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AT Funding - AT Funding Guide - Public & Private Insurance - Medicare - Page 1

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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).

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Medicare is a health insurance program for:

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Contact Information

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)

Provider Relations:
(866) 419-9458

Consumer Inquiries:
(800) 842-2052

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.

New Castle:
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

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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.)

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).

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Health Plan Options

Medicare offers several options for health care coverage from which beneficiaries may select. The two general categories of plans are:

There are two types of Medicare+Choice plans:

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)

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Medical Necessity

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:

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Durable Medical Equipment (DME)

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:

Medicare-covered DME has several other important characteristics. The following are some examples:

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The Payment Process

Medicare assigns an allowable charge or amount to devices and services based on the lower of:

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.

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Funding of Specific AT Categories

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.

Computer Access

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.

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Equipment Prescription, Justification & Claim Submission*

*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.)

Medicare - Page 1  |  Page 2  |  Page 3  |  Page 4 

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