H&J DME Accepted Insurances
In network provider for Medicare, NY Medicaid and most private insurances.
We are also a Medicare competitive bid winner in the prefabricated knee brace category.
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Accepted Insurance Plans
We accept a wide range of insurance plans to cover your durable medical equipment (DME) and supplies. Hover over each plan for comprehensive details. All information is provided to help you understand coverage requirements, eligibility criteria, and plan specifics without leaving our site.
Major Insurance Providers
AETNA
Aetna provides comprehensive coverage including DME.
Pros: Extensive national network, broad coverage options.
Cons: Some items may need pre-authorization; plan details vary by region.
Ideal For: Individuals seeking a large network and multiple plan types (Employer, Individual, Medicare Advantage).
Eligibility & Documentation:
Premiums vary by plan type and region.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
For employer or marketplace plans, you’ll generally meet a deductible first. Afterward, co‑pays or co‑insurance apply until you reach your out‑of‑pocket maximum. For Medicare Advantage, the Part B deductible and co‑insurance rules apply. Check your Summary of Benefits or Evidence of Coverage for exact amounts.
Telehealth Services:
Aetna often provides telehealth options for consultations and follow‑ups. You may discuss DME needs, get prescriptions, or obtain referrals remotely. Telehealth may have standard co‑pays or be low‑cost. Verify details on the member portal or by calling member services.
Coverage Limits and Exclusions:
DME must be medically necessary. Some items may have yearly quantity limits or may not be covered if considered “convenience” items.
Prior Authorizations & Referrals:
Certain DME may require prior authorization. A doctor’s prescription or referral might be needed.
How to Verify Coverage:
Check your member handbook or call Aetna member services. Ask for in‑network DME providers and pre‑authorization requirements.
Claim Submission Tips:
Usually, DME suppliers bill Aetna directly. Keep copies of prescriptions and approval letters.
Pros: Extensive national network, broad coverage options.
Cons: Some items may need pre-authorization; plan details vary by region.
Ideal For: Individuals seeking a large network and multiple plan types (Employer, Individual, Medicare Advantage).
Eligibility & Documentation:
- Employer: Must meet employer criteria.
- Individual/Family: ACA enrollment periods; income/residency documents may be needed.
- Medicare Advantage: Have Medicare A & B and live in plan area.
Premiums vary by plan type and region.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
For employer or marketplace plans, you’ll generally meet a deductible first. Afterward, co‑pays or co‑insurance apply until you reach your out‑of‑pocket maximum. For Medicare Advantage, the Part B deductible and co‑insurance rules apply. Check your Summary of Benefits or Evidence of Coverage for exact amounts.
Telehealth Services:
Aetna often provides telehealth options for consultations and follow‑ups. You may discuss DME needs, get prescriptions, or obtain referrals remotely. Telehealth may have standard co‑pays or be low‑cost. Verify details on the member portal or by calling member services.
Coverage Limits and Exclusions:
DME must be medically necessary. Some items may have yearly quantity limits or may not be covered if considered “convenience” items.
Prior Authorizations & Referrals:
Certain DME may require prior authorization. A doctor’s prescription or referral might be needed.
How to Verify Coverage:
Check your member handbook or call Aetna member services. Ask for in‑network DME providers and pre‑authorization requirements.
Claim Submission Tips:
Usually, DME suppliers bill Aetna directly. Keep copies of prescriptions and approval letters.
AETNA BETTER HEALTH
Aetna Better Health focuses on Medicaid‑based managed care, including DME.
Pros: Low or no out‑of‑pocket cost for eligible individuals.
Cons: Eligibility rules vary by state.
Ideal For: Low‑income individuals/families who qualify for Medicaid.
Eligibility & Documentation:
Generally, minimal or no premiums for Medicaid beneficiaries.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Medicaid typically imposes little to no deductibles or co‑pays for DME. Out‑of‑pocket costs are minimal, ensuring services remain accessible.
Telehealth Services:
Aetna Better Health may offer telehealth for consultations or follow‑ups, saving travel time. This can help quickly secure medical orders or verify DME needs. Confirm availability with member services.
Coverage Limits and Exclusions:
Coverage follows Medicaid guidelines. Some items may require medical justification and certain non‑essential items might not be covered.
Prior Authorizations & Referrals:
Many DME items need prior authorization. A doctor’s order is typically required.
How to Verify Coverage:
Review your Medicaid benefits handbook or call Aetna Better Health member services.
Claim Submission Tips:
Your DME supplier usually handles claims. Keep approval letters on file.
Pros: Low or no out‑of‑pocket cost for eligible individuals.
Cons: Eligibility rules vary by state.
Ideal For: Low‑income individuals/families who qualify for Medicaid.
Eligibility & Documentation:
- Must meet state Medicaid income/resource criteria.
Generally, minimal or no premiums for Medicaid beneficiaries.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Medicaid typically imposes little to no deductibles or co‑pays for DME. Out‑of‑pocket costs are minimal, ensuring services remain accessible.
Telehealth Services:
Aetna Better Health may offer telehealth for consultations or follow‑ups, saving travel time. This can help quickly secure medical orders or verify DME needs. Confirm availability with member services.
Coverage Limits and Exclusions:
Coverage follows Medicaid guidelines. Some items may require medical justification and certain non‑essential items might not be covered.
Prior Authorizations & Referrals:
Many DME items need prior authorization. A doctor’s order is typically required.
How to Verify Coverage:
Review your Medicaid benefits handbook or call Aetna Better Health member services.
Claim Submission Tips:
Your DME supplier usually handles claims. Keep approval letters on file.
ANTHEM BCBS
Anthem Blue Cross Blue Shield offers various plans (Employer, Individual, Medicare Advantage) with DME coverage.
Pros: Large network, preventive health emphasis.
Cons: Some DME may need pre‑authorization; costs vary.
Ideal For: Those seeking a well‑known brand and diverse plan options.
Eligibility & Documentation:
Premiums depend on plan type and region.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
For commercial and marketplace plans, you’ll usually have a deductible, then pay co‑pays or co‑insurance until reaching the out‑of‑pocket maximum. Medicare Advantage may involve the Part B deductible and a set co‑insurance for DME. Refer to your Summary of Benefits or Evidence of Coverage.
Telehealth Services:
Anthem often includes telehealth benefits. You can consult with providers for DME‑related needs virtually. Telehealth might have a similar or lower cost‑share than in‑person visits. Check member resources.
Coverage Limits and Exclusions:
Coverage typically extends to medically necessary DME. Some equipment may have annual quantity limits.
Prior Authorizations & Referrals:
Certain DME may require prior authorization or a referral.
How to Verify Coverage:
Check your Summary of Benefits or call Anthem BCBS member services.
Claim Submission Tips:
Suppliers typically bill Anthem directly. Keep prescriptions and authorization letters.
Pros: Large network, preventive health emphasis.
Cons: Some DME may need pre‑authorization; costs vary.
Ideal For: Those seeking a well‑known brand and diverse plan options.
Eligibility & Documentation:
- Employer: Meet employer eligibility rules.
- Individual/Family: ACA enrollment; provide residency/income for subsidies.
- Medicare Advantage: Have A & B, reside in service area.
Premiums depend on plan type and region.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
For commercial and marketplace plans, you’ll usually have a deductible, then pay co‑pays or co‑insurance until reaching the out‑of‑pocket maximum. Medicare Advantage may involve the Part B deductible and a set co‑insurance for DME. Refer to your Summary of Benefits or Evidence of Coverage.
Telehealth Services:
Anthem often includes telehealth benefits. You can consult with providers for DME‑related needs virtually. Telehealth might have a similar or lower cost‑share than in‑person visits. Check member resources.
Coverage Limits and Exclusions:
Coverage typically extends to medically necessary DME. Some equipment may have annual quantity limits.
Prior Authorizations & Referrals:
Certain DME may require prior authorization or a referral.
How to Verify Coverage:
Check your Summary of Benefits or call Anthem BCBS member services.
Claim Submission Tips:
Suppliers typically bill Anthem directly. Keep prescriptions and authorization letters.
CIGNA
Cigna provides nationwide coverage across Employer, Individual, and Medicare Advantage plans.
Pros: Global network, various plan options.
Cons: Some plans may have higher premiums or require referrals.
Ideal For: Those needing coverage in multiple locations.
Eligibility & Documentation:
Premiums vary by plan type.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
After meeting your deductible, co‑pays or co‑insurance may apply. Out‑of‑pocket maximums limit yearly costs. Medicare Advantage members follow Part B rules plus plan specifics. Check your plan’s Summary of Benefits.
Telehealth Services:
Cigna typically offers telehealth. You can get consults, approvals, or prescriptions for DME items online, often at reduced cost. Review your member portal for telehealth details.
Coverage Limits and Exclusions:
DME must be medically necessary. Non‑essential items may be excluded.
Prior Authorizations & Referrals:
Some DME requires prior authorization and a physician’s order.
How to Verify Coverage:
Review your Explanation of Coverage or call Cigna member services.
Claim Submission Tips:
DME providers usually handle claims. Retain prescriptions and approvals.
Pros: Global network, various plan options.
Cons: Some plans may have higher premiums or require referrals.
Ideal For: Those needing coverage in multiple locations.
Eligibility & Documentation:
- Employer: Meet employer criteria.
- Individual/Family: Enroll during ACA periods; income/residency docs as needed.
- Medicare Advantage: Have A & B, reside in plan area.
Premiums vary by plan type.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
After meeting your deductible, co‑pays or co‑insurance may apply. Out‑of‑pocket maximums limit yearly costs. Medicare Advantage members follow Part B rules plus plan specifics. Check your plan’s Summary of Benefits.
Telehealth Services:
Cigna typically offers telehealth. You can get consults, approvals, or prescriptions for DME items online, often at reduced cost. Review your member portal for telehealth details.
Coverage Limits and Exclusions:
DME must be medically necessary. Non‑essential items may be excluded.
Prior Authorizations & Referrals:
Some DME requires prior authorization and a physician’s order.
How to Verify Coverage:
Review your Explanation of Coverage or call Cigna member services.
Claim Submission Tips:
DME providers usually handle claims. Retain prescriptions and approvals.
EMPIRE BLUE CROSS BLUE SHIELD
Empire BCBS serves New York State with various plan types (Employer, Individual, Medicare Advantage).
Pros: Strong local network.
Cons: Coverage varies by tier; pre‑authorizations may apply.
Ideal For: NY residents seeking a well‑known, local plan.
Eligibility & Documentation:
Premiums differ by plan. Subsidies may apply for marketplace plans.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
You’ll typically meet a deductible, then pay co‑pays or co‑insurance for DME. Medicare Advantage members may owe Part B cost‑sharing. Annual out‑of‑pocket maximums limit expenses. Check your Summary of Benefits.
Telehealth Services:
Empire often includes telehealth options to consult with providers for DME prescriptions or follow‑ups. Telehealth may have similar or lower cost‑sharing than in‑person visits. Confirm details in member materials.
Coverage Limits and Exclusions:
DME must be medically necessary. Non‑essential or comfort items may not be covered.
Prior Authorizations & Referrals:
Some DME requires prior authorization and a doctor’s prescription.
How to Verify Coverage:
Review plan materials or call Empire BCBS member services.
Claim Submission Tips:
Suppliers typically bill directly. Keep medical necessity documents.
Pros: Strong local network.
Cons: Coverage varies by tier; pre‑authorizations may apply.
Ideal For: NY residents seeking a well‑known, local plan.
Eligibility & Documentation:
- Employer: Follow employer eligibility rules.
- Individual/Family: ACA enrollment; NY residency/income for subsidies.
- Medicare Advantage: Have A & B, live in Empire’s NY service area.
Premiums differ by plan. Subsidies may apply for marketplace plans.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
You’ll typically meet a deductible, then pay co‑pays or co‑insurance for DME. Medicare Advantage members may owe Part B cost‑sharing. Annual out‑of‑pocket maximums limit expenses. Check your Summary of Benefits.
Telehealth Services:
Empire often includes telehealth options to consult with providers for DME prescriptions or follow‑ups. Telehealth may have similar or lower cost‑sharing than in‑person visits. Confirm details in member materials.
Coverage Limits and Exclusions:
DME must be medically necessary. Non‑essential or comfort items may not be covered.
Prior Authorizations & Referrals:
Some DME requires prior authorization and a doctor’s prescription.
How to Verify Coverage:
Review plan materials or call Empire BCBS member services.
Claim Submission Tips:
Suppliers typically bill directly. Keep medical necessity documents.
FIDELIS
Fidelis Care offers Medicaid, Child Health Plus, Essential Plans, and Medicare Advantage in NY.
Pros: Affordable state‑sponsored options.
Cons: Regional limitations in NY.
Ideal For: NY residents seeking cost‑effective coverage through public programs.
Eligibility & Documentation:
Medicaid/CHP often have no or low premiums. Essential Plans and Medicare Advantage vary.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Medicaid beneficiaries typically have minimal or no cost‑sharing. Essential and Medicare Advantage plans may have small co‑pays or co‑insurance. Check plan specifics.
Telehealth Services:
Fidelis often supports telehealth appointments. Members can get DME‑related consults or follow‑ups online, potentially with low or no co‑pay. Confirm with member services.
Coverage Limits and Exclusions:
DME must be medically necessary. Certain limits apply.
Prior Authorizations & Referrals:
Many DME items require authorization and a doctor’s order.
How to Verify Coverage:
Check the member handbook or call Fidelis member services.
Claim Submission Tips:
Suppliers handle billing. Keep approval letters.
Pros: Affordable state‑sponsored options.
Cons: Regional limitations in NY.
Ideal For: NY residents seeking cost‑effective coverage through public programs.
Eligibility & Documentation:
- Medicaid/CHP/Essential: Meet income/resource limits; provide residency/income proof.
- Medicare Advantage: Have A & B, live in service area.
Medicaid/CHP often have no or low premiums. Essential Plans and Medicare Advantage vary.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Medicaid beneficiaries typically have minimal or no cost‑sharing. Essential and Medicare Advantage plans may have small co‑pays or co‑insurance. Check plan specifics.
Telehealth Services:
Fidelis often supports telehealth appointments. Members can get DME‑related consults or follow‑ups online, potentially with low or no co‑pay. Confirm with member services.
Coverage Limits and Exclusions:
DME must be medically necessary. Certain limits apply.
Prior Authorizations & Referrals:
Many DME items require authorization and a doctor’s order.
How to Verify Coverage:
Check the member handbook or call Fidelis member services.
Claim Submission Tips:
Suppliers handle billing. Keep approval letters.
HUMANA
Humana focuses on Medicare Advantage plans with DME coverage.
Pros: Senior‑focused plans, good support.
Cons: Availability varies by county.
Ideal For: Medicare beneficiaries seeking a range of plan options.
Eligibility & Documentation:
Monthly premiums may apply in addition to Part B.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
You may owe the Part B deductible if not already met, plus co‑insurance for DME. Humana Medicare Advantage plans have an annual out‑of‑pocket maximum that limits your total spending.
Telehealth Services:
Humana often offers telehealth coverage. You can discuss DME needs, get prescriptions, or seek authorizations virtually. Costs are often similar or less than in‑person visits. Check your Evidence of Coverage.
Coverage Limits and Exclusions:
Only medically necessary DME is covered.
Prior Authorizations & Referrals:
Many DME items require prior authorization and a doctor’s prescription.
How to Verify Coverage:
Review your Evidence of Coverage or call Humana member services.
Claim Submission Tips:
Suppliers usually bill Humana. Keep Medicare and Humana IDs on hand.
Pros: Senior‑focused plans, good support.
Cons: Availability varies by county.
Ideal For: Medicare beneficiaries seeking a range of plan options.
Eligibility & Documentation:
- Medicare Advantage: Have A & B, reside in Humana’s service area.
Monthly premiums may apply in addition to Part B.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
You may owe the Part B deductible if not already met, plus co‑insurance for DME. Humana Medicare Advantage plans have an annual out‑of‑pocket maximum that limits your total spending.
Telehealth Services:
Humana often offers telehealth coverage. You can discuss DME needs, get prescriptions, or seek authorizations virtually. Costs are often similar or less than in‑person visits. Check your Evidence of Coverage.
Coverage Limits and Exclusions:
Only medically necessary DME is covered.
Prior Authorizations & Referrals:
Many DME items require prior authorization and a doctor’s prescription.
How to Verify Coverage:
Review your Evidence of Coverage or call Humana member services.
Claim Submission Tips:
Suppliers usually bill Humana. Keep Medicare and Humana IDs on hand.
Medicaid and Medicare
AFFINITY
Affinity Health Plan provides Medicaid managed care.
Pros: Comprehensive low‑cost coverage for eligible NY residents.
Cons: Limited regional availability.
Ideal For: Medicaid‑eligible individuals seeking managed care options.
Eligibility & Documentation:
Typically no premiums for Medicaid enrollees.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Medicaid usually involves little to no cost‑sharing for DME. Out‑of‑pocket expenses are minimal or zero.
Telehealth Services:
Affinity may offer telehealth visits for DME‑related consultations. This can streamline getting approvals or prescriptions. Verify with member services.
Coverage Limits and Exclusions:
Must be medically necessary. Certain limits apply based on Medicaid rules.
Prior Authorizations & Referrals:
Many DME requests require prior authorization and a doctor’s order.
How to Verify Coverage:
Check Affinity member materials or call member services.
Claim Submission Tips:
Suppliers file claims. Keep any approval letters.
Pros: Comprehensive low‑cost coverage for eligible NY residents.
Cons: Limited regional availability.
Ideal For: Medicaid‑eligible individuals seeking managed care options.
Eligibility & Documentation:
- Medicaid Managed Care: Meet NY Medicaid income/resource criteria.
Typically no premiums for Medicaid enrollees.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Medicaid usually involves little to no cost‑sharing for DME. Out‑of‑pocket expenses are minimal or zero.
Telehealth Services:
Affinity may offer telehealth visits for DME‑related consultations. This can streamline getting approvals or prescriptions. Verify with member services.
Coverage Limits and Exclusions:
Must be medically necessary. Certain limits apply based on Medicaid rules.
Prior Authorizations & Referrals:
Many DME requests require prior authorization and a doctor’s order.
How to Verify Coverage:
Check Affinity member materials or call member services.
Claim Submission Tips:
Suppliers file claims. Keep any approval letters.
AGEWELL
AgeWell NY integrates Medicare and Medicaid for seniors and those needing long‑term care.
Pros: Integrated, senior‑focused coverage.
Cons: Regional to NY.
Ideal For: NY seniors who are dual‑eligible.
Eligibility & Documentation:
Dual‑eligibles often pay little to no premiums.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Dual‑eligible plans usually have minimal out‑of‑pocket costs for DME due to Medicaid subsidies.
Telehealth Services:
AgeWell may provide telehealth for LTC and DME coordination. Seniors can get assessments or renew prescriptions remotely. Check with member services.
Coverage Limits and Exclusions:
DME must be medically necessary. Certain limits may apply.
Prior Authorizations & Referrals:
Prior authorization common. A physician’s order is typically required.
How to Verify Coverage:
Review plan materials or call AgeWell member services.
Claim Submission Tips:
Suppliers handle claims. Keep approval letters.
Pros: Integrated, senior‑focused coverage.
Cons: Regional to NY.
Ideal For: NY seniors who are dual‑eligible.
Eligibility & Documentation:
- Medicare: Have A & B.
- Medicaid: Meet state criteria.
Dual‑eligibles often pay little to no premiums.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Dual‑eligible plans usually have minimal out‑of‑pocket costs for DME due to Medicaid subsidies.
Telehealth Services:
AgeWell may provide telehealth for LTC and DME coordination. Seniors can get assessments or renew prescriptions remotely. Check with member services.
Coverage Limits and Exclusions:
DME must be medically necessary. Certain limits may apply.
Prior Authorizations & Referrals:
Prior authorization common. A physician’s order is typically required.
How to Verify Coverage:
Review plan materials or call AgeWell member services.
Claim Submission Tips:
Suppliers handle claims. Keep approval letters.
ALPHACARE
AlphaCare offers integrated Medicare‑Medicaid services, focusing on home/community‑based care.
Pros: Strong in‑home support for chronic conditions.
Cons: Limited NY service area.
Ideal For: Those needing coordinated in‑home LTC.
Eligibility & Documentation:
Dual‑eligibles often have minimal costs.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Usually minimal or no out‑of‑pocket costs for DME, given dual coverage.
Telehealth Services:
AlphaCare may offer telehealth visits for DME needs. This can expedite authorization and reduce travel. Confirm with member services.
Coverage Limits and Exclusions:
DME must be needed for home care. Some limits apply.
Prior Authorizations & Referrals:
A physician’s order and authorization commonly required.
How to Verify Coverage:
Review AlphaCare materials or call member services.
Claim Submission Tips:
Suppliers bill directly. Keep documentation.
Pros: Strong in‑home support for chronic conditions.
Cons: Limited NY service area.
Ideal For: Those needing coordinated in‑home LTC.
Eligibility & Documentation:
- Medicare: Have A & B.
- Medicaid: Meet eligibility rules.
Dual‑eligibles often have minimal costs.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Usually minimal or no out‑of‑pocket costs for DME, given dual coverage.
Telehealth Services:
AlphaCare may offer telehealth visits for DME needs. This can expedite authorization and reduce travel. Confirm with member services.
Coverage Limits and Exclusions:
DME must be needed for home care. Some limits apply.
Prior Authorizations & Referrals:
A physician’s order and authorization commonly required.
How to Verify Coverage:
Review AlphaCare materials or call member services.
Claim Submission Tips:
Suppliers bill directly. Keep documentation.
ELDER PLAN
Elder Plan focuses on Medicare/Medicaid LTC for seniors, including DME.
Pros: Excellent for LTC, integrated coverage.
Cons: Primarily for older adults in certain NY areas.
Ideal For: Seniors needing combined Medicare/Medicaid benefits.
Eligibility & Documentation:
Dual‑eligible seniors often have minimal premiums.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
For dual‑eligibles, cost‑sharing for DME is minimal or none.
Telehealth Services:
Elder Plan may support telehealth for LTC coordination. Remote visits can facilitate DME approvals. Check member resources.
Coverage Limits and Exclusions:
DME must be medically necessary for LTC at home.
Prior Authorizations & Referrals:
Prior authorization and a doctor’s prescription likely needed.
How to Verify Coverage:
Check Elder Plan docs or call member services.
Claim Submission Tips:
Suppliers handle claims. Retain approvals.
Pros: Excellent for LTC, integrated coverage.
Cons: Primarily for older adults in certain NY areas.
Ideal For: Seniors needing combined Medicare/Medicaid benefits.
Eligibility & Documentation:
- Medicare: A & B.
- Medicaid: Low‑income criteria.
Dual‑eligible seniors often have minimal premiums.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
For dual‑eligibles, cost‑sharing for DME is minimal or none.
Telehealth Services:
Elder Plan may support telehealth for LTC coordination. Remote visits can facilitate DME approvals. Check member resources.
Coverage Limits and Exclusions:
DME must be medically necessary for LTC at home.
Prior Authorizations & Referrals:
Prior authorization and a doctor’s prescription likely needed.
How to Verify Coverage:
Check Elder Plan docs or call member services.
Claim Submission Tips:
Suppliers handle claims. Retain approvals.
MEDICARE
Medicare is a federal program for seniors and certain disabled individuals. Part B covers medically necessary DME.
Pros: Nationwide coverage.
Cons: Some cost‑sharing applies.
Ideal For: Individuals 65+ or with qualifying disabilities.
Eligibility & Documentation:
Part B premiums apply.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
You must meet the Part B deductible, then typically pay 20 % co‑insurance for DME. If you have a Medigap or Medicare Advantage plan, your out‑of‑pocket may be lower.
Telehealth Services:
Medicare covers certain telehealth services. For DME, you may consult with a doctor virtually to get prescriptions or referrals, subject to Medicare’s telehealth rules.
Coverage Limits and Exclusions:
Only medically necessary DME is covered.
Prior Authorizations & Referrals:
Some DME may require prior authorization and a prescription.
How to Verify Coverage:
Consult “Medicare & You” or call Medicare.
Claim Submission Tips:
Medicare‑enrolled suppliers bill Medicare directly. Keep your Medicare ID handy.
Pros: Nationwide coverage.
Cons: Some cost‑sharing applies.
Ideal For: Individuals 65+ or with qualifying disabilities.
Eligibility & Documentation:
- Age 65+ or qualifying disability, with Parts A & B.
Part B premiums apply.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
You must meet the Part B deductible, then typically pay 20 % co‑insurance for DME. If you have a Medigap or Medicare Advantage plan, your out‑of‑pocket may be lower.
Telehealth Services:
Medicare covers certain telehealth services. For DME, you may consult with a doctor virtually to get prescriptions or referrals, subject to Medicare’s telehealth rules.
Coverage Limits and Exclusions:
Only medically necessary DME is covered.
Prior Authorizations & Referrals:
Some DME may require prior authorization and a prescription.
How to Verify Coverage:
Consult “Medicare & You” or call Medicare.
Claim Submission Tips:
Medicare‑enrolled suppliers bill Medicare directly. Keep your Medicare ID handy.
METROPLUS
MetroPlus offers Medicaid, Medicare Advantage, and marketplace plans in NYC.
Pros: Low‑cost coverage, local NYC focus.
Cons: Limited to NYC.
Ideal For: NYC residents seeking affordable coverage.
Eligibility & Documentation:
Medicaid: minimal or no premium. Medicare Advantage/Marketplace: premiums vary.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Medicaid members generally have low cost‑sharing. Medicare Advantage/Marketplace members have deductibles and co‑pays, limited by out‑of‑pocket maxima. Check plan documents.
Telehealth Services:
MetroPlus often provides telehealth. You can address DME needs, prescriptions, or approvals remotely. Confirm co‑pays or coverage details with member services.
Coverage Limits and Exclusions:
DME must be medically necessary. Some limits apply.
Prior Authorizations & Referrals:
Many DME items require prior authorization.
How to Verify Coverage:
Check MetroPlus materials or call member services.
Claim Submission Tips:
Suppliers handle billing. Keep authorization letters.
Pros: Low‑cost coverage, local NYC focus.
Cons: Limited to NYC.
Ideal For: NYC residents seeking affordable coverage.
Eligibility & Documentation:
- Medicaid/CHP: Meet income limits.
- Medicare Advantage: Have A & B, NYC resident.
- Marketplace: ACA enrollment; residency/income proof.
Medicaid: minimal or no premium. Medicare Advantage/Marketplace: premiums vary.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Medicaid members generally have low cost‑sharing. Medicare Advantage/Marketplace members have deductibles and co‑pays, limited by out‑of‑pocket maxima. Check plan documents.
Telehealth Services:
MetroPlus often provides telehealth. You can address DME needs, prescriptions, or approvals remotely. Confirm co‑pays or coverage details with member services.
Coverage Limits and Exclusions:
DME must be medically necessary. Some limits apply.
Prior Authorizations & Referrals:
Many DME items require prior authorization.
How to Verify Coverage:
Check MetroPlus materials or call member services.
Claim Submission Tips:
Suppliers handle billing. Keep authorization letters.
NY MEDICAID
New York Medicaid covers DME for low‑income residents.
Pros: No or minimal cost for eligible individuals.
Cons: Must meet strict income/resource guidelines.
Ideal For: Low‑income NY residents needing full coverage.
Eligibility & Documentation:
Generally no premiums for qualifying individuals.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Medicaid typically imposes no or very low cost‑sharing. DME often comes at no out‑of‑pocket cost if covered.
Telehealth Services:
NY Medicaid may support telehealth visits, making it easier to obtain prescriptions and approvals for DME. Confirm with the Medicaid helpline or your plan.
Coverage Limits and Exclusions:
Must be medically necessary. Some limits apply.
Prior Authorizations & Referrals:
Prior authorization often required. A doctor’s prescription is needed.
How to Verify Coverage:
Review official Medicaid materials or call NY Medicaid helpline.
Claim Submission Tips:
Providers file claims. Keep approval letters.
Pros: No or minimal cost for eligible individuals.
Cons: Must meet strict income/resource guidelines.
Ideal For: Low‑income NY residents needing full coverage.
Eligibility & Documentation:
- Meet NY Medicaid income/resource limits.
Generally no premiums for qualifying individuals.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Medicaid typically imposes no or very low cost‑sharing. DME often comes at no out‑of‑pocket cost if covered.
Telehealth Services:
NY Medicaid may support telehealth visits, making it easier to obtain prescriptions and approvals for DME. Confirm with the Medicaid helpline or your plan.
Coverage Limits and Exclusions:
Must be medically necessary. Some limits apply.
Prior Authorizations & Referrals:
Prior authorization often required. A doctor’s prescription is needed.
How to Verify Coverage:
Review official Medicaid materials or call NY Medicaid helpline.
Claim Submission Tips:
Providers file claims. Keep approval letters.
Specialized Health Plans
AMIDA CARE
Amida Care specializes in Medicaid coverage for individuals with HIV/AIDS or chronic conditions.
Pros: Condition‑focused support.
Cons: Targeted eligibility, NY‑based.
Ideal For: Medicaid‑eligible individuals with specific health conditions.
Eligibility & Documentation:
Typically no premiums for Medicaid‑eligible enrollees.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Minimal or no cost‑sharing for DME, ensuring affordability.
Telehealth Services:
Amida Care may provide telehealth options to manage DME‑related needs, reducing travel and waiting times. Contact member services for info.
Coverage Limits and Exclusions:
DME must be medically necessary. Some limits may apply.
Prior Authorizations & Referrals:
Prior authorization and a doctor’s order are often required.
How to Verify Coverage:
Review Amida Care documents or call member services.
Claim Submission Tips:
Suppliers usually bill the plan directly. Keep records.
Pros: Condition‑focused support.
Cons: Targeted eligibility, NY‑based.
Ideal For: Medicaid‑eligible individuals with specific health conditions.
Eligibility & Documentation:
- Must have HIV/AIDS or similar chronic condition and meet Medicaid criteria.
Typically no premiums for Medicaid‑eligible enrollees.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Minimal or no cost‑sharing for DME, ensuring affordability.
Telehealth Services:
Amida Care may provide telehealth options to manage DME‑related needs, reducing travel and waiting times. Contact member services for info.
Coverage Limits and Exclusions:
DME must be medically necessary. Some limits may apply.
Prior Authorizations & Referrals:
Prior authorization and a doctor’s order are often required.
How to Verify Coverage:
Review Amida Care documents or call member services.
Claim Submission Tips:
Suppliers usually bill the plan directly. Keep records.
CLOVER HEALTH
Clover Health offers Medicare Advantage plans.
Pros: Preventive care emphasis, tech‑oriented.
Cons: Limited service areas.
Ideal For: Medicare beneficiaries wanting a modern approach.
Eligibility & Documentation:
Premiums may apply alongside Part B.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Part B deductible and co‑insurance may apply for DME. Clover Health caps your annual out‑of‑pocket costs.
Telehealth Services:
Clover Health supports telehealth. You can get DME consultations, approvals, or prescriptions remotely, often at standard co‑pay rates. Check your Evidence of Coverage.
Coverage Limits and Exclusions:
DME must be medically necessary.
Prior Authorizations & Referrals:
Prior authorization likely needed.
How to Verify Coverage:
Review your Evidence of Coverage or call Clover member services.
Claim Submission Tips:
Suppliers handle billing. Keep approvals.
Pros: Preventive care emphasis, tech‑oriented.
Cons: Limited service areas.
Ideal For: Medicare beneficiaries wanting a modern approach.
Eligibility & Documentation:
- Medicare Advantage: Have A & B, reside in service area.
Premiums may apply alongside Part B.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Part B deductible and co‑insurance may apply for DME. Clover Health caps your annual out‑of‑pocket costs.
Telehealth Services:
Clover Health supports telehealth. You can get DME consultations, approvals, or prescriptions remotely, often at standard co‑pay rates. Check your Evidence of Coverage.
Coverage Limits and Exclusions:
DME must be medically necessary.
Prior Authorizations & Referrals:
Prior authorization likely needed.
How to Verify Coverage:
Review your Evidence of Coverage or call Clover member services.
Claim Submission Tips:
Suppliers handle billing. Keep approvals.
HAMASPIK
Hamaspik serves individuals with intellectual/developmental disabilities via Medicaid.
Pros: Specialized, personalized care.
Cons: Strict eligibility.
Ideal For: Those needing tailored Medicaid LTC.
Eligibility & Documentation:
No or minimal premiums for Medicaid‑eligible.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Typically no or very low cost‑sharing for DME under Medicaid guidelines.
Telehealth Services:
Telehealth may be offered to coordinate DME needs, reducing in‑person visits. Confirm with Hamaspik member services.
Coverage Limits and Exclusions:
DME must be medically necessary. Some limits apply.
Prior Authorizations & Referrals:
Prior authorization and specialist evaluation may be required.
How to Verify Coverage:
Check plan materials or call member services.
Claim Submission Tips:
Suppliers handle claims. Keep evaluation reports.
Pros: Specialized, personalized care.
Cons: Strict eligibility.
Ideal For: Those needing tailored Medicaid LTC.
Eligibility & Documentation:
- Must have a qualifying disability and meet Medicaid rules.
No or minimal premiums for Medicaid‑eligible.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Typically no or very low cost‑sharing for DME under Medicaid guidelines.
Telehealth Services:
Telehealth may be offered to coordinate DME needs, reducing in‑person visits. Confirm with Hamaspik member services.
Coverage Limits and Exclusions:
DME must be medically necessary. Some limits apply.
Prior Authorizations & Referrals:
Prior authorization and specialist evaluation may be required.
How to Verify Coverage:
Check plan materials or call member services.
Claim Submission Tips:
Suppliers handle claims. Keep evaluation reports.
HEALTH CARE PARTNERS
Health Care Partners offers coordinated care through Medicare Advantage or employer plans.
Pros: Integrated, patient‑centered approach.
Cons: Regional availability.
Ideal For: Those valuing coordinated care.
Eligibility & Documentation:
Premiums vary by plan type.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
For Medicare Advantage, after meeting the Part B deductible (if applicable), co‑insurance applies until reaching the out‑of‑pocket maximum. Employer plans follow their own deductible/co‑pay structure. Check your Summary of Benefits.
Telehealth Services:
Telehealth may be available for DME assessments, simplifying the process. Contact member services to learn more.
Coverage Limits and Exclusions:
Only medically necessary DME covered.
Prior Authorizations & Referrals:
Prior authorization often required. Referrals may be needed.
How to Verify Coverage:
Check plan materials or call member services.
Claim Submission Tips:
Suppliers bill the plan. Keep approvals.
Pros: Integrated, patient‑centered approach.
Cons: Regional availability.
Ideal For: Those valuing coordinated care.
Eligibility & Documentation:
- Medicare Advantage: Have A & B.
- Employer Plans: Meet employer criteria.
Premiums vary by plan type.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
For Medicare Advantage, after meeting the Part B deductible (if applicable), co‑insurance applies until reaching the out‑of‑pocket maximum. Employer plans follow their own deductible/co‑pay structure. Check your Summary of Benefits.
Telehealth Services:
Telehealth may be available for DME assessments, simplifying the process. Contact member services to learn more.
Coverage Limits and Exclusions:
Only medically necessary DME covered.
Prior Authorizations & Referrals:
Prior authorization often required. Referrals may be needed.
How to Verify Coverage:
Check plan materials or call member services.
Claim Submission Tips:
Suppliers bill the plan. Keep approvals.
INDEPENDENCE CARE SYSTEM (ICS)
ICS provides Medicaid‑managed LTC in NY, including DME.
Pros: Personalized LTC support at home.
Cons: Must qualify for nursing‑home level care.
Ideal For: Disabled or elderly needing in‑home care.
Eligibility & Documentation:
No premiums for Medicaid‑eligible. DME typically low or no cost.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Usually no deductible or co‑pays for Medicaid LTC plans, making DME affordable.
Telehealth Services:
ICS may offer telehealth assessments for DME. This can expedite approvals without an in‑person visit.
Coverage Limits and Exclusions:
DME must be crucial for in‑home care. Some limits apply.
Prior Authorizations & Referrals:
Prior authorization often required. Nurse assessments may be needed.
How to Verify Coverage:
Check ICS materials or call member services.
Claim Submission Tips:
Providers handle claims. Keep assessment reports.
Pros: Personalized LTC support at home.
Cons: Must qualify for nursing‑home level care.
Ideal For: Disabled or elderly needing in‑home care.
Eligibility & Documentation:
- Medicaid MLTC: Meet financial and functional criteria.
No premiums for Medicaid‑eligible. DME typically low or no cost.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Usually no deductible or co‑pays for Medicaid LTC plans, making DME affordable.
Telehealth Services:
ICS may offer telehealth assessments for DME. This can expedite approvals without an in‑person visit.
Coverage Limits and Exclusions:
DME must be crucial for in‑home care. Some limits apply.
Prior Authorizations & Referrals:
Prior authorization often required. Nurse assessments may be needed.
How to Verify Coverage:
Check ICS materials or call member services.
Claim Submission Tips:
Providers handle claims. Keep assessment reports.
INTEGRA MLTC
Integra MLTC provides Medicaid LTC at home, including DME.
Pros: Personalized home‑care plans.
Cons: Must need nursing‑home level care.
Ideal For: Chronically ill or disabled adults needing LTC at home.
Eligibility & Documentation:
No premiums for Medicaid‑qualified individuals.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Minimal to no cost‑sharing for DME under MLTC.
Telehealth Services:
Telehealth visits may be offered to assess DME needs, reducing in‑home provider visits. Contact Integra.
Coverage Limits and Exclusions:
DME must support independence at home. Some limits apply.
Prior Authorizations & Referrals:
Prior authorization and assessments needed.
How to Verify Coverage:
Review Integra materials or call member services.
Claim Submission Tips:
Providers submit claims. Keep authorization records.
Pros: Personalized home‑care plans.
Cons: Must need nursing‑home level care.
Ideal For: Chronically ill or disabled adults needing LTC at home.
Eligibility & Documentation:
- Medicaid financial and functional criteria required.
No premiums for Medicaid‑qualified individuals.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Minimal to no cost‑sharing for DME under MLTC.
Telehealth Services:
Telehealth visits may be offered to assess DME needs, reducing in‑home provider visits. Contact Integra.
Coverage Limits and Exclusions:
DME must support independence at home. Some limits apply.
Prior Authorizations & Referrals:
Prior authorization and assessments needed.
How to Verify Coverage:
Review Integra materials or call member services.
Claim Submission Tips:
Providers submit claims. Keep authorization records.
LOCALL 1199
Local 1199 provides health benefits for 1199SEIU union members.
Pros: Strong, negotiated benefits.
Cons: Limited to union members and dependents.
Ideal For: 1199SEIU members seeking comprehensive coverage.
Eligibility & Documentation:
Minimal or no premiums depending on the union contract.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Union plans often have low cost‑sharing for DME. Check your union benefits guide for exact amounts.
Telehealth Services:
Many union plans include telehealth, making it easier to get DME approvals or follow‑ups. Check your benefits handbook.
Coverage Limits and Exclusions:
DME must be medically necessary.
Prior Authorizations & Referrals:
Prior authorization may be needed. Doctor’s referral might be required.
How to Verify Coverage:
Check union benefits handbook or call member services.
Claim Submission Tips:
Suppliers bill the plan. Keep prescriptions.
Pros: Strong, negotiated benefits.
Cons: Limited to union members and dependents.
Ideal For: 1199SEIU members seeking comprehensive coverage.
Eligibility & Documentation:
- Must be an active union member or dependent. Show union ID/employment verification.
Minimal or no premiums depending on the union contract.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Union plans often have low cost‑sharing for DME. Check your union benefits guide for exact amounts.
Telehealth Services:
Many union plans include telehealth, making it easier to get DME approvals or follow‑ups. Check your benefits handbook.
Coverage Limits and Exclusions:
DME must be medically necessary.
Prior Authorizations & Referrals:
Prior authorization may be needed. Doctor’s referral might be required.
How to Verify Coverage:
Check union benefits handbook or call member services.
Claim Submission Tips:
Suppliers bill the plan. Keep prescriptions.
MAGNACARE
MagnaCare administers employer and union health plans.
Pros: Large networks, flexible benefits.
Cons: Must be covered through an employer/union partner.
Ideal For: Employees/union members under MagnaCare plans.
Eligibility & Documentation:
Costs vary by negotiated plan.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Typically, a deductible applies, followed by co‑insurance or co‑pays. An out‑of‑pocket maximum limits costs. Check your Summary of Benefits.
Telehealth Services:
Many MagnaCare‑administered plans offer telehealth. This can help secure DME prescriptions remotely. Confirm details with member services.
Coverage Limits and Exclusions:
DME must be medically necessary.
Prior Authorizations & Referrals:
Prior authorization is common for DME.
How to Verify Coverage:
Check employer’s HR portal or call MagnaCare member services.
Claim Submission Tips:
Suppliers bill the plan. Keep authorization docs.
Pros: Large networks, flexible benefits.
Cons: Must be covered through an employer/union partner.
Ideal For: Employees/union members under MagnaCare plans.
Eligibility & Documentation:
- Employer/Union‑based: Meet the organization’s criteria.
Costs vary by negotiated plan.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Typically, a deductible applies, followed by co‑insurance or co‑pays. An out‑of‑pocket maximum limits costs. Check your Summary of Benefits.
Telehealth Services:
Many MagnaCare‑administered plans offer telehealth. This can help secure DME prescriptions remotely. Confirm details with member services.
Coverage Limits and Exclusions:
DME must be medically necessary.
Prior Authorizations & Referrals:
Prior authorization is common for DME.
How to Verify Coverage:
Check employer’s HR portal or call MagnaCare member services.
Claim Submission Tips:
Suppliers bill the plan. Keep authorization docs.
MOLINA
Molina Healthcare offers Medicaid, Medicare, and marketplace plans.
Pros: Affordable, focusing on low‑income and senior populations.
Cons: Limited state availability.
Ideal For: Those seeking cost‑effective public or subsidized coverage.
Eligibility & Documentation:
Medicaid: no/low premium. Medicare Advantage/Marketplace vary.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Medicaid beneficiaries often pay little to nothing for DME. Medicare Advantage/Marketplace enrollees have deductibles, co‑pays, and limited out‑of‑pocket maximums. Check plan details.
Telehealth Services:
Molina typically supports telehealth visits. You can consult providers remotely about DME needs, often at lower cost. Confirm coverage via member services.
Coverage Limits and Exclusions:
DME must be medically necessary.
Prior Authorizations & Referrals:
Prior authorization common. A doctor’s order required.
How to Verify Coverage:
Check your benefit documents or call member services.
Claim Submission Tips:
Suppliers handle billing. Keep approval letters.
Pros: Affordable, focusing on low‑income and senior populations.
Cons: Limited state availability.
Ideal For: Those seeking cost‑effective public or subsidized coverage.
Eligibility & Documentation:
- Medicaid/CHIP: Meet state income guidelines.
- Medicare Advantage: Have A & B, reside in service area.
- Marketplace: ACA enrollment periods, provide income/residency info.
Medicaid: no/low premium. Medicare Advantage/Marketplace vary.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Medicaid beneficiaries often pay little to nothing for DME. Medicare Advantage/Marketplace enrollees have deductibles, co‑pays, and limited out‑of‑pocket maximums. Check plan details.
Telehealth Services:
Molina typically supports telehealth visits. You can consult providers remotely about DME needs, often at lower cost. Confirm coverage via member services.
Coverage Limits and Exclusions:
DME must be medically necessary.
Prior Authorizations & Referrals:
Prior authorization common. A doctor’s order required.
How to Verify Coverage:
Check your benefit documents or call member services.
Claim Submission Tips:
Suppliers handle billing. Keep approval letters.
MOLINA ‑ SR. WHOLE HEALTH NY
Senior Whole Health by Molina serves dual‑eligibles with integrated Medicare/Medicaid coverage.
Pros: Integrated coverage, low cost for seniors.
Cons: Must meet dual‑eligibility criteria.
Ideal For: NY seniors enrolled in Medicare and Medicaid.
Eligibility & Documentation:
Dual‑eligibles usually have minimal or no premiums.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
With dual eligibility, DME cost‑sharing is often negligible. Medicaid helps cover Medicare’s cost‑sharing.
Telehealth Services:
Telehealth may be available to manage DME needs from home, improving convenience for seniors. Confirm details with member services.
Coverage Limits and Exclusions:
Must be medically necessary DME.
Prior Authorizations & Referrals:
Prior authorization and a doctor’s order likely needed.
How to Verify Coverage:
Check plan documents or call member services.
Claim Submission Tips:
Suppliers bill directly. Keep approvals.
Pros: Integrated coverage, low cost for seniors.
Cons: Must meet dual‑eligibility criteria.
Ideal For: NY seniors enrolled in Medicare and Medicaid.
Eligibility & Documentation:
- Dual‑eligible: Medicare A & B plus Medicaid eligibility.
Dual‑eligibles usually have minimal or no premiums.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
With dual eligibility, DME cost‑sharing is often negligible. Medicaid helps cover Medicare’s cost‑sharing.
Telehealth Services:
Telehealth may be available to manage DME needs from home, improving convenience for seniors. Confirm details with member services.
Coverage Limits and Exclusions:
Must be medically necessary DME.
Prior Authorizations & Referrals:
Prior authorization and a doctor’s order likely needed.
How to Verify Coverage:
Check plan documents or call member services.
Claim Submission Tips:
Suppliers bill directly. Keep approvals.
VNS CHOICE
VNS Choice, affiliated with Visiting Nurse Service of NY, focuses on home‑based LTC (Medicare/Medicaid).
Pros: Home health expertise, integrated LTC.
Cons: Limited NY regions.
Ideal For: Those needing comprehensive in‑home LTC coverage.
Eligibility & Documentation:
Minimal or no premiums for Medicaid‑qualified individuals.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Typically minimal or no cost‑sharing for LTC‑related DME under Medicaid MLTC.
Telehealth Services:
VNS Choice may use telehealth for care coordination. You can request DME consultations remotely. Check member materials.
Coverage Limits and Exclusions:
DME must be essential for home care.
Prior Authorizations & Referrals:
Prior authorization common, with nurse or physician assessment needed.
How to Verify Coverage:
Consult VNS Choice materials or call member services.
Claim Submission Tips:
Suppliers handle billing. Keep assessments and approvals.
Pros: Home health expertise, integrated LTC.
Cons: Limited NY regions.
Ideal For: Those needing comprehensive in‑home LTC coverage.
Eligibility & Documentation:
- Medicaid MLTC: Meet financial/functional criteria.
Minimal or no premiums for Medicaid‑qualified individuals.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Typically minimal or no cost‑sharing for LTC‑related DME under Medicaid MLTC.
Telehealth Services:
VNS Choice may use telehealth for care coordination. You can request DME consultations remotely. Check member materials.
Coverage Limits and Exclusions:
DME must be essential for home care.
Prior Authorizations & Referrals:
Prior authorization common, with nurse or physician assessment needed.
How to Verify Coverage:
Consult VNS Choice materials or call member services.
Claim Submission Tips:
Suppliers handle billing. Keep assessments and approvals.
Regional and Local Plans
ARCHCARE
ArchCare supports elderly care, MLTC, and PACE programs in NY.
Pros: Specialized elderly/long‑term care support.
Cons: Limited to NY regions.
Ideal For: Seniors needing PACE or MLTC in NY.
Eligibility & Documentation:
Often no or low premiums due to Medicaid eligibility.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Minimal or no cost‑sharing for covered DME under PACE/MLTC programs.
Telehealth Services:
ArchCare may offer telehealth for consultations and care coordination, including DME needs. Check member services.
Coverage Limits and Exclusions:
Only medically necessary DME. Some limits apply.
Prior Authorizations & Referrals:
Prior authorization common. A care assessment may be required.
How to Verify Coverage:
Review ArchCare materials or call member services.
Claim Submission Tips:
Suppliers bill the plan. Keep approvals.
Pros: Specialized elderly/long‑term care support.
Cons: Limited to NY regions.
Ideal For: Seniors needing PACE or MLTC in NY.
Eligibility & Documentation:
- PACE: 55+ and nursing‑home level care.
- MLTC: Medicaid‑eligible with LTC needs.
Often no or low premiums due to Medicaid eligibility.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Minimal or no cost‑sharing for covered DME under PACE/MLTC programs.
Telehealth Services:
ArchCare may offer telehealth for consultations and care coordination, including DME needs. Check member services.
Coverage Limits and Exclusions:
Only medically necessary DME. Some limits apply.
Prior Authorizations & Referrals:
Prior authorization common. A care assessment may be required.
How to Verify Coverage:
Review ArchCare materials or call member services.
Claim Submission Tips:
Suppliers bill the plan. Keep approvals.
BCBS OF WESTERN NY
BCBS of Western NY provides regional coverage (Individual, Family, Medicare Advantage).
Pros: Strong local network.
Cons: Limited to Western NY region.
Ideal For: Western NY residents wanting community‑based coverage.
Eligibility & Documentation:
Premiums vary by plan.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Generally, you must meet a deductible, then pay co‑pays or co‑insurance for DME. Medicare Advantage includes Part B cost‑sharing. Out‑of‑pocket maximums limit total spending. Check your Summary of Benefits.
Telehealth Services:
BCBS of Western NY often includes telehealth. You can obtain DME‑related consultations online, possibly at lower cost. Confirm in your plan documents.
Coverage Limits and Exclusions:
DME must be medically necessary.
Prior Authorizations & Referrals:
Prior authorization may be required.
How to Verify Coverage:
Check Summary of Benefits or call member services.
Claim Submission Tips:
Suppliers bill directly. Keep prescriptions.
Pros: Strong local network.
Cons: Limited to Western NY region.
Ideal For: Western NY residents wanting community‑based coverage.
Eligibility & Documentation:
- Individual/Family: ACA enrollment, residency proof.
- Medicare Advantage: A & B, in coverage area.
Premiums vary by plan.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Generally, you must meet a deductible, then pay co‑pays or co‑insurance for DME. Medicare Advantage includes Part B cost‑sharing. Out‑of‑pocket maximums limit total spending. Check your Summary of Benefits.
Telehealth Services:
BCBS of Western NY often includes telehealth. You can obtain DME‑related consultations online, possibly at lower cost. Confirm in your plan documents.
Coverage Limits and Exclusions:
DME must be medically necessary.
Prior Authorizations & Referrals:
Prior authorization may be required.
How to Verify Coverage:
Check Summary of Benefits or call member services.
Claim Submission Tips:
Suppliers bill directly. Keep prescriptions.
BRIGHT HEALTHCARE
Bright Healthcare provides Individual/Family and Medicare Advantage plans in select regions.
Pros: User‑friendly, preventive care focus.
Cons: Limited regional availability.
Ideal For: Those wanting a modern, simplified plan experience.
Eligibility & Documentation:
Premiums vary by plan type and location.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
For marketplace plans, meet your deductible, then pay co‑pays or co‑insurance until you hit the out‑of‑pocket max. Medicare Advantage: Part B rules apply with a plan‑specific maximum. Check your Evidence of Coverage or Summary of Benefits.
Telehealth Services:
Bright Healthcare supports telehealth appointments. This can speed up getting DME‑related prescriptions or approvals. Review your member portal.
Coverage Limits and Exclusions:
Only medically necessary DME covered.
Prior Authorizations & Referrals:
Prior authorization often required.
How to Verify Coverage:
Review your Evidence of Coverage or call member services.
Claim Submission Tips:
Suppliers handle billing. Keep approvals.
Pros: User‑friendly, preventive care focus.
Cons: Limited regional availability.
Ideal For: Those wanting a modern, simplified plan experience.
Eligibility & Documentation:
- Individual/Family: ACA enrollment.
- Medicare Advantage: A & B, reside in service area.
Premiums vary by plan type and location.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
For marketplace plans, meet your deductible, then pay co‑pays or co‑insurance until you hit the out‑of‑pocket max. Medicare Advantage: Part B rules apply with a plan‑specific maximum. Check your Evidence of Coverage or Summary of Benefits.
Telehealth Services:
Bright Healthcare supports telehealth appointments. This can speed up getting DME‑related prescriptions or approvals. Review your member portal.
Coverage Limits and Exclusions:
Only medically necessary DME covered.
Prior Authorizations & Referrals:
Prior authorization often required.
How to Verify Coverage:
Review your Evidence of Coverage or call member services.
Claim Submission Tips:
Suppliers handle billing. Keep approvals.
CARE CONNECT
Care Connect (availability may vary) focused on preventive care and integrated coverage.
Pros: Preventive care focus.
Cons: Availability changed; verify current offerings.
Ideal For: Those who previously accessed Care Connect’s model.
Eligibility & Documentation:
Premiums vary; check current status.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
If still active, you would meet a deductible first, then co‑pays/co‑insurance apply. An out‑of‑pocket maximum caps yearly costs. Refer to plan documents.
Telehealth Services:
If offered, telehealth can help with DME needs. Check if Care Connect still provides telehealth benefits.
Coverage Limits and Exclusions:
DME must be medically necessary.
Prior Authorizations & Referrals:
Likely needed for certain DME.
How to Verify Coverage:
If plan still operates, contact member services or review documentation.
Claim Submission Tips:
Suppliers usually bill the plan. Keep approvals.
Pros: Preventive care focus.
Cons: Availability changed; verify current offerings.
Ideal For: Those who previously accessed Care Connect’s model.
Eligibility & Documentation:
- Individual/Family: ACA enrollment if still available.
- Employer Plans: Follow employer rules.
Premiums vary; check current status.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
If still active, you would meet a deductible first, then co‑pays/co‑insurance apply. An out‑of‑pocket maximum caps yearly costs. Refer to plan documents.
Telehealth Services:
If offered, telehealth can help with DME needs. Check if Care Connect still provides telehealth benefits.
Coverage Limits and Exclusions:
DME must be medically necessary.
Prior Authorizations & Referrals:
Likely needed for certain DME.
How to Verify Coverage:
If plan still operates, contact member services or review documentation.
Claim Submission Tips:
Suppliers usually bill the plan. Keep approvals.
CONNECTICARE
ConnectiCare serves Connecticut residents with various plans (Individual, Family, Employer).
Pros: Local CT focus, strong preventive care.
Cons: Limited to Connecticut.
Ideal For: CT residents seeking a community‑oriented insurer.
Eligibility & Documentation:
Premiums vary; subsidies may apply on the CT marketplace.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Typically, you’ll face a deductible, then co‑pays or co‑insurance for DME. An annual out‑of‑pocket maximum caps costs. Check your Summary of Benefits.
Telehealth Services:
ConnectiCare usually supports telehealth visits, allowing remote DME‑related consultations at convenient rates. Confirm details with member services.
Coverage Limits and Exclusions:
DME must be medically necessary.
Prior Authorizations & Referrals:
Prior authorization may be required.
How to Verify Coverage:
Check ConnectiCare materials or call member services.
Claim Submission Tips:
DME suppliers bill the plan. Keep medical necessity docs.
Pros: Local CT focus, strong preventive care.
Cons: Limited to Connecticut.
Ideal For: CT residents seeking a community‑oriented insurer.
Eligibility & Documentation:
- Individual/Family: ACA enrollment in CT.
- Employer: Meet employer criteria.
Premiums vary; subsidies may apply on the CT marketplace.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Typically, you’ll face a deductible, then co‑pays or co‑insurance for DME. An annual out‑of‑pocket maximum caps costs. Check your Summary of Benefits.
Telehealth Services:
ConnectiCare usually supports telehealth visits, allowing remote DME‑related consultations at convenient rates. Confirm details with member services.
Coverage Limits and Exclusions:
DME must be medically necessary.
Prior Authorizations & Referrals:
Prior authorization may be required.
How to Verify Coverage:
Check ConnectiCare materials or call member services.
Claim Submission Tips:
DME suppliers bill the plan. Keep medical necessity docs.
Additional Insurance Plans
UNITED HEALTHCARE
UnitedHealthcare offers various plans (Employer, Individual, Medicare Advantage) with DME coverage.
Pros: Extensive national network.
Cons: Costs and coverage vary widely.
Ideal For: Those wanting nationwide coverage.
Eligibility & Documentation:
Varies by plan type.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Commercial and marketplace plans have deductibles, co‑pays/co‑insurance, and an out‑of‑pocket max. Medicare Advantage includes Part B rules plus plan limits. Check your Summary of Benefits or Evidence of Coverage.
Telehealth Services:
UHC often provides telehealth. You can address DME needs remotely, often with standard cost‑sharing. Review member materials.
Coverage Limits and Exclusions:
Must be medically necessary DME.
Prior Authorizations & Referrals:
Prior authorization may be needed.
How to Verify Coverage:
Check your Summary of Benefits or call UHC member services.
Claim Submission Tips:
Suppliers bill UHC. Keep authorization letters.
Pros: Extensive national network.
Cons: Costs and coverage vary widely.
Ideal For: Those wanting nationwide coverage.
Eligibility & Documentation:
- Employer: Meet employer criteria.
- Individual/Family: ACA enrollment; subsidies possible.
- Medicare Advantage: A & B, reside in service area.
Varies by plan type.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Commercial and marketplace plans have deductibles, co‑pays/co‑insurance, and an out‑of‑pocket max. Medicare Advantage includes Part B rules plus plan limits. Check your Summary of Benefits or Evidence of Coverage.
Telehealth Services:
UHC often provides telehealth. You can address DME needs remotely, often with standard cost‑sharing. Review member materials.
Coverage Limits and Exclusions:
Must be medically necessary DME.
Prior Authorizations & Referrals:
Prior authorization may be needed.
How to Verify Coverage:
Check your Summary of Benefits or call UHC member services.
Claim Submission Tips:
Suppliers bill UHC. Keep authorization letters.
BCBS
Blue Cross Blue Shield is a federation of local companies offering DME coverage.
Pros: Nationwide recognition, local presence.
Cons: Benefits vary by region.
Ideal For: Those looking for a trusted brand with local variations.
Eligibility & Documentation:
Premiums depend on local BCBS affiliate and plan type.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Typically, a deductible applies, followed by co‑insurance or co‑pays. Out‑of‑pocket maximum limits expenses. Medicare Advantage follows Part B cost‑sharing plus plan rules.
Telehealth Services:
Most BCBS affiliates offer telehealth. This can help secure prescriptions or authorizations for DME remotely.
Coverage Limits and Exclusions:
Medically necessary DME only.
Prior Authorizations & Referrals:
Often required for certain DME items.
How to Verify Coverage:
Check local BCBS documents or call member services.
Claim Submission Tips:
Suppliers typically handle claims. Keep records.
Pros: Nationwide recognition, local presence.
Cons: Benefits vary by region.
Ideal For: Those looking for a trusted brand with local variations.
Eligibility & Documentation:
- Employer: Meet employer criteria.
- Individual/Family: ACA enrollment.
- Medicare Advantage: A & B, service area restrictions.
Premiums depend on local BCBS affiliate and plan type.
Deductibles, Co‑Pays, and Out‑of‑Pocket Costs:
Typically, a deductible applies, followed by co‑insurance or co‑pays. Out‑of‑pocket maximum limits expenses. Medicare Advantage follows Part B cost‑sharing plus plan rules.
Telehealth Services:
Most BCBS affiliates offer telehealth. This can help secure prescriptions or authorizations for DME remotely.
Coverage Limits and Exclusions:
Medically necessary DME only.
Prior Authorizations & Referrals:
Often required for certain DME items.
How to Verify Coverage:
Check local BCBS documents or call member services.
Claim Submission Tips:
Suppliers typically handle claims. Keep records.
AETNA
(Duplicate Entry) Aetna details can be found in the “Major Insurance Providers” section above.
CIGNA
(Duplicate Entry) Cigna details can be found in the “Major Insurance Providers” section above.
HUMANA
(Duplicate Entry) Humana details can be found in the “Major Insurance Providers” section above.
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