Understanding Medicare Coverage
At Edgepark, we understand that insurance coverage, including Medicare, can be hard to figure out. That’s why we take the time to explain your benefits and take care of the insurance paperwork for you. The guide below explains how Edgepark works with Medicare to help you get the covered supplies you need.
What is covered?
Edgepark carries nearly 40,000 items, from more than 700 manufacturers
• Ostomy Supplies
Edgepark accepts Medicare assignment on most items. This means that Edgepark accepts Medicare’s reimbursement along with your financial responsibility (including applicable deductible or coinsurance) as payment in full. If you have a supplemental policy, you may have no financial responsibility!
*Edgepark does not bill Medicare for diabetes supplies.
When can I order?
Under Medicare guidelines, you must have nearly depleted the supplies you have at home to be eligible for additional products. Edgepark recommends you have 7 or fewer days’ worth of supplies remaining. If you have more than 7 days of supplies remaining, we will adjust your shipment date accordingly.
When you place your order, you will be asked:
1. Approximately how many of each supply (i.e. pouches, barriers, etc.) do you have remaining?
2. Typically, how many days will this amount of supplies last for you?
Knowing the answer to these two questions ahead of time will help with processing your order more accurately and efficiently.
If you have a nurse visiting you at home and you have Medicare coverage, all of your supplies must be provided to you by your home care agency. The homecare facility is reimbursed for these supplies through Medicare based on a predetermined, fixed amount. This method of reimbursement is referred to as PPS (Prospective Payment System).
How much is covered?
Understanding What Quantities of Supplies Are Covered
Medicare refers to this as Limits.
Medicare provides coverage for a specific quantity of each type of supply, also called a “limit.” While placing your order, if you request an amount that is over the limit, we will let you know.
If you have a medical need for additional supplies, we will contact your doctor for a prescription and supporting clinical documentation as required by Medicare.
What is my financial responsibility?
Understanding Your Financial Responsibility
Your financial responsibility depends on your insurance coverage. The following
Medicare’s allowable price is $100.00 (allowable prices vary by state). Medicare will pay 80% of the $100.00 allowable price, which is $80.00. That means that your coinsurance will be 20% of $100.00, or $20.00.
If you have supplemental insurance, you may have no financial responsibility.
Understanding Additional Expenses
In some cases, Medicare may not reimburse you for certain medical supplies. For instance, if your request for an over-the-limit quantity of supplies is not approved by your doctor, or if you request certain types of supplies while under home care service, you will have to complete and send Edgepark an ABN (Advance Beneficiary Notice) form acknowledging that you are financially responsible for paying for these supplies. We will either mail or fax this form to you.
We may also request an updated prescription, also known as a PWO (Physician’s Written Order) from your doctor. Once we have reviewed this medical documentation, we will ship your supplies.
There may be times when Medicare requests that you fill out certain forms to process your order. These forms are available for download on our Required Forms & Instructions page.
Visit our Medicare FAQs page for more information.
Commonly Used Terms
The predetermined amount you must pay for a covered medical service first, before your insurance begins paying its share.
Medicare has specific quantity guidelines, or limits, for certain medical supplies.
This is the amount for which you are financially responsible once you’ve met your deductible. It is the percentage (typically 25% or less) of the allowed cost (allowable) for covered medical services, which you are responsible for paying.
A PPS (Prospective Payment System) is a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount to home health agencies.
If you are ordering a product that may or may not be covered by Medicare for your diagnosis, or you are ordering more than what is allowed, Medicare requires that Edgepark send you an ABN (Advance Beneficiary Notification) to make you aware of costs for which you are responsible, and that Medicare will most likely not reimburse you for the product.
This information is for educational purposes only; is not an endorsement of Edgepark by Medicare or other government agencies; and is subject to change based on Medicare regulations. Financial responsibility for supplies is subject to an individual’s insurance coverage.