Medicare coverage of lymphedema garments launched on January 1, 2024. While it’s great that patients are now covered, many questions remain about how that coverage will work.
Our team is working hard to understand all the details of this new coverage, and this update will help you understand how we’re approaching the implementation and why we’ve chosen our particular strategy. We will also provide more details on how we expect the implementation of Medicare coverage to evolve over time.
Here are some answers to our most frequently asked questions at this point:
Q: Are garments free?
No, Medicare coverage does not mean that garments are free, and using that term is very misleading. Medicare patients always have a 20% co-insurance and a $240 annual deductible for 2024. They will ALWAYS have SOME out-of-pocket costs associated with lymphedema garments unless they have a supplement or secondary insurance that picks up the remaining cost.
PLEASE ensure patients understand their garments will not be free even with this new coverage.
Q. How will Compression Care handle Medicare claims?
Until further notice, we will be processing Medicare claims as “non-assignment.” This means the patient will pay 100% upfront (as has historically been the case); but now, patients will receive any reimbursement they are due directly from Medicare via a check in the mail with their Explanation of Benefits (EOB).
Based on the expectations Medicare has set, we anticipate the reimbursement to be 80% of the allowable for each specific garment (all Medicare patients have a 20% co-insurance), less any remaining deductible that the patient has for this year (all Medicare patients have a $240 annual deductible). Those patients who may have a supplemental or secondary plan that picks up the 20% co-insurance, or potentially even the deductible, may also be reimbursed for those obligations.
In all cases, we will do our best to help patients understand what we EXPECT to happen; but since this is all so new for everyone, we don’t feel comfortable making any promises until we see this new program in action.
Q: What if a patient has a Medicare Advantage Plan (MAP) instead of traditional Medicare?
At this point, we have yet to see a MAP that has added this coverage. While we expect that will change at some point this year, MAPs are allowed to set their own pricing. We expect patients with MAPs will pay as much or more than those with traditional Medicare.
Q: Are therapists going to be paid a measuring fee?
No. During a conference call last year with the US Medical Compression Alliance, this was mentioned by one of the presenters in error. The new LTA law does not allow us to induce you, as a therapist, in any way.
However, we are aware of efforts underway to provide you with a code that you can bill under your typical services categories. As this develops, we will continue to pass along more information.
Q: Are all compression garments now covered by Medicare?
There is a lot of misinformation about which compression garments will be covered. The Lymphedema Treatment Act ONLY provides coverage for compression garments used for the treatment of lymphedema.
Coverage only applies to these 4 specific diagnosis codes:
- I89.0 Lymphedema, not elsewhere classified
- I97.2 Postmastectomy lymphedema syndrome
- I97.89 Other postprocedural complications and disorders of the circulatory system, not elsewhere classified
- Q82.0 Hereditary lymphedema
Q: What documentation is necessary to qualify for Medicare coverage?
For your ease of use, we’ve created a handout explaining the documentation requirements for Medicare coverage. Download the handout here.
If you need a form for the written physician order, here are convenient links to ours:
We Will Keep You Updated
The entire launch of Medicare’s coverage is fast-changing, and there are currently more questions than answers. As information evolves, we’ll keep you posted with the necessary updates and our plan to approach each stage of the process.
At Compression Care, our billing experts are at the forefront of DME retailers across the country. They are learning the best way to prevent patients from paying more out of pocket than necessary with this new Medicare coverage, which continues to be a driving principle of our company.
Please don’t hesitate to reach out if you have any questions about LTA implementation or anything else. Thank you for trusting us with the care of your patients!
Chief Operating Officer, Compression Care
Email: [email protected] | Phone: (629) 230-7774