Medicare FAQ

What is a Medicare deductible?

A deductible is the amount you must pay each year before Medicare begins paying its portion of your medical bill. There are deductibles for both the Part A (Hospital Insurance) and Part B (doctor services) portions of Medicare. Your deductible is taken out of your claims when Medicare receives them. Medicare will not start paying on your claims until you have met your annual deductible. The Medicare Part A deductible for 2005 is $912.00 per benefit period. The Medicare Part B deductible for 2005 is $110.00. If you have any questions on the status of your deductible please contact 1-800-MEDICARE (1-800-633-4227).

Is a power wheelchair or scooter supplier supposed to waive my coinsurance or Part B deductible?

The Medicare Part B deductible is the amount you must pay for health care before Medicare begins to pay. The coinsurance is the percent of the Medicare-approved amount that you have to pay after you pay the Part B deductible. In the Original Medicare Plan, the Medicare Part B coinsurance is generally 20 percent of the Medicare-approved amount for the item.

Medicare law requires a supplier of durable medical equipment, such as power wheelchairs and scooters, to bill Medicare for the supplier?s actual charge. Medicare pays 80 percent of the lesser of the supplier?s actual charge or the fee schedule amount, and you pay the remaining 20 percent. It is unlawful for a supplier to routinely waive the Medicare Part B coinsurance and deductible, because that results in Medicare paying 100 percent of the supplier's actual charge. However, a supplier may waive your coinsurance and/or deductible if you have a financial hardship and can?t pay your Medicare Part B deductible or coinsurance. If this applies to you, the supplier must document and show that an effort was made to collect your deductible and coinsurance.

Note:  If your power wheelchair or scooter supplier routinely waives Medicare copayments and deductibles, you should report these actions to the appropriate Durable Medical Equipment Regional Carrier (DMERC) or by contacting the Inspector General's Hotline at 1-800-HHS-TIPS.

What is in the DME category?

Some of the items included in the Durable Medical Equipment category, but not limited to:

  • Diabetic supplies
  • Canes, crutches, walkers
  • Commode chairs
  • Home oxygen equipment
  • Hospital beds
  • Power Operated Vehicles (POVs or scooters)
  • Seat lift mechanisms
  • Traction equipment
  • Wheelchairs

What is a Certificate of Medical Necessity?

A Certificate of Medical Necessity (CMN) is a form required by Medicare authorizing the use of certain durable medical items and equipment prescribed by a physician. This form is to be completed by your doctor or the doctor's employee. Your supplier will coordinate with your doctor to see that all the necessary information is submitted to Medicare. A change in prescription and/or a change in your condition requires that an updated certificate be completed and submitted.

What supplies require a certificate of medical necessity (CMN)?

The following items require a CMN:

  • Air-fluidized beds
  • Continuous Positive Airway Pressure (CPAP) devices
  • Hospital beds
  • External infusion pumps
  • Lymphedema pumps/pneumatic compression devices
  • Osteogenesis stimulators
  • Parenteral and enteral nutrition
  • Oxygen
  • Power Operated Vehicles (POVs), or Scooters
  • Seat lift mechanisms
  • Transcutaneous electronic nerve stimulators (TENS Units)
  • Wheelchairs

What is Durable Medical Equipment?

Durable Medical Equipment (or DME) is equipment which meets all of the following requirements:

  • Can withstand repeated use
  • Is primarily and customarily used to serve a medical purpose
  • Is generally not useful to a person in the absence of an illness or injury
  • Is appropriate for use in the home

Often a physician will prescribe special equipment for use by a beneficiary in his/her home. The equipment may provide therapeutic benefits or enable the beneficiary to perform certain tasks that s/he is unable to undertake due to certain medical conditions and/or illnesses.