrist and forearm braces can be Custom Fitted or provided Off-the-Shelf.
    • Custom Fitted braces are manufactured devices that:
      • may be supplied as a kit that requires some assembly,
      • require fitting by a certified orthotist, and
      • require substantial modification at the time of the fitting to ensure a proper fit.
    • Off-the-Shelf braces are manufactured devices that:
      • may be supplied as a kit that requires some assembly,
      • require minimal adjustment by you as the beneficiary for a proper fit, and
      • do not require a certified orthotist to ensure the best possible fit.

Medicare Supplier Standards

Below is a summary of the standards Medicare requires of home medical equipment suppliers. Our company meets or exceeds all of these standards.

  1. A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements and cannot contract with an individual or entity to provide licensed services.
  1. A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days.
  1. An authorized individual (one whose signature is binding) must sign the application for billing privileges.
  1. A supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or from any other Federal procurement or non-procurement programs.
  1. A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment.
  1. A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty.
  1. A supplier must maintain a physical facility on an appropriate site. This standard requires that the location is accessible to the public and staffed during posted hours of business. The location must be at least 200 square feet and contain space for storing records.
  1. A supplier must permit CMS, or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these standards. The supplier location must be accessible to beneficiaries during reasonable business hours, and must maintain a visible sign and posted hours of operation.
  1. A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a beeper, answering machine, answering service or cell phone during posted business hours is prohibited.
  1. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier’s place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations.
  1. A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from contacting a Medicare beneficiary based on a physician’s oral order unless an exception applies.
  1. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items, and maintain proof of delivery.
  1. A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.
  1. A supplier must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicare-covered items it has rented to beneficiaries.
  1. A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.
  1. A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item.
  1. A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier.
  1. A supplier must not convey or reassign a supplier number; i.e., the supplier may not sell or allow another entity to use its Medicare billing number.
  1. A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility.
  1. Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it.
  1. A supplier must agree to furnish CMS any information required by the Medicare statute and implementing regulations.
  1. All suppliers must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services, for which the supplier is accredited in order for the supplier to receive payment of those specific products and services (except for certain exempt pharmaceuticals).
  1. All suppliers must notify their accreditation organization when a new DMEPOS location is opened.
  1. All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare.
  1. All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.
  1. Must meet the surety bond requirements specified in 42 C.F.R. 424.57(c).
  1. A supplier must obtain oxygen from a state- licensed oxygen supplier.
  1. A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F.R. 424.516(f).
  1. DMEPOS suppliers are prohibited from sharing a practice location with certain other Medicare providers and suppliers.

DMEPOS suppliers must remain open to the public for a minimum of 30 hours per week with certain exceptions.