Vol. 2, No. 5, Sept/Oct 1994	Previous Issues Subscribe to AT Messenger Download PDF Viewer
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FINANCING ASSISTIVE TECHNOLOGY: Medicare-The New Game in Town

Ron Sibert, Funding Specialist, DATI

Part B Medicare health insurance is the primary AT funding mechanism for adults with disabilities and for those who are elderly or have end-stage renal disease. Although much has changed in the past few years about the way Medicare handles equipment claims, program eligibility and the types of coverage it offers have remained essentially unchanged since the program was established in the mid-sixties.

Medicare offers two types of coverage: Parts A and B. The first type, Part A, is automatic for all Medicare beneficiaries, and is basically hospitalization insurance. Part B, the type of coverage that pays for assistive technology (called durable medical equipment [DME] in the language of Medicare) is optional coverage. Note that Medicare insurance has costs such as:

• a monthly premium ($36.60 in 1993),
• an annual deductible ($100 in 1993),
• a 20% coinsurance ("co-pay") charge.

Under certain circumstances, other insurers may cover these costs. For example, the Delaware Medical Assistance Program (Medicaid) will pay all three types of costs for qualified persons. Major medical insurance policies often cover the co-pay. Note here that Medicare only covers 80% of the allowable charge for a piece of equipment-the remaining 20% must be paid by the beneficiary or other insurance. It is also useful to know that the co-pay may sometimes be waived if the consumer can document financial hardship. However, equipment suppliers must always bill their Medicare-insured customers for the 20% co-pay. They must also be careful not to grant hardship waivers on a regular basis, because habitual failure to charge co-pay is considered insurance fraud, which is illegal.

Next is the all-important issue of medical necessity. Medicare will purchase many types of assistive devices, but only if they can be deemed medically necessary. So what does that mean? From Medicare's standpoint, it means that the equipment must be:

• prescribed by a doctor
• directly related to the patient's medical condition/diagnosis
• expected to improve the patient's condition and/or ability to function.

In other words, Medicare will only pay for equipment if the prescribing physician can certify in writing that the equipment is needed to help the person reduce or manage problems associated with a diagnosed medical condition.

Very often, specific diagnoses and/or symptoms must be present in order for certain types of items to be covered. For example, in order to qualify for Medicare purchase of a motorized wheelchair, a person must have a severe neurological, neuromuscular, or orthopedic disorder. The electric wheelchair happens to have several specific covered diagnoses associated with it. In order to qualify for the equipment, the person in our example must have one or more of those diagnoses, be completely wheelchair confined, and be unable to propel a standard wheelchair manually as a direct result of her/his diagnosed condition. Finally, in addition to all of the above, the chair must be prescribed by one of four types of specialists: a neurologist (nervous system specialist), a physiatrist (a doctor of physical/rehabilitative medicine), an orthopedic (bone) specialist, or a cardiac (heart) specialist.

Don't be discouraged, though. Not all equipment has such complex coverage criteria/requirements. Even when such complexity exists, it is not necessary for the patient or the doctor to be completely familiar with every detail. Equipment suppliers that bill Medicare must be registered Medicare equipment providers. Such dealers are usually familiar enough with the coverage requirements of the equipment they sell to advise doctors and their patients about all aspects of the prescription process.

However, the first and most important step in obtaining equipment through Medicare (or any other source) is the performance of an evaluation by a qualified professional. The information obtained in the evaluation will help assure selection of an appropriate device. It will also help the doctor write a correct and compelling equipment justification; and it is often that justification that determines whether or not Medicare will cover the prescribed equipment.