CASE FLASH: COVERAGE OF DURABLE MEDICAL EQUIPMENT IN MEDICARE PRIVATE PLANS

Mrs. M is enrolled in a Medicare private health plan. A few months ago, she tripped and injured her ankle. Her doctor prescribed a special ankle brace to help her get around the house. When Mrs. M went to get the brace at the medical equipment supplier, she made sure that the supplier billed her Medicare private health plan. The next month, however, Mrs. M got a letter from her plan, stating that it would not pay for the ankle brace.

Mrs. M called the Medicare Rights Center and asked a hotline counselor why the plan would not cover her brace. The counselor explained to Mrs. M that things like ankle braces are usually considered Durable Medical Equipment, or DME, and are covered under Medicare Part B when obtained from a supplier who is enrolled in Medicare. However, if you are in a Medicare private health plan, your plan may also require you to go to a DME supplier in the plan’s network, or get prior authorization to have your DME covered. Together, Mrs. M and the MRC counselor called her plan and found out that the plan requires members to use DME suppliers in the plan’s network. While the DME supplier Mrs. M used was enrolled in Medicare, it was not a part of the plan’s network.

The counselor explained that Mrs. M is responsible for the full cost of the brace and advised her to always remember to check with the plan to make sure that she chooses an in-network provider, whether it be for DME, home health or any type of service. Mrs. M decided to switch back to Original Medicare during the Annual Coordinated Election Period (November 15-December 31 each year), so that she could go to any Medicare-enrolled provider without having to worry about a plan’s network.

-From “Case Flash: Coverage Of Durable Medical Equipment”, MEDICARE WATCH, a biweekly electronic newsletter of the Medicare Rights Center, Vol. 10, No. 25: December 11, 2007.

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