External Infusion Pumps
- Does Medicare Cover External Infusion Pumps? External infusion pumps are medical devices used to deliver drugs under pressure at a controlled flow rate directly into a vein or muscle. There are various conditions and criteria that you must meet in order to get coverage under Medicare. Your doctor or supplier can give you more detailed information regarding those requirements. If Medicare covers the infusion pump, then any drugs and needed supplies will also be covered. If Medicare doesn’t cover your infusion pump, supplemental health insurance may be needed to help cover the cost.
To ensure that Medicare pays for your external infusion pump you must follow the steps below:
- Only your doctor can prescribe an external infusion pump for you, so do not order anything until you have visited your doctor, no matter what the sales person tells you.
- The doctor must document your need for an external infusion pump in your medical records, and give you a signed and dated order (prescription) for it.
- The supplier must receive the order before Medicare is billed and it must be kept on file by the supplier.
- If you receive your Medicare through a Medicare Advantage Plan (like an HMO or PPO) it is likely you will have to follow the plan’s steps for approval and purchase. Call your plan’s customer service number and ask about their steps for coverage of an external infusion pump. Your doctor must complete a Certificate of Medical Necessity.
Medicare Part B and External Infusion Pumps
You must have Medicare Part B coverage and your doctor must have documented your need for the external infusion pump and required medications. The doctor must also write you an order (prescription) for the supplies clearly stating why you need it. You must be able to show that the drugs used with the pump are in themselves reasonable and necessary for treatment. This therapy is often started in the hospital and can continue at home after discharge, but it can also be started at home. Longer-term infusion therapy, the kind done at home, usually requires an access site on the torso of the body, rather than in the arms or hands. Therapy may continue until the patient no longer needs the medication or is able to go to an ambulatory infusion center or physician office for ongoing infusions.
Some of the most common reasons for needing home infusion therapy include the following:
- Chronic pain
- Gastrointestinal (GI) problems, Crohn’s disease, bowel obstructions, irritable bowel syndrome
- Heart failure
- Immune system problems
- Serious infections
Home use will require interaction with a team of health care providers that include the doctor, an infusion pharmacist and nurse. Each plays a key role:
- The doctor orders the medication and evaluates its effectiveness through lab tests and input from the pharmacist and nurse.
- The pharmacist prepares the prescribed medication and ensures that the medication, infusion pump, and supplies are delivered to the right patient, at the right time, in the right dosage.
- The nurse teaches the patient/caregiver how to use the pump and medication, so that they can do it independently.
External Infusion Pump Costs
External infusion pumps are in the Capped Rental category for durable medical equipment; that means you may choose to rent or purchase an infusion pump. How much you pay will depend on whether or not you have Part B coverage.
However, in general, if you are enrolled in Medicare Part B:
- After you have paid your yearly deductible, you will pay 20% of the approved Medicare amount.
- If you have a Medigap/Medicare Supplemental plan, you might owe little to no money.
- You will pay less if you buy from a supplier who accepts assignment.
- If you receive your Medicare through a Medicare Advantage Plan, you may owe little to nothing depending on the plan with which you have signed up and your benefits with the plan.
It is important to do your homework. Read about the factors that affect how much coverage you will receive. Make sure all paperwork is completed correctly and that you buy your equipment through an approved supplier that accepts assignment.
External Infusion Pump through Certified Dealers
You will save money if you order from a Medicare-approved provider. Suppliers must meet strict standards to qualify as a Medicare supplier and will have a Medicare supplier number. You may also buy your pump from any store that sells them. However, if the supplier from which you order your external infusion pump is not enrolled in Medicare, Medicare will not pay for the equipment.
Things you should think about before you choose a supplier:
- There are two types of Medicare suppliers: participating suppliers and those who are enrolled but have chosen not to participate.
- Participating suppliers will not charge more than the Medicare allowed amount.
- A Medicare-approved provider who does not want to participate can charge more than the Medicare-approved amount. However, they cannot charge more than 15% above the Medicare-approved amount. They may also ask you to pay the entire bill when you pick up the equipment. In this situation Medicare will send the reimbursement directly to you. However, be prepared to wait; it may take a couple of months to receive payment.
- If you receive your Medicare coverage through a Medicare Advantage Plan (like an HMO or PPO), it is likely that the plan will have its own steps for equipment purchases. In addition, the plan may have restrictions on the supplier from which you can buy. It is important to know that your health plan must supply at least what Medicare covers—they cannot supply less. Depending on your plan you may actually receive more coverage than you would get with Medicare alone. It is wise to call your Medicare Advantage Plan’s customer service and ask about your coverage before you order an external infusion pumps and supplies.