Durable Medical Equipment (DME a. Coverage includes purchase or rental, when Medically Necessary, of such DME that:
i. can withstand repeated use (i.e. could normally be rented and used by successive patients);
ii. is primarily and customarily used to serve a medical purpose;
iii. generally is not useful to a person in the absence of illness or injury; and
iv. is appropriate for use in a Member’s home.
b. Some examples of DME are: standard hospital beds, crutches, canes, walkers, wheelchairs, oxygen, respiratory equipment, apnea monitors and insulin pumps. DME does not include hearing aids or corrective lenses, dental devices, or the professional fees for fitting same. It also does not include medical supplies and devices, such as a corset, which do not require prescriptions. AvMed will pay for rental of equipment up to the purchase price. Repair of Member owned DME, and replacement of DME solely because it is old or used, is not covered.
c. The determination of whether a covered item will be paid under the DME, orthotics or prosthetics benefits will be based upon its classification as defined by the Centers for Medicare and Medicaid Services.
Durable Medical Equipment (DME. Benefits are provided for DME. If more than one item can meet your functional needs, Benefits are available only for the item that meets the minimum specifications for your needs. If you purchase an item that exceeds these minimum specifications, we will pay only the amount that we would have paid for the item that meets the minimum specifications, and you will be responsible for paying any difference in cost. DME includes, but isn’t limited to: • Canes. • Cochlear implants and batteries for cochlear implants. • Commode chairs. • Continuous glucose monitors. • Continuous passive motion devices. • Continuous Positive Airway Pressure (CPAP) devices. • Crutches. • Hospital beds. • Insulin pumps. • Infusion pumps. • Nebulizers and peak flow meters. • Oxygen equipment. • Patient lifts. • Pressure-reducing support surfaces. • Suction pumps. • Traction equipment. • Walkers.
Durable Medical Equipment (DME a. Coverage includes purchase or rental, when Medically Necessary, of such DME that:
i. can withstand repeated use (i.e. could normally be rented and used by successive patients);
ii. is primarily and customarily used to serve a medical purpose;
iii. generally is not useful to a person in the absence of illness or injury; and
iv. is appropriate for use in a Member’s home.
b. Some examples of DME are: standard hospital beds, crutches, canes, walkers, wheelchairs, oxygen, respiratory equipment, apnea monitors and insulin pumps. DME does not include hearing aids or corrective lenses, dental devices, or the professional fees for fitting same. It also does not include medical supplies and devices, such as a corset, which do not require prescriptions. AvMed will pay for rental of equipment up to the purchase price.
c. The determination of whether a covered item will be paid under the DME, orthotics or prosthetics benefits will be based upon its classification as defined by the Centers for Medicare and Medicaid Services.
Durable Medical Equipment (DME. You must purchase or rent the DME from the vendor we identify or purchase it directly from the prescribing Network Physician. 40% Yes Yes
Durable Medical Equipment (DME. Medical equipment that can withstand repeated use, is customarily used to serve a medical purpose, is generally not useful in the absence of illness or injury and is appropriate for use in the enrollee’s home.
Durable Medical Equipment (DME. Provider – a Participating Provider of Durable Medical Equipment that has contracted with the HMO to provide Covered Supplies to Members.
Durable Medical Equipment (DME. As medically necessary. Specified DME services shall be covered/non-covered in accordance with TennCare rules and regulations. Medical Supplies As medically necessary. Specified medical supplies shall be covered/non-covered in accordance with TennCare rules and regulations. Emergency Air And Ground Ambulance Transportation As medically necessary. Non-emergency Medical Transportation (including Non- Emergency Ambulance Transportation) Covered non-emergency medical transportation (NEMT) services are necessary non-emergency transportation services provided to convey members to and from TennCare covered services (see definition in Exhibit A to Attachment XI). Non emergency transportation services shall be provided in accordance with federal law and the Bureau of TennCare’s rules and policies and procedures. TennCare covered services (see definition in Exhibit A to Attachment XI) include services provided to a member by a non-contract or non-TennCare provider if (a) the service is covered by Tennessee’s Medicaid State Plan or Section 1115 demonstration waiver, (b) the provider could be a TennCare provider for that service, and (c) the service is covered by a third party resource (see definition in Section 1 of the Agreement). If a member requires assistance, an escort (as defined in TennCare rules and regulations) may accompany the member; however, only one (1) escort is allowed per member (see TennCare rules and regulations). Except for fixed route and commercial carrier transport, the CONTRACTOR shall not make separate or additional SERVICE BENEFIT LIMIT payment to a NEMT provider for an escort. Covered NEMT services include having an accompanying adult ride with a member if the member is under age eighteen (18). Except for fixed route and commercial carrier transport, the CONTRACTOR shall not make separate or additional payment to a NEMT provider for an adult accompanying a member under age eighteen (18). The CONTRACTOR is not responsible for providing NEMT to HCBS, including services provided through a 1915(c) waiver program for persons with intellectual disabilities (i.e., mental retardation) and HCBS provided through the CHOICES program. However, as specified in Section 2.11.1.8 in the event the CONTRACTOR is unable to meet the access standard for adult day care (see Attachment III) for CHOICES Group 2 or 3 members, the CONTRACTOR shall provide and pay for the cost of transportation for the member to the adult day care facility until such time the CONTRAC...
Durable Medical Equipment (DME a. Items that are not covered include:
i. bed related items: bed trays, over-the-bed tables, bed wedges, pillows, custom bedroom equipment, mattresses, including non-power mattresses, custom mattresses and posturepedic mattresses;
ii. bath related items: bath lifts, non-portable whirlpools, bathtub rails, toilet rails, raised toilet seats, bath benches, bath stools, hand held showers, paraffin baths, bath mats, and spas;
iii. chairs, lifts and standing devices: computerized or gyroscopic mobility systems, roll about chairs, geriatric chairs, hip chairs, seat lifts (mechanical or motorized), patient lifts (mechanical or motorized – manual hydraulic lifts are covered if patient is 2-person transfer), and auto tilt chairs;
iv. electric or powered scooters; non-standard customized wheelchairs, motorized or manual;
v. fixtures to real property, including ceiling lifts and wheelchair ramps;
vi. car/van modifications;
vii. air quality items: air conditioners, room humidifiers, vaporizers, air purifiers and electrostatic machines;
viii. blood/injection related items: blood pressure cuffs, centrifuges, nova pens and needleless injectors; and
ix. other equipment: heat lamps, heating pads, cryounits, cryotherapy machines, electronic- controlled therapy units, ultraviolet cabinets, sheepskin pads and boots, postural drainage board, AC/DC adaptors, enuresis alarms, magnetic equipment, scales (baby and adult), stair gliders, elevators, saunas, any exercise equipment, emergency alert equipment, and diathermy machines.
b. The replacement of DME solely because it is old or used is excluded.
Durable Medical Equipment (DME. Coverage includes purchase or rental when Medically Necessary, of such DME that:
Durable Medical Equipment (DME. You must purchase or rent the DME from the vendor we identify or purchase it directly from the prescribing Network Physician. 40% Yes Yes SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Amounts or, for specific Covered Health Care Services as described in the definition of Recognized Amount in the Policy, Recognized Amounts. The Allowed Amounts provision near the end of this Schedule of Benefits will tell you when you are responsible for amounts that exceed the Allowed Amount.
