Medicare, Medicaid, Private Insurance & Private Pay

We accept:

 

 Medicare non-assignment accepted for noncompetitive   bidding equipment and services;

 Medicare Managed Plans MMAI;

 IL Medicaid & its Managed Plans FHP: ICP:

     

 Aetna Better Health;

 Blue Cross Community Health Plans;

 Cigna Health Spring;

 Community Care Alliance;

 County Care;

 IlliniCare;

 Meridian;

 Molina

 BCBS PPO;

 BCBS insurance market plans;

 Tricare;

...and many other. Please call us at 847-824-0500 for details.



Medicare Coverage

Medicaid Coverage

Medicare benefits qualifications:

  1. Individuals 65 years of age or older

  2. Individuals under 65 with permanent kidney failure (beginning three months after dialysis begins), or

  3. Individuals under 65, permanently disabled and entitled to Social Security benefits (beginning 24 months after the start of disability benefits)

Types of Medicare:

  1. Medicare Part A benefits cover hospital stays, home health care and hospice services.

  2. Medicare Part B benefits cover physician visits, laboratory tests, ambulance services and home medical equipment.

  3. While oftentimes you do not have to pay a monthly fee to have Part A benefits, the Part B program requires a monthly premium to stay enrolled depending on your income. Typically, this amount will be taken from your Social Security check.

Your part and cost:

  1. Every year, in addition to your monthly premium, you will have to pay deductable out of pocket and then 20 percent of all approved charges if the provider agrees to accept Medicare payments.

  2. Unfortunately, your medical equipment provider cannot automatically waive this 20 percent or your deductible without suffering penalties from Medicare. Your provider must attempt to collect the coinsurance and deductible if those charges are not covered by another insurance plan. 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.

  3. If your medical equipment provider 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:

  1. Medicare will pay only for items that meet your basic needs. Oftentimes you will find that your provider 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 provider should give you the option to allow you to privately pay a little extra money to get the product that you really want.

  2. To take advantage of this opportunity, a new form has been approved by the Centers for Medicare and Medicaid Services (CMS) that allows patients to upgrade to a piece of equipment that they like better than other standard options for which they may otherwise qualify.

  3. The Advance Beneficiary Notice, or ABN, 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 provider 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.

What is a Durable Medical Equipment (DME):

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:

  1. Withstands repeated use (excluded many disposable items such as underpads)

  2. Is used for a medical purpose (meaning there is an underlying condition which the item should improve)

  3. Is useless in the absence of illness or injury (thus excluding any item preventive in nature such as bathroom safety items used to prevent injuries)

  4. Used in the home (which excludes all items that are needed only when leaving the confines of the home setting)

Prescriptions & CMN:

  1. Every item billed to Medicare requires a detailed physician's order or a special form called a Certificate of Medical Necessity (CMN), and sometimes additional documentation will be required.

  2. Nurse Practitioners, Physician Assistants, Interns, Residents and Clinical Nurse Specialists can also order medical equipment and sign CMNs when they are treating a patient.

Prescriptions Before Delivery:

For some items, Medicare requires your provider to have completed documentation (which is more than just a call-in order or a prescription from your doctor) before these items can be delivered to you:

  1. Decubitus care (wheelchair cushions and pressure-relieving surfaces placed on a hospital bed)

  2. Seat lift mechanisms

  3. TENS Units (for pain management)

  4. Power Operated Vehicles/Scooters

  5. Electric or Power Wheelchairs

  6. Negative Pressure Wound Therapy (wound vacs)

How does Medicare pay for the equipment?

  1. Typically there are four ways Medicare will pay for a covered item:

    • Purchase it outright; then the equipment belongs to you,

    • 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, accessories, and oxygen contents.

      • Beyond the 36 months, Medicare will limit payments to replacement of accessories, and allows a small fee for monthly content and to check the equipment every six months.

  2. After an item has been purchased for you, you will be responsible for calling your provider any time 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.

Please call your private insurance provider for coverage.

 If you need an item that is not listed, please call us.

 

In addition, we are able to sell all of our new or used equipment if you want to pay cash

PULMONARY PROVIDERS GROUP, INC.


4521 W Lawrence Ave, Suite 110
Chicago, IL 60630
United States

Office Hours: 9:30a - 5:30p Mon - Fri
 

ph: 847-824-0500

fax: 847-824-0529

alt: 24-HOURS 877-214-0400