- Medicare Overview
- Contact Information
- Health Plan Options
- Medical Necessity
- Durable Medical Equipment
- The Payment Process
- Funding of Specific AT Categories
- Equipment Prescription, Justification and Claim Submission
The Medicare program was authorized under Title XVIII of the Social Security Act of 1965. It is often confused with the Medicaid Program (Title XIX) because their names are so similar. While they have a few points in common, the two programs are actually very different. For example, the federal government (Centers for Medicare & Medicaid Services or "CMS") administers Medicare, and the rules are the same for every state in the nation. This is not true of Medicaid. Also, Medicare requires co-payments and annual deductibles; Medicaid does not. While Medicare eligibility is based on age, disability, and work history, Medicaid generally does not consider work history. Instead, Medicaid looks to either poverty level or SSI related groups (those over 65, blind persons, and those permanently disabled) in determining eligibility. Medicare, on the other hand, does not consider income in determining eligibility. Some persons are dually eligible for Medicare and Medicaid.
Medicare is another major funding source for AT, which in the language of both the Medicare and Medicaid systems is called durable medical equipment (DME).
Medicare is a health insurance program for:
- Individuals who are age 65 or over
- People of all ages who are permanently and totally disabled. (The definition of disability is stated in the Social Security Act as the inability to engage in any substantial gainful activity by reason of any medically determined physical or mental impairment which can be expected to result in death, or has lasted or can be expected to last for a continuous period of not less than 12 months, or blindness (20/200 or less in better eye)[Sec. 216(i)1]. Also, the claimant must have been receiving Social Security Disability benefits for at least 24 months before s/he may qualify for Medicare disability insurance. An exception to this 24 month rule has been made for persons under age 65 with Amyotrophic Lateral Sclerosis (ALS/Lou Gehrig's disease). These persons can receive Medicare coverage during the first month in which they receive Social Security Disability benefits.
- People with end stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant).
In the case of those enrolled in the original Medicare plan (approximately 90% of all Medicare beneficiaries), Medicare DME claims are being administered by DME Regional Carriers (DMERCs). The carrier for the region to which Delaware belongs (Region A) is Health Now of New York, Inc. Contact information for questions about bills for DME and a list of approved DME suppliers is as follows:
DMERC Region A
(800) 842-2052 (voice), (800) 842-9519 (TTY)
Questions about Part B bills, services, and fraud and abuse for
Region A are directed to a separate carrier, Trailblazer
Health Enterprises. Contact information for Trailblazer is as follows:
(800) 444-4606 (voice), (800) 516-6684 (TTY)
Questions regarding Medicare eligibility may be directed to the Social Security Administration office in the consumer's county of residence.
92 Reads Way
New Castle, DE 19720
(302) 323-0304 (voice)
300 South New St.
Dover, DE 19901
(302) 674-5162 (voice)
600 N. DuPont Hwy.
Georgetown, DE 19947
(302) 856-9620 (voice)
A general phone number for Medicare is (800) 633-4227.
Individuals using telecommunication devices for the deaf/text telephones may call: (800) 325-0778
Medicare offers two types of coverage: Parts A & B.
Part A: Institutional health care coverage - This is essentially hospitalization insurance. However, Part A covers some DME (e.g., wheelchairs, oxygen, walkers) as Home Health Care. Part A coverage is mandatory for all Medicare beneficiaries. There is no premium for most beneficiaries.
Part B: Optional medical insurance - This is the type of coverage that pays for most DME as well as some of the services not covered by Part A, such as some physical and occupational therapy. If you are eligible for premium-free Part A, you are automatically eligible for Part B. Part B is voluntary and it has the following costs: (Under some circumstances, these costs may be covered by Medicaid or other insurers.)
- A monthly premium ($66.60 in 2004). All Medicare beneficiaries, regardless of which type plan covers them, must pay this premium.
- An annual deductible ($100 in 2004)
- 20% co-insurance - 20% of the Medicare approved amount for a device or service after the deductible is paid. (Co-insurance may be paid by another insurer or waived if the beneficiary can document financial hardship, but the supplier must always bill for the 20 percent co-payment balance that Medicare does not cover. Medicare+Choice members are not necessarily subject to the $100 deductible and 20 percent co-insurance requirements. Instead, those plans are allowed by Medicare to charge members up to $105 monthly in cost sharing.)
Some individuals with low incomes may qualify for both Medicaid and Medicare benefits. When there is dual coverage, the Medicaid program may pay Medicare premiums, deductibles and co-payments, and for some services not covered by Medicare as well (Refer to Poverty Level-Related Groups in the Medicaid section).
Medicare offers several options for health care coverage from which beneficiaries may select. The two general categories of plans are:
- Original Medicare Plan - this is sometimes called fee-for-service which means that beneficiaries are usually charged a fee for each health care service or supply they receive. The federal government manages this plan and members have the flexibility to go any doctor, specialist, or hospital that accepts Medicare.
- Medicare+Choice - these plans provide health care under contract to Medicare, which pays a set amount of money to these plans each month for beneficiaries' health care. Medicare+Choice beneficiaries are supposed to receive the same services under Parts A and B as those covered under the Original Medicare Plan.
There are two types of Medicare+Choice plans:
- Managed care plans (MCOs), which are like health maintenance organizations (HMOs). In order to be eligible to join an MCO, one cannot be diagnosed with permanent kidney failure and must have Part B coverage. With the MCO type of plan, beneficiaries usually must see a doctor or specialist who belongs to that plan. One generally needs a referral from a primary care doctor before visiting a specialist. Some MCO plans have a more costly, point-of-service option which allows a beneficiary to go to a doctor or specialist who is not part of the plan.
- Private fee-for-service plans. With these plans, Medicare pays a certain amount each month to a private insurance company, which then provides health care coverage to Medicare enrollees who join this plan. The insurer and the insurance company pay a fee for each visit to a doctor and each service. The private company, rather than the Medicare program, decides how much it and the beneficiary will pay as well as what services the beneficiary will receive. With a private fee-for-service plan, beneficiaries can choose any doctor or specialist who accepts the plan's payment.
The open enrollment period for Medicare+Choice is November of each year. Questions about this should be directed to the Centers for Medicare & Medicaid Services at (800) 633-4227.
In Delaware, there is one MCO, Coventry Health Care, which offers coverage under Medicare+Choice. As of 2004, the MCO is being referred to as Medicare Advantage. Those who subscribe to the Medicare Advantage plan pay $90 each month in addition to the $66.60 Part B premium. Like Original Medicare Plan members, Coventry members pay 20 percent of the cost for each Medicare approved service. Contact information is as follows:
Coventry Health Care of Delaware, Inc.
Plan name - Advantra
(888) 781-9411 (voice)
(800) 735-2966 (TTY/TDD)
In Delaware, there is one private fee-for-service plan, administered by Sterling Life Insurance Company. Those enrolled under this plan pay $78 each month in addition to the $66.60 Part B premium. Beneficiaries who fail to notify Sterling of a DME purchase over $750 will have to pay 70 percent of the billed charges. Otherwise, beneficiaries pay 50 percent of the cost for each Medicare approved DME item.
Contact information is as follows:
Sterling Life Insurance Company
Sterling Option I
(888) 858-8572 (voice)
(800) 858-8567 (TTY/TDD)
Like Medicaid, Medicare will purchase various types of assistive devices if a Medicare provider supplies them and the items are considered medically necessary. Medically necessary services and supplies must be:
- Prescribed by a physician, consistent with standards of good medical practice in the local community
- Proper and needed for the diagnosis, direct care, and treatment of a medical condition
- Expected to provide therapeutic benefits
- Not mainly for the convenience of beneficiary or doctor.
Medicare will usually pay for an assistive device if it can be considered durable medical equipment (DME) and is covered under Title XVIII. The federal government usually defines durable medical equipment as:
- That which can withstand repeated use
- Is customarily used for a medical purpose
- Is generally not useful to a person in the absence of an illness, injury, or disability
- Is necessary for use in the home.
Medicare-covered DME has several other important characteristics. The following are some examples:
- Most commonly used home medical equipment such as wheelchairs, ambulatory aids, hospital beds, heating and decubitus pads, and seat lift chair mechanisms each have their own coverage criteria. Equipment suppliers are the best sources of this information and most will provide it upon request.
- Each service or piece of DME that Medicare routinely covers has a special HCFA Common Procedure Coding System (HCPCS) code. It is beyond the scope of this guide to list them here, but each DME supplier that accepts Medicare assignment has a Medicare Provider Manual that lists these codes.
- Certain equipment that is not customarily purchased by Medicare may in fact be covered when the prescribing physician can provide a very strong, reasonable medical justification for that device. In fact, this is true of just about all insurance carriers when the policy covers DME. For example, a person with asthma typically would not use a power wheelchair. Under certain conditions, however, such a device may be medically necessary for an individual with a very severe form of this condition. It would fall to the physician to provide a compelling justification for the use of AT in atypical situations.
Medicare assigns an allowable charge or amount to devices and services based on the lower of:
- The fee schedule amount
- Actual charge.
Medicare then pays 80 percent of the allowable charge and the consumer's private resources or other insurance must pick up the remaining 20 percent.
Medicare pays for the "least costly alternative." A device may have special features that make it more convenient for the user, but also more costly. When the additional device features are not related to the user's medical condition, Medicare's allowable price level is likely to be the cost of the standard, less expensive item. If the standard item is not desirable, it is possible to combine Medicare funds with other resources to obtain the higher-priced product.
Aids for Daily Living (ADL)
Medicare does not generally fund ADL devices because they do not meet the "primarily medical" test.
Switches and Environmental Control Units (ECU)
Medicare generally does not fund ECU devices for the same reason it does not fund ADL devices. However, Medicare has funding codes for these devices so if there is very strong evidence that a particular ECU device is "primarily medical," it may be worth trying to get it funded through Medicare.
Assistive Listening Devices
Medicare does not fund Assistive Listening Devices.Aids for Low Vision. Medicare does not cover Aids for Low Vision such as magnifiers, CCTVs, and screen enlargement software.
Augmentative and Alternative Communication (AAC)
Medicare covers AAC devices as "speech generating devices" (SGD). This wording emphasizes that Medicare's coverage is not as broad as Medicaid's since it is limited to devices that generate speech. A description of Medicare’s process is available.
Medicare will fund only computers and personal digital assistants that are "dedicated SGDs" (that is, they run AAC software exclusively).
Seating, Positioning, and Mobility
Medicare covers wheelchairs, scooters, walkers, and other AT devices in this category. A description of Medicare’s process is available.
Home Modifications and Vehicle Modifications
Medicare does not fund home and vehicle modifications.
Orthotics and Prosthetics
Medicare provides funding for orthotics and prosthetics. Medicare makes a distinction between "orthotics" and "durable medical equipment." Examples of orthotics and prosthetics are artificial limbs and eyes, breast prostheses, corrective lenses after cataract surgery, and leg, arm, and neck braces.
*Remember to first try to access AT through private insurance if the person with disabilities has that type of insurance.
Medicare will only pay for equipment if a physician prescribes it, the beneficiary has Medicare Part B coverage, and the needed AT is consistent with Medicare's definition of DME. (Certain equipment may require a specialist's prescription. For instance, under Medicare regulations, only a neurologist, physiatrist, orthopedist, or cardiac specialist may prescribe a motorized wheelchair.)