Medicare and SpinLife
Medicare, Medicaid and Insurance: there are few topics that generate more questions from our customers. And it’s no wonder! Understanding coverage and eligibility for durable medical equipment is historically complex and confusing. In the last few years Medicare (federal program predominantly used for those 62+ in age), Medicaid state programs, and private insurance(such as United Anthem, Aetna, Cigna, etc…) have all significantly lowered their reimbursement amounts and increased the documentation requirements for most categories of durable medical equipment, including lift chairs, scooters, and Group 2 power wheelchairs (the type sold by SpinLife). This means that in over 95% of cases, mobility scooters, lift chairs and Group 2 power wheelchairs are not covered.
Because less than 5% of lift chairs, scooters, and power wheelchairs are covered through Medicare, Medicaid, and insurance, we found that filing claims resulted in unnecessary delays for our customers, with little chance of coverage. Therefore, SpinLife no longer files claims with Medicare, Medicaid or private insurance.
In cases where the items are eligible for coverage, you still have to jump through hoops in submitting information, get a pre-authorization, and wait 6 or more weeks for your equipment. In most of those cases, you are not able to select your own product but are limited to what your local equipment dealer chooses to stock.
At SpinLife, you pick the equipment you want, there is no prescription required, and there is no waiting for paperwork from a physician or for a prior authorization from Medicare. We recommend talking to a SpinLife Product Expert to find a product that meets your budget, and discussing our attractive financing options.
Also, please note: Medicare will not cover product if the beneficiary is in a nursing home, skilled nursing facility, home health facility or hospice facility. The facility is responsible for providing the necessary equipment. The beneficiary or their family can always choose to purchase their own equipment.
If you are interested in exploring if Medicare or private insurance will cover a product, here is information to help you better understand the process. You will need to locate and work with a local dealer in your area. SpinLife does not submit claims to Medicare, Medicaid, or private insurance, and you can not submit a claim on your own if you purchase your product from SpinLife. The following information is for informational purposes only.
Medicare and Rentals vs. Purchases
Medicare Capped Rental
Medicare does not purchase most items directly, but rather rents them for the first 13 months. This is called Capped Rental. Capped Rental Items are items where Medicare will pay a monthly rental fee for a period not to exceed 13 months, after which the ownership of the equipment is transferred to the Medicare beneficiary and it is the beneficiary’s responsibility to arrange for any required equipment service or repair. Many of the items sold on SpinLife fall into this category. Examples of this type of equipment include manual wheelchairs, mobility scooters, power wheelchairs, hospital beds, alternating pressure pads, air-fluidized beds, nebulizers, suction pumps, continuous airway pressure (CPAP) devices, patient lifts and trapeze bars.
Items Inexpensive or Routinely Purchased items Notification
Inexpensive or routinely purchased items include Lift Chair seat lift mechanisms, canes, walkers, crutches, commode chairs, low pressure and positioning equalization pads, home blood glucose monitors, pneumatic compressors (lymphedema pumps), bed side rails, and traction equipment. These items can be purchased or rented, although the total amount paid for monthly rentals cannot exceed the fee schedule purchase amount.
How much will I be reimbursed through Medicare if I rent or purchase from a local, eligible dealer?
Medicare assigns every product that is eligible for reimbursement what is called an "allowable amount". The allowable amount is the maximum amount that Medicare will consider as the total price of the item. The allowable amount for each item varies slightly by state. Medicare will reimburse a local dealer 80% of the allowable amount. The other 20%, or copay, remains your responsibility.
Here are allowable amounts for items commonly purchased on SpinLife:
- Lift Chair Mechanisms (HCPCS Code E0627): The allowable range is between $229-$280. View a state-by-state reimbursement chart.
- Wheelchair cushions that provide skin protection and/or positioning (HCPCS Code E2605-E2622): The allowable ranges from $250 - $350 for standard sizes, depending on the specific cushion you choose.
Please note the following important information about Medicare reimbursement amounts:
- Any applicable deductibles must be met before Medicare will reimburse you for their portion of the allowable amount on an approved claim.
Coverage details for wheelchairs, walkers, scooters and power wheelchairs:
Medicare covers power-operated vehicles (scooters), walkers, and wheelchairs as durable medical equipment (DME). Medicare helps cover DME if:
- The doctor treating your condition submits a written order stating that you have a medical need for a wheelchair or scooter for use in your home.
- You have limited mobility and meet all of these conditions:
- You have a health condition that causes significant difficulty moving around in your home
- You are unable to do activities of daily living (like bathing, dressing, getting in or out of a bed or chair, or using the bathroom), even with the help of a cane, crutch, or walker.
- You are able to safely operate and get on and off the wheelchair or scooter, or have someone with you who’s always available to help you safely use the device.
- Your doctor who’s treating you for the condition that requires a wheelchair or scooter and your supplier are both enrolled in Medicare.
- You can use the equipment within your home (for example, it’s not too big to fit through doorways in your home or blocked by floor surfaces or things in its path).
You pay 20% of the Medicare-approved amount after you pay your Medicare Part B deductible for the year. Medicare pays the other 80%. If you’re in a Medicare Advantage Plan (like an HMO or PPO), you must contact your plan to find out about costs and which DME suppliers you can use.
What is the reimbursement criteria for Manual Wheelchairs?
If you can’t use a cane or walker safely, but you have enough upper body strength or have someone who’s available to help, you may qualify for a manual wheelchair. The most appropriate manual wheelchair for you may have to be rented first, even if you eventually plan to buy it. 2 Types of equipment (continued)
What is the reimbursement criteria for Scooters?
If you can’t use a cane or walker, or can’t operate a manual wheelchair, you may qualify for a power-operated scooter, if you can safely get in and out of it and are strong enough to sit up and safely operate the controls. Note: If you don’t need a scooter on a long-term basis, you can rent the equipment to lower your costs. Talk to your supplier to find out more about this option.
What is the reimbursement criteria for Power Wheelchairs?
If you can’t use a manual wheelchair in your home, or if you don’t qualify for a power-operated scooter because you aren’t strong enough to sit up or to work the scooter controls safely, you may qualify for a power wheelchair. Note: Before you get either a power wheelchair or scooter, you must have a face-to-face exam with your doctor. The doctor will review your needs and help you decide if you can safely operate the device. If so, the doctor will submit a written order telling Medicare why you need the device and that you’re able to operate it. Tips: You must have a medical need for Medicare to cover a power wheelchair or scooter. Medicare won’t cover this equipment if it’ll be used mainly for leisure or recreational activities, or if it’s only needed to move around outside your home.
What is the reimbursement criteria for Lift Chairs?
Medicare only covers the seat-lift mechanism, but not the actual chair/furniture portion itself. The reimbursement amount is between $170-$250 depending on the state (view chart) in which the beneficiary is located if the coverage criteria are met. A lift chair is considered medically necessary if all of the following coverage criteria are met:
- The beneficiary must have severe arthritis of the hip or knee only, or have a severe neuromuscular disease. This must be specifically documented by your physician.
- The seat lift mechanism must be a part of the physician’s course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in the patient’s condition.
- The patient must be completely incapable of standing up from a regular armchair or any chair in their home.
- Once standing, the patient must have the ability to walk, even if a cane, walker or other assistance is required. Medicare will not cover this item if the beneficiary has a wheelchair, scooter, or power wheelchair on file.
- By Medicare standards, the fact that a beneficiary has difficulty or is even incapable of getting up from a chair, particularly a low chair is not sufficient justification for a seat lift mechanism. Almost all beneficiaries who are capable of ambulating can get out of an ordinary chair, if the seat height is appropriate and the chair has arms.
- Medicare requires that the physician ordering the seat lift mechanism must be the attending physician or a consulting physician for the disease or condition resulting in the need for a seat lift.
If you wish to pursue Medicare billing for your lift chair, please visit the Medicare website at www.medicare.com or call 1-800-MEDICARE.
What is the reimbursement criteria for wheelchair cushions?
For wheelchair cushions, the wheelchair for which the cushion will be used must already be on file with Medicare. Medicare requires the local dealer to submit the manufacturer, model, serial number and the date of purchase of the wheelchair on file.
The beneficiary must also either have a current pressure sore or have a previous history of a pressure sore on record due to the fact that Medicare will not cover any preventative items. Documentation of the pressure sore (staging, treatment, etc.) and positioning requirements must also be provided in the form of chart notes from your physician.
How can I find out if my physician has a valid NPI and PECOS enrollment?
Please note: Effective May 1, 2013, in order to be eligible for Medicare reimbursement on any durable medical equipment purchase, your prescribing physician must:
- Have a valid national provider identifier (NPI).
- Be enrolled in the Medicare Provider Enrollment, Chain and Ownership System (PECOS).
If your prescribing physician does not have a valid NPI or PECOS enrollment, your claim will be denied. To view a list of physicians and non-physician practitioners who have a valid NPI and PECOS enrollment, you can visit this government website and download the PDF document titled Medicare Ordering and Referring File [PDF]. You can also contact your physician’s office for this information.
Can SpinLife bill Medicaid for my items?
SpinLife does not work with any state Medicaid programs.