You may have heard that starting January 1, 2024, Medicare launched coverage of compression garments for the treatment of lymphedema. While it’s great that we will now have access to this coverage, we caution patients and providers that many questions remain about how it will work.
At Pretty in Pink Boutique, our team is working hard to understand all the details of this new coverage and how it will affect you as the year progresses. It is essential to us that you never pay more out of pocket than necessary, so we are approaching this implementation very strategically.
Below are some details on how we expect Medicare coverage to evolve and some key elements of the LTA that it’s important to understand.
Here are some answers to our most frequently asked questions at this point:
Q: With Medicare, will compression garments for lymphedema be free?
Unfortunately, Medicare coverage of lymphedema garments does NOT mean they will be completely free.
As a Medicare patient, you have a $240 annual deductible and a 20% co-insurance for services. You will always have some out-of-pocket costs associated with lymphedema garments unless you have supplemental or secondary insurance to cover the remaining costs.
We are emphasizing this point to our patients so you never feel misled by the rollout of this new coverage.
Q. How will Pretty in Pink Boutique handle Medicare claims?
Until further notice, we will be processing all Medicare claims for compression garments for lymphedema as “non-assignment.” As has historically been the case, you will pay 100% upfront for your garments, and then we will file the claim on your behalf. We believe this is the best method so that Medicare will reimburse you directly via a check in the mail along with an Explanation of Benefits (EOB) explaining the amount that is reimbursed.
Based on the expectations Medicare has set, we expect your reimbursement amount to be 80% of the allowable for each specific garment (all Medicare patients have a 20% co-insurance), less any remaining deductible that you have for this year (all Medicare patients have a $240 annual deductible). If you have supplemental or secondary insurance that picks up the 20% co-insurance, or potentially even the deductible, you may also be reimbursed for those obligations.
In all cases, we will do our best to help you understand what we EXPECT to happen. Since this is all so new, we don’t feel comfortable making any promises until we see this new program in action.
Q: What if I have 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 to pay as much or more than those with traditional Medicare. As more information comes out, we will keep you updated on how MAPs address the LTA implementation.
Q: Does Medicare now cover all compression garments?
The Lymphedema Treatment Act ONLY provides coverage for compression garments used to treat lymphedema.
There is a lot of misinformation about this topic, so we want to help communicate that compression garments for medical conditions other than lymphedema will not be included.
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 launch of Medicare’s coverage is fast-changing, and there are currently more questions than answers. Our driving principle is to ensure you never pay more out of pocket than necessary, so we are approaching this implementation conservatively.
At Pretty in Pink Boutique, we have some of the best billing experts in the country, so we will continue to learn and evolve our processes as the year progresses. We will also keep you posted with the necessary updates and our plan of approach.
Please don’t hesitate to ask any questions about The Lymphedema Treatment Act, your medicare coverage, or anything else in your treatment process. Thank you for trusting us with your care!