How Are Nebulizers Covered by Medicare?

Nebulizers are medical devices that convert liquid medicine into a fine mist, which can then be inhaled directly into the lungs through a mouthpiece or mask. This method of drug delivery is often used for individuals experiencing various respiratory conditions, allowing medications to quickly reach the affected areas. Conditions such as asthma, chronic obstructive pulmonary disease (COPD), and cystic fibrosis frequently benefit from nebulizer therapy, as it helps manage symptoms like wheezing and clears lung secretions.

Nebulizer Coverage Under Medicare Part B

Medicare classifies nebulizers as Durable Medical Equipment (DME) due to their ability to withstand repeated use, serve a medical purpose, and be suitable for home use for at least three years. Medicare Part B, which covers medical insurance, is typically responsible for the costs associated with DME, including nebulizers and their necessary accessories. These accessories often include tubing, mouthpieces, and medication cups.

For Medicare Part B to cover a nebulizer, it must be prescribed by a physician for use in the home. This coverage extends not only to the nebulizer machine itself but also to certain medications administered through it, provided they are considered reasonable and necessary. While Medicare Part A (Hospital Insurance) may cover nebulizer costs if needed during inpatient care, Part B addresses home use.

Ensuring Medical Necessity and Eligibility

To qualify for Medicare coverage, a doctor must issue a prescription for the nebulizer and its associated medications, confirming they are medically necessary for a specific condition. The prescription and medical records must clearly document the diagnosis and the ongoing need for nebulizer therapy.

The doctor’s order, a Standard Written Order (SWO), must include the beneficiary’s name, the order date, a general description of the item, and the treating practitioner’s signature. It should also specify the frequency and dosage of medications, if applicable. Timely documentation is required to verify continued medical need.

Steps to Obtain Your Nebulizer and Supplies

After a physician determines medical necessity and provides documentation, the next step is acquiring the nebulizer. It is essential to obtain the equipment from a supplier enrolled in Medicare. Medicare provides an online supplier directory and resources like State Health Insurance Assistance Programs (SHIP) to help locate approved DME suppliers in your area.

After selecting a Medicare-approved supplier, provide them with the physician’s prescription and any supporting medical documentation. The supplier will then process the order, often handling the claim submission to Medicare on your behalf. They will also typically arrange for delivery of the nebulizer and provide instruction on its proper use, setup, and maintenance.

Financial Obligations and Billing

Under Medicare Part B, after the annual deductible is met, Medicare typically covers 80% of the Medicare-approved amount for the nebulizer and its accessories. The beneficiary is then responsible for the remaining 20% coinsurance.

Choosing a supplier who accepts “Medicare assignment” is beneficial because they agree to accept the Medicare-approved amount as full payment. This means they can only charge the beneficiary the deductible and coinsurance, preventing higher out-of-pocket costs. If a supplier does not accept assignment, they may charge more than the Medicare-approved amount, and the beneficiary could be responsible for the difference. Medicare Advantage Plans (Part C) also cover nebulizers, as they are required to provide at least the same coverage as Original Medicare, though cost-sharing rules may vary by plan.