Funding & Insurance for Mobility Equipment Flashcards

An Advance Beneficiary Notice of Noncoverage (ABN) must be issued by a DME supplier when:

Answer: Medicare is likely to deny payment and the beneficiary should know they may be financially responsible

An ABN informs beneficiaries before receiving items or services that Medicare likely will not pay, giving them the option to proceed and assume financial responsibility.

Vocational Rehabilitation (VR) funding for mobility equipment is most applicable when the equipment is primarily intended to:

Answer: Enable a person with a disability to prepare for, obtain, or maintain employment

State VR agencies fund equipment and services directly tied to an individual's employment goals as part of an Individualized Plan for Employment (IPE).

Which organization accredits DME suppliers and is recognized by CMS as a condition of Medicare enrollment for complex rehab technology suppliers?

Answer: The Joint Commission (TJC) or Accreditation Commission for Health Care (ACHC)

CMS requires DME suppliers to hold accreditation from a CMS-approved accrediting organization such as TJC or ACHC as a condition of Medicare enrollment.

A client's private insurer uses an 'in-network' requirement for DME. What risk does the CMC face if they recommend a supplier who is out-of-network?

Answer: The client may face significantly higher out-of-pocket costs or a complete lack of coverage

Out-of-network DME suppliers may result in higher cost-sharing or no coverage at all under plans with strict network requirements, increasing the client's financial burden.

The 13-month capped rental rule for power wheelchairs under Medicare means:

Answer: After 13 months of rental payments, Medicare transfers ownership of the chair to the beneficiary

Under Medicare's capped rental policy, after 13 months of continuous use and rental payments, ownership of the power wheelchair transfers to the beneficiary.

A state Children's Health Insurance Program (CHIP) covers mobility equipment for a pediatric client. Which entity sets the specific DME coverage policies for CHIP?

Answer: The individual state that administers its CHIP plan

CHIP is administered by individual states, which set their own benefit packages within federal guidelines, resulting in varying DME coverage policies across states.

When a CMC identifies that a client qualifies for multiple funding sources (Medicare + state Medicaid), which principle governs the order in which these payers are billed?

Answer: Medicare is always billed first as primary payer; Medicaid is billed last as payer of last resort

Medicaid is statutorily the payer of last resort, meaning all other applicable payers including Medicare must be billed before Medicaid is billed for any remainder.