Questions About The Lymphedema Treatment Act/FAQs
Effective January 1, 2024, Medicare is paying for products used to treat and manage lymphedema.
With the roll-out of the Lymphedema Treatment Act (LTA), many within the lymphedema community are confronted with questions about how to obtain lymphedema products under the provisions of the LTA. Also, many are experiencing lengthy delays in obtaining the lymphedema products that they need, or are simply not able to get the specific items that they want. To help navigate the process of obtaining your lymphedema products, we created this page which will hopefully help you understand the process and allow you to get the products you need more quickly.
Do You Have Questions About Medicare Coverage Of Lymphedema Products Under The Lymphedema Treatment Act?
We are listing some of the more common questions, comments, concerns and frustrations that we are hearing about Medicare paying for products used to treat and manage lymphedema. By better understanding the provisions of the Lymphedema Treatment Act and some of the hurdles that you have to go through for Medicare to pay for your lymphedema products, we will hopefully make the process a little easier. Do any of the following situations apply to you?
"Do I meet the eligibilty criteria to qualify for Medicare coverage?"
The requirements for having Medicare pay for your lymphedema products under the Lymphedema Treatment Act are quite specific and patients are finding out that they don't qualify for coverage under the LTA for a variety of reasons:
- They don't have Medicare Part B coverage
- They have not formally been diagnosed as having lymphedema
- They have not seen an authorized practitioner in the past 6 months, or their medical records havn't been sufficiently documented with a plan of care for treating their condition
- They don't have a prescription for the lymphedema products they are seeking
- They are seeking products to treat venous insufficiency and not lymphedema
If any of the situations listed above apply to you, then you likely will not be eligible for Medicare to pay for lymphedema products that you need to treat your lymphedema.
.................................."The garments that I want are not being offered by my enrolled Medicare DMEPOS supplier."
For Medicare to pay for lymphedema products, they must be ordered through an enrolled Medicare DMEPOS (Durable Medical Equipment, Prosthetic and Orthotic Supplies) supplier. The established Medicare reimbursement rates for lymphedema products to enrolled suppliers under the LTA are limited and therefore not all products may be offered by these suppliers. This is especially true for many higher-end, higher-quality, more expensive products, as well as the general line of compression bandages and bandaging supplies. Many of the enrolled Medicare DMEPOS suppliers are simply not able to offer the more expensive lymphedema products due to the limited reimbursement rates.
Because of the limited reimbursement rates, even as a covered patient, you may experience a more limited offering of compression garments than you might otherwise expect. It is very likely that your options will be from a selection of basic, lower-grade products while the higher-end products will not be available to you under the Medicare reimbursement.
.................................."It is taking too long for me to get my lymphedema products!"
There are certain steps that need to be followed to obtain your products under the LTA.
Any delays in completing these steps, to include obtaining the required information, or insufficient documentation, will impact the timeframe in which you can expect to receive your products.
- First, you must find an enrolled Medicare DMEPOS supplier who offers the items that you want.
- Assuming that the products you desire will be covered, you will be required to provide a HIPPA (Privacy Rule), Medical Record Release and likely a Financial Responsibility Form to your supplier.
- Before processing the order, your supplier will need to obtain your medical records from your healthcare practitioner, which establish your eligibility for coverage under the LTA.
- Your medical records must be sufficiently documented to include your medical condition and plan of care for treating your lymphedema, to include:
- Diagnosis codes
- Stage/phase of lymphedema
- Duration of treatment/need for products
- Anatomical location(s) requiring treatment
- Type, description and quantity of products needed for treatment
- Measurements for compression garments, if applicable
- Frequency of product replacement
This is one of the most common complaints that we are hearing about obtaining your products under the Lymphedema Treatment Act. Because the LTA has specific requirements for Medicare to pay for lymphedema products, enrolled suppliers must ensure that each step is followed to make sure that they can be reimbursed. Furthermore, the need for medical records, along with the associated privacy rules of these records, makes the entire process dependent on the suppliers being able to get these records. Any delays in getting the records, or insufficient documentation contained therein, will certainly impact the timeframe in which you can expect to receive your items.
.................................."It is still costly for me to obtain my products under the LTA!"
While Medicare will pay for lymphedema products, as an eligible participant you are still required to pay the Medicare Part B $240 annual deductible, plus the on-going 20% co-pay for the products that you order.
Your enrolled supplier may be charging more for a covered product to ensure that they maximize the amount that they are reimbursed by Medicare under the LTA reimbursement rates. In this case, you are responsible for paying 20% of that higher amount as part of your co-payment. So for your initial purchase(s), you may be be paying more for your items ($240 deductible plus the 20% co-pay) than you otherwise would had you bought them for a lower cash-pay price. This is especially true if you are purchasing only a single or few items in a year.
Also, when you consider that you may be getting a lower grade of compression product, your annual out-of-pocket costs may become much higher as you will have to replace these products more frequently.
.................................."I don't have Medicare B coverage but I do have private insurance. Will my lymphedema products be covered under that plan?"
Coverage of compression products for treating lymphedema under a private insurance plan depends on the individual plan coverage. Your private insurance plan may or may not cover the lymphedema products that you need. You will have to check on your individual plan to see what items are, or are not covered. In cases where the products are covered, the plan’s reimbursement rates may not be the same as those specified by the LTA. Also, it is likely that you will be responsible for an annual deductible, plus an on-going co-pay for all items that you purchase through your plan.
While historically, private insurance plans have mirrored Medicare coverage, in several cases it appears that the private insurance coverage is LESS than what is offered under LTA Medicare coverage. If your private insurance plan fits into this category, you can expect that the lymphedema supplies you need likely will not be covered or obtainable through an insurance billing supplier.
Even if covered, you should also consider whether it is more economical for you to obtain your lymphedema products through your private insurance plan, paying the annual deductible and on-going co-pay, or simply self-pay through a lower priced cash payment supplier.
.................................."I need my products NOW and can't keep waiting while jumping through the hoops so that Medicare will pay. Can I purchase my lymphedema products from Bandages Plus and then submit the claim directly to Medicare or my private insurance by myself?"
The simple answer is YES! Medicare allows individual patients to file a claim for a variety of reasons, including cases where your provider is not enrolled in Medicare. Since Bandages Plus is not an enrolled DMEPOS (Durable Medical Equipment, Prosthetic and Orthotic Supplies) supplier, you can purchase your products and file a claim directly with Medicare. Information on how to file a claim, along with the required documents can be found on the Medicare website: How do I file a claim? For private insurance plans, you will have to check with your individual plan regarding the process and requirements, but you should be able to file a claim for your covered lymphedema products. You will likely have to submit an itemized invoice for all lymphedema products purchased, along with the corresponding HCPC code for each product. Click here to see the Healthcare Common Procedure Coding (HCPC) System Codes for lymphedema products covered under the LTA.
Please note that, other than providing an itemized bill for the lymphedema products purchased, Bandages Plus will not be able to assist you in submitting a claim directly with Medicare or your private insurance plan.
Bandages Plus offers competitive pricing for all compression products, and with excellent turnaround timeframes you can expect to have your needed supplies very quickly without having the long wait time that many are experiencing. While Bandages Plus can't guarantee the success of your claim, if you choose to purchase your lymphedema products with us and file a claim for reimbursement, you:
- Won't have to search for an enrolled Medicare supplier
- Will shorten the time that you have to wait for your products
- Can choose from all of the best lymphedema products in the industry
- Will be purchasing your products at some of the lowest prices in the industry
"I am having a hard time finding an enrolled Medicare DMEPOS supplier where I can get my lymphedema products."
To obtain lymphedema products and have Medicare pay, the products must be ordered through an enrolled Medicare DMEPOS (Durable Medical Equipment, Prosthetic and Orthotic Supplies) supplier. So unfortunately, if you want to get your garments through the provisions of the LTA, you will have to find an enrolled Medicare supplier who can offer the products that you want.
Bandages Plus is not a Medicare DMEPOS supplier and so we will not be able to provide lymphedema products under the LTA. While we have provided past referrals to recommended national medical coding and billing suppliers who can bill under the LTA, we are no longer participating in any referral process at this time.
.................................."I still have questions regarding the LTA and how I can get the lymphedema products that I need."
There are still a lot of questions regarding coverage under the LTA and the roll-out of this Act is a learning process for the entire lymphedema community. While we might not have all the answers, Bandages Plus remains committed to helping you to the best of our ability. If you have any unanswered questions, please email us at lta@bandagesplus.com and we will help how we can. You can also print the downloadable version of our summary on obtaining lymphedema products from Medicare.
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See Related Lymphedema Treatment Act Topics:
Why Order Compression Garments From Bandages Plus
Lymphedema Treatment Act (LTA)
Medicare Coverage For Lymphedema Supplies: A Checklist