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Medicare

Medicare Overview

Medicare is a federal health insurance program available to individuals aged 65 and older, certain people with disabilities*, and adults and children with end-stage renal disease.

Some individuals qualify for both Medicare and MassHealth (Medicaid). In these cases, Medicare is the primary payer and must be billed first for durable medical equipment (DME). However, MassHealth may cover Medicare premiums, deductibles, and coinsurance. Most DME is paid for on a rental basis.

*Medicare coverage begins 24 months after a person becomes eligible for Social Security Disability Insurance (SSDI), except for those with amyotrophic lateral sclerosis (ALS), who qualify immediately.

About Medicare

Medicare is divided into four parts. Parts A and B are commonly known as “traditional” Medicare, as they were established before Parts C and D. Here’s a breakdown of each part:

  • Part A covers hospital insurance. It includes inpatient hospital stays, skilled nursing facilities, hospice care, and some home health services, including DME when classified as home health care. Most people receive Part A without a premium. As of 2007, the deductible is $992, and coinsurance applies after 60 days of hospitalization.
  • Part B covers medical insurance. It pays for outpatient care, physical and occupational therapy, some home health services, and DME. Those eligible for Part A can choose to enroll in Part B for a monthly premium. In 2007, the premium is $93.50 per month, with a $131 annual deductible and a 20% coinsurance requirement after the deductible is met. Low-income individuals may have these costs covered by MassHealth.
  • Part C is Medicare Advantage. It offers an alternative way to receive Medicare benefits by combining Parts A and B, and often Part D (prescription drug coverage), along with additional benefits like extended hospital stays and preventive care. Medicare Advantage plans are provided by private HMOs or preferred provider organizations under contract with Medicare. While coverage is standardized, premiums vary, making it important to compare plans. DME is covered.
  • Part D provides prescription drug coverage. Costs, including premiums, vary by plan, which are offered by private insurers. Coverage is available as a stand-alone Part D plan or as part of a Medicare Advantage plan.

Medigap policies are supplemental insurance plans available to those with traditional Medicare (Parts A and B, but not Part C). These private plans help cover out-of-pocket costs not included in Medicare. They are unnecessary for those enrolled in a Medicare Advantage plan.

Who May Be Eligible?

Medicare is available to most individuals aged 65 and older, as well as people of any age with end-stage renal disease or those who have received Social Security Disability Insurance (SSDI) benefits for at least 24 months. Individuals with amyotrophic lateral sclerosis (ALS) qualify for Medicare in their first month of SSDI eligibility.

Medicare recipients are responsible for coinsurance costs, including a 20% share for durable medical equipment (DME) under Part B, after meeting an annual deductible. Part B also requires a separate monthly premium. However, individuals who qualify for both MassHealth and Medicare Part A may have their Part B premiums, coinsurance, and deductible covered by MassHealth, subject to income and asset limits. This assistance is provided through the MassHealth Buy-In program, which helps with premiums, or the MassHealth Senior Buy-In program, which covers premiums, coinsurance, and deductibles.

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 www.medicare.gov/Publications/Pubs/pdf/11045.pdf

Medicare Part A covers some DME as home health care. Examples of covered equipment include wheelchairs, oxygen, and walkers. There is an annual deductible of $992 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?

Getting the equipment you need through Medicare can be a complex process. Here’s a step-by-step guide:

  • Obtain a prescription from your doctor, physician assistant, or nurse practitioner (primary care provider) for the necessary DME. Note: Treating practitioners must conduct a face-to-face examination before prescribing power mobility devices.
  • Find a Medicare-enrolled supplier. This supplier should coordinate with your doctor to gather the required information for Medicare submission. You can locate enrolled suppliers at www.medicare.gov (scroll down and click “Find suppliers of medical equipment in your area”) or call 1-800-MEDICARE (633-4227). If the supplier is not enrolled, Medicare will not cover the claim.
  • Confirm if the supplier “participates” (accepts assignment). Participating suppliers agree to Medicare’s allowable cost for DME, meaning you pay only the 20% coinsurance after meeting your annual deductible—unless Medigap, Medicare Advantage, or MassHealth covers it. Suppliers that are only “enrolled” may accept assignment case by case, potentially requiring you to pay more. Some non-participating suppliers may also require full upfront payment, leaving you responsible for submitting the claim for reimbursement.
  • Ask whether the DME must be rented or purchased. Most DME is paid for on a rental basis, with Medicare covering 80% of the monthly rental fee. Certain equipment, like wheelchairs, requires a “purchase option” letter in the 10th rental month. If you choose to buy, Medicare may also cover 80% of repairs and replacement parts.
  • Obtain a “certificate of medical necessity” if required. Your primary care provider may need to document how the equipment is essential for your treatment and its therapeutic benefits. Your supplier should inform you if this certificate is needed.
  • Request “Advance Determination of Medicare Coverage (ADMC)” for high-cost equipment. If you need expensive items, like a custom electric wheelchair, your supplier can request prior approval before delivery. ADMC only confirms if the DME is approvable—it does not guarantee the price Medicare will pay, nor can it be appealed.
  • Submit the claim. Once you receive the equipment, your supplier submits the full claim by mail. You’ll receive a Medicare Summary Notice (MSN), which can take up to three months for covered items. Denials are issued immediately, while approved claims detail what Medicare will pay, what you owe, and if additional information is required from your doctor.

What If I Need to Appeal a Denial for DME?

Finding out after the fact that you owe more than expected for your DME can be frustrating. In Massachusetts, National Heritage Insurance Company (NHIC) is responsible for Medicare claim decisions as the Durable Medical Equipment Regional Carrier (DMERC). Your Medicare Summary Notice (claim decision) will include details on how to appeal and your deadline for filing.

If you disagree with a denial—whether it’s about coverage or the amount you’re billed—you have 120 days to request reconsideration for Medicare Part A or Part B (“traditional” Medicare) claims. Medicare Advantage enrollees must follow their plan’s specific appeal process, which is outlined in the claim decision. Keep in mind that Medicare Advantage plans must cover at least as much DME as traditional Medicare.

Medicare has 60 days to review your appeal. If the denial could put your health at serious risk, you can request an expedited decision, and Medicare must respond within 72 hours. If your appeal is denied, you can escalate it to the next level, potentially taking your case to an administrative law judge and, if the disputed amount is significant, even to federal district court.

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 www.medicare.gov/basics/appeals.asp 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