Funding for Medically Necessary AT 
Medicare
Medicare is federal health insurance for people 65 years of age and older, some people with disabilities*, and adults and children with end-stage renal disease.
Some people may have both Medicare and MassHealth (Medicaid). In these cases, Medicare is the "payer of first resort" and must be billed for your DME needs first (MassHealth, however, may pay your Medicare premium, deductible, and coinsurance requirement). Most DME is paid for on a rental basis.
*Medicare coverage begins after 24 months of entitlement to Social Security Disability benefits (SSDI). There is an exception for people with amyotrophic lateral sclerosis (ALS).
About Medicare:
Medicare is made up of 4 "parts". Parts A and B are often referred to as "traditional" Medicare (they pre-date parts C and D). Below is a brief explanation of each part:
- Part A is hospital insurance. It will also pay for nursing facilities, home health care, hospice care, and some DME as home health care. Part A is provided without premiums for most people. In 2012 the deductible is $1,156. Coinsurance rates apply after your first 60 days in the hospital.
- Part B is medical insurance. It will pay for outpatient services, physical and occupational therapy, some home health care as well as DME. People who get Part A can choose to pay for Part B coverage. In 2012 the premium is $99.90/month for most people (see 2012 Medicare Costs), plus there is a $140/year deductible, and 20% coinsurance applies after the deductible is paid (outpatient mental health services is 40% of Medicare-approved amount). Low-income people, however, can have their premium, deductible, and coinsurance covered by MassHealth.
- Part C is Medicare Advantage (it is unofficially known as Part C). This is another way to get your Medicare benefits. Medicare Advantage plans include Part A, Part B, and often Part D (prescription drug) coverage PLUS some expanded benefits (such as extended hospitalization and preventive care). You can buy a Medicare Advantage plan from a private HMO or preferred provider organization that has a contract with Medicare. These plans are somewhat controversial; premiums can vary widely while benefits generally do not (so it's a good idea to shop around). DME is covered.
- Part D is prescription drug coverage; premiums and other costs vary by plan, which are provided by private health insurers (like the Medicare Advantage program). You can sign up for stand-alone Part D plans or get these benefits through a Medicare Advantage plan.
Medigap plans are another insurance product that people with "traditional" Medicare (Parts A and B, but not a C plan) often purchase. These are private insurance plans intended to fill benefits gaps not provided by Parts A and B, and they are not necessary for people who have purchased a Medicare Advantage (Part C) plan.
Who is Eligible?
Medicare is available to most people age 65 years and older, people of all ages with end-stage renal disease, and people who have been receiving Social Security Disability benefits (SSDI) for a minimum of 24 months (people with amyotrophic lateral sclerosis [ALS] are eligible in their first month of SSDI).
Medicare recipients pay coinsurance (20% of Medicare-approved amount for DME under Part B) after payment of an annual deductible. Medicare Part B requires an additional monthly fee (premium). People who are eligible for both MassHealth and Medicare Part A may have their Medicare Part B premiums, coinsurance, and deductible paid for by MassHealth (income and asset tests apply). This is known as MassHealth Buy-In (premium assistance) and MassHealth Senior Buy-In (premiums, co-insurance 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 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 getting the equipment you need through Medicare is complicated. Here's an outline of the process:
- Get a prescription for the needed DME from your doctor, physician assistant, or nurse practitioner (primary care provider). Note: treating practitioners must conduct face-to-face examinations before prescribing power mobility devices.
- Find a supplier enrolled in Medicare. This supplier should work with your doctor to get all the required information necessary to submit to Medicare. You can find enrolled suppliers at the Medicare Supplier Directory. Or call 1-800-MEDICARE [633-4227]. If the supplier is not "enrolled" then Medicare will not pay your claim.
- Ask if the supplier is "participating" (or "accepts assignment"). Participating suppliers accept the "allowable cost" for the DME as "assigned" by Medicare. Using a participating supplier means that you pay the 20% coinsurance for the DME (after your annual deductible) unless you have Medigap, Medicare Advantage, or MassHealth paying your coinsurance (i.e. "supplemental insurance"). If the supplier is not participating, but "enrolled only", it means they "accept assignment" on a case-by-case basis and you may end up having to pay more (since Medicare pays 80% of the Medicare allowable cost only). You may also have to pay the entire charge up front and submit the claim to Medicare for reimbursement (if the item is found to be covered).
- Ask the Medicare-enrolled supplier if Medicare allows for purchase or rent of the equipment. Most DME is paid for on a rental basis. Medicare will pay 80% of the monthly rental payments, and certain items (i.e. wheelchairs) require a "purchase option" letter to be sent in the 10th month of renting. If you choose to purchase, Medicare may also cover repairs/replacement parts (at 80%).
- If necessary, get a "certificate of medical necessity" from your primary care provider describing how the device is part of the course of treatment for your condition and explaining its therapeutic value to you. Your enrolled supplier should know if you need this certificate.
- "Advance Determination of Medicare Coverage (ADMC)" (i.e. prior approval) may be requested by your supplier for expensive items (i.e. customized electric wheelchairs) before they will deliver your equipment. ADMCs do not address the price Medicare will pay for the item and they cannot be appealed. They confirm, only, that the DME is approvable.
- Once you have the equipment, the supplier submits the entire claim by mail and you receive a Medicare Summary Notice (MSN) in the mail (denials are issued right away; covered claim notices can take up to three months). This notice tells you if the claim is approvable, the portion to be paid by the supplier, the portion you may be billed, or if additional information or clarification is needed from your doctor.
What If I Need to Appeal a Denial for DME?
It can be frustrating to learn, after the fact, that you are responsible for more of the cost of your DME than you may have anticipated. In Massachusetts, National Heritage Insurance Company (NHIC) is responsible for Medicare claim decisions (it is the Durable Medical Equipment Regional Carrier [DMERC]). Information on how to appeal and your appeal deadline must be listed on the Medicare Summary Notice (claim decision) you receive from NHIC.
Consider an appeal if you disagree about whether an item is covered or the amount you may be billed. You have 120 days to request a reconsideration or review for Medicare Part A or Part B ("traditional" Medicare) claims. People enrolled in Medicare Advantage plans follow the appeal rules for their individual plan (and these are listed on your claim decision)-keep in mind that Medicare Advantage plans must cover at least as much DME as traditional Medicare covers.
Medicare has 60 days to respond to your appeal. If a claim denial could seriously jeopardize your health, ask for a fast decision (Medicare must respond within 72 hours). If you are again denied, you can choose to appeal to the next level, and then (if enough money is at stake) to an administrative law judge, and then to a 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 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
