Medicare
Medicare is federal health insurance available for people age 65 and older, certain individuals with disabilities*, and adults and children diagnosed with end-stage renal disease.
Some individuals may qualify for both Medicare and MassHealth (Medicaid). In these situations, Medicare acts as the “payer of first resort,” meaning Medicare must be billed first for your durable medical equipment (DME) needs. (MassHealth, however, might cover your Medicare premiums, deductibles, and coinsurance.)
Most DME provided by Medicare is covered on a rental basis.
*Medicare coverage typically begins after an individual has received Social Security Disability Insurance (SSDI) benefits for 24 months. An exception exists for individuals diagnosed with amyotrophic lateral sclerosis (ALS).
About Medicare:
Medicare consists of 4 separate “parts.” Parts A and B are usually referred to as “traditional” Medicare, since they existed before Parts C and D. A brief description of each part is provided below:
- Part A covers hospital insurance, including inpatient hospital stays, skilled nursing facility care, home health care, hospice care, and certain DME as part of home health care. Most people receive Part A without paying a premium. In 2012, the deductible is $1,156. Coinsurance charges apply after the initial 60 hospital days.
- Part B covers medical insurance. It pays for outpatient services, physical and occupational therapy, some home health services, and DME. Those enrolled in Part A may choose to pay for Part B coverage. In 2012, the standard monthly premium is $99.90 for most people (see 2012 Medicare Costs). There is also an annual deductible of $140, and after the deductible is met, Medicare covers 80% while beneficiaries pay 20% coinsurance (for outpatient mental health services, the coinsurance is 40%). Low-income individuals, however, may have their premium, deductible, and coinsurance covered by MassHealth.
- Part C is Medicare Advantage (often informally called Part C). It provides Medicare coverage through private HMOs or preferred provider organizations contracted with Medicare. Medicare Advantage plans include Parts A and B coverage, often Part D (prescription drug coverage), and additional benefits like extended hospitalization and preventive care. These plans can be somewhat controversial because premiums vary significantly while benefits usually do not. Shopping carefully is recommended. DME coverage is included.
- Part D provides prescription drug coverage. Costs and premiums vary widely by the plan chosen. Like Medicare Advantage plans, Part D coverage is obtained through private insurance companies. You can choose a standalone Part D plan or get prescription coverage through a Medicare Advantage plan.
Medigap plans are separate private insurance plans frequently purchased by individuals who have traditional Medicare (Parts A and B, but not Part C). These plans fill benefit gaps not covered by Parts A and B. If you have enrolled in a Medicare Advantage (Part C) plan, a Medigap plan is generally unnecessary.
Who is Eligible?
Medicare is available to most people who are age 65 and older, individuals of any age with end-stage renal disease, and individuals who have been receiving Social Security Disability Insurance benefits (SSDI) for at least 24 months (people diagnosed with amyotrophic lateral sclerosis [ALS] qualify in their first month of SSDI eligibility).
Medicare beneficiaries are responsible for coinsurance payments (20% of Medicare-approved amounts for DME under Part B) after the annual deductible has been paid. Medicare Part B requires payment of a monthly premium. Individuals eligible for both Medicare Part A and MassHealth may have their Part B premiums, deductibles, and coinsurance costs paid by MassHealth, depending upon income and asset eligibility guidelines. This assistance is called MassHealth Buy-In (premium assistance) and MassHealth Senior Buy-In (premium, co-insurance, and deductible assistance).
For more on Medicare eligibility visit www.medicare.gov
For more on MassHealth Buy-In options visit www.mass.gov/masshealth
What DME Services are Provided?
In general, Medicare covers prescribed medical equipment for use in the home only. Equipment must be medically necessary and generally used for medical purposes. Mobility devices must have a medical need to use it in the home. If a device is needed to help you get to work, school, or medical appointments, it will not be covered. Medicare has a consumer-oriented guide to DME available for download at this Medicare website.
Medicare Part A covers some DME as home health care. Examples of covered equipment include wheelchairs, oxygen, and walkers. There is an annual deductible that must be met before Medicare will pay for any DME.
Medicare Part B will pay for 80% of the allowable cost of most DME after you have met your annual deductible. A monthly premium also applies.
Examples of DME covered by Medicare may include:
- Air fluidized beds
- Blood glucose monitors
- Bone growth stimulators
- Canes (except white canes for the blind)
- Cochlear implants
- Commode chairs
- Home oxygen equipment
- Hospital beds
- Infusion pumps
- Nebulizers
- Prosthetics/orthotics
- Patient lifts
- Power operated vehicles or scooters
- Pressure pads, mattresses, lamb’s wool pads
- Speech generating devices
- Traction equipment
- Transcutaneous electronic nerve stimulators (TENS)
- Ventilators
- Walkers
- Wheelchairs
What DME Services are NOT Provided?
Equipment necessary for convenience, leisure, or education is not covered. Examples of equipment not usually covered by Medicare include:
- Braille teaching texts
- Catheters
- Air conditioners/dehumidifiers
- Elevators
- Raised toilet seats
- Sauna baths
- Speech teaching machine
- Telephone alert systems
How are DME Services Provided?
The process for obtaining durable medical equipment (DME) through Medicare is complicated. Below is an outline of the steps:
- Obtain a prescription for the required DME from your doctor, physician assistant, or nurse practitioner (primary care provider). Note: the provider must perform a face-to-face examination before prescribing power mobility equipment.
- Find a supplier who is enrolled with Medicare. The supplier must coordinate with your medical provider to gather all necessary documentation for submission to Medicare. You can find enrolled suppliers in the Medicare Supplier Directory or call 1-800-MEDICARE [633-4227]. If the supplier is not enrolled with Medicare, your claim will not be paid.
- Confirm whether the supplier is “participating” (also known as “accepts assignment”). Participating suppliers agree to accept Medicare’s allowable cost for the DME. Using a participating supplier means you only pay the standard 20% coinsurance (after your annual deductible), unless coinsurance is covered through Medigap, Medicare Advantage, or MassHealth. If the supplier is enrolled but not participating, they accept assignment on a case-by-case basis, and you could pay more because Medicare covers only 80% of the allowed amount. You may also need to pay the full cost upfront and then submit a reimbursement claim to Medicare.
- Ask your enrolled Medicare supplier if Medicare covers the equipment as a rental or allows it to be purchased. Most DME is provided on a rental basis. Medicare will pay 80% of monthly rental fees. Certain items, such as wheelchairs, require the supplier to send you a “purchase option” letter in the 10th rental month. If you choose to purchase the item, Medicare may cover 80% of repair and replacement parts.
- If required, obtain a “certificate of medical necessity” from your primary care provider detailing how the DME is integral to treating your condition and its therapeutic benefit. Your supplier should inform you if this certificate is necessary.
- Your supplier may request an “Advance Determination of Medicare Coverage” (ADMC) (also called prior authorization) for costly items, such as customized power wheelchairs, before providing the equipment. ADMCs determine only if Medicare will cover the DME item; they do not specify the payment amount and are not subject to appeal. They merely confirm whether Medicare approves the device.
- Once you have received the equipment, your supplier submits the complete claim to Medicare, and you will receive a Medicare Summary Notice (MSN) in the mail. Denials are typically issued immediately, while approvals can take up to three months. The MSN will explain whether the claim was approved, what portion is paid by Medicare, what you owe, and if additional information or clarification is needed.
What If I Need to Appeal a Denial for DME?
It can be frustrating to discover, after the fact, that you owe more for your DME than anticipated. In Massachusetts, Medicare claims for DME are managed by the National Heritage Insurance Company (NHIC), known as the Durable Medical Equipment Regional Carrier (DMERC). The Medicare Summary Notice (MSN) you receive will provide information about your appeal rights, including deadlines.
If you disagree with a denial or the amount you owe, you can appeal the decision. You have 120 days to appeal Medicare Part A or Part B (“traditional” Medicare) claims. Individuals enrolled in Medicare Advantage plans follow their plan’s specific appeal procedures (these procedures are detailed in your claim decision). Keep in mind that Medicare Advantage plans must cover at least the same amount of DME as traditional Medicare.
Medicare must respond to your appeal within 60 days. If denial of the claim could significantly endanger your health, you can request an expedited decision (which Medicare must provide within 72 hours). If denied again, you may proceed with further appeals—potentially up to federal district court—if sufficient costs are involved.
In general it’s a good idea to get help with Medicare appeals. Help is available from the Medicare Advocacy Project of the Massachusetts Legal Assistance Corporation. Visit www.mlac.org or www.masslegalhelp.org. For more information on Medicare appeals visit this Medicare web page or call the Medicare Rights Center: 1-888-466-9050 (leave a message and someone will call you back).
Contact Medicare:
1-800-MEDICARE [633-4227]
www.medicare.gov
To reach the Social Security Administration, call:
1-800-772-1213 VOICE or
1-800-325-0778 TTY
(the SSA answers questions from 7 a.m. to 7 p.m. Monday through Friday)
www.ssa.gov