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If you have applied for Social Security retirement benefits, you are automatically enrolled in both Medicare Part A and Part B if you are over age 65 and are receiving Social Security or Railroad Retirement Benefits; have been receiving Social Security Disability for two years; have ALS; or have end-stage renal disease. If you are applying for Social Security retirement for any other reason, it may be necessary for you to fill out a separate Medicare application. Check with the Social Security Administration office to see if an additional application for Medicare is necessary. Some widows/widowers with disabilities may be eligible for Medicare before the age of 65. Contact the Social Security Office for more details and to see if you qualify.
You can apply for Medicare through your local Social Security office. Check your local phone book for the office closest to your home. This office takes applications, assists in filing claims, and provides information about the Medicare program.
The Advocates for Medicare Patients has attorneys on staff for Medicare/Medicaid questions. If you have any questions, you should contact them directly. One of the staff attorneys will discuss your questions in detail with you.
This agency will accept individual appeals which have merit (instances where there has been an improper application of law or misinterpretation of rules/regulations).
Medicare is a federal health insurance program (Title XVIII of the Social Security Act) which was established by Congress in 1965. The federal government contracts with private insurance companies to process claims. Recently due to structural reorganization, Medicare claims for durable medical equipment and supplies are now centrally processed in one of four national regions. Maine is in Region I, which means that claims are processed out of Philadelphia. Other claims (i.e., doctors visits, laboratory tests, hospital stays) are processed locally.
Funding for assistive technology devices and/or services depends on the type of carrier. Much of the state variance depends on the type of carrier.
On January 1, 2001, Medicare began to cover and provide reimbursement for most Augmentative/Alternative Communication (AAC) devices (referred to by Medicare as "speech generating devices" or "SGD". Medicare classifies SGDs as "durable medical equipment (DME). SGDs are available to Medicare beneficiaries when the beneficiary: is enrolled in Medicare Part B; lives in his/ her own home, or an assisted living facility (but not in a hospital, skilled nursing facility, or hospice); is determined, following an assessment by a speech-language pathologist, to require an AAC device (SGD) to meet daily functional communication needs; and has a physician prescribe the AAC device (SGD).
Medicare has issued 2 separate sets of guidance discussing coverage of AAC devices. Both sets of guidance state that the scope of Medicare coverage for AAC devices is limited to "dedicated devices". Traditionally, a dedicated device is manufactured for sole purpose of speech communication. On May 4, 2001, however, Centers for Medicare and Medicaid Services (CMS) sent formal notices that "hybrid or integrated" devices (computer-based and PDA-based AAC devices/speech generating devices) are covered when they have been modified to run only AAC software. Speech Language
Pathologists should ask manufacturers about the availability, cost and procedure related to a "key" that will "unlock" these features of these devices. In addition, Medicare has acknowledged that SGDs are covered when they have been modified to run only AAC software.
Medicare payment for AAC devices is based on 3 concepts: cost reimbursement, fee schedules, and assignment. Cost reimbursement means that the Medicare beneficiary must incur a charge before a claim can be submitted. After the charge is incurred, the claims procedure begins. A fee schedule has been established for each of the 4 AAC device "codes". The fee schedule for any item or service is the amount that Medicare believes is a "reasonable charge" for that item or service.
Because many items are expensive, vendors may offer beneficiaries the chance to obtain items at less cost, if the beneficiary assigns (transfers) his/her right to Medicare payment to the vendor. In exchange, the vendor agrees to provide the item at 20% of the fee schedule amount (or actual cost, if less) and if the item costs more than the fee schedule, that there will be no additional charges for the item.
Medicare will pay 80% of the lesser of the following for any covered SGD: the actual charge for the device; or, the fee schedule established for the device. Medicare requires the beneficiary to pay one of the following amounts for an AAC device: 20% of the actual charge for the device, if the actual charge is less than the applicable fee schedule amount; 20% of the fee schedule for device, if the manufacturer/vendor is willing to "accept assignment"; the full retail price for the device, if the manufacturer does not "accept assignment"; nothing if the manufacturer agrees to "accept assignment" and the special circumstances for waiver of the beneficiary's co-payment exist. Medicare beneficiaries may use other funding sources to meet their Medicare co-payment requirements: Medi-gap insurance, insurance coverage from spouse or other family members, or Maine Care if the beneficiary has been determined to be "dually eligible" for Medicare and Maine Care.
There are general requirements for devices/services. The device or service:
The Medicare Program may not always pay for needed assistive technology. The following is a brief explanation of some of the "gaps" in coverage. This is only to be used as an example.
Seatlift chairs:
Medicare will only pay for the seatlift chair mechanism, the chair itself is not covered.Only cataract patients have lenses and eyeglass frames purchased. Maintenance, repair or replacement coverage depends on the type of equipment and the contract.
Durable Medical Equipment and Oxygen:
Medicare will not pay for durable medical equipment (DME) or oxygen if the individual lives in a nursing facility. DME, however, is covered for the individual who lives at home.Hospital Bed:
Medicare will only pay for the electric hospital bed if the person has a caregiver.Infusion Pumps:
External infusion pumps for people with diabetes requiring injections of insulin are not covered.Custom wheelchairs:
Customized, electric wheelchairs are sometimes reimbursed by Medicare. The problem arises, however, in the reimbursement rate that Medicare pays. The "usual, customary, and reasonable" rate paid by Medicare in many cases is less than a third of the actual purchase price of the wheelchair. If the DME vendor does not accept Medicare assignment, then the individual must pay the difference. In Maine, if the individual who requires an electric wheelchair is also a member of Maine Care, Maine Care will accept the amount paid by Medicare as a supplement to the amount which would have been authorized if the individual was not a Medicare recipient. If you are an individual who is eligible for both Medicare and Maine Care and need an electric wheelchair, contact Maine Care Member Services at 207 624-7539, Option 1 (Augusta area) or at 1 800 321-5557 (statewide) and they can help you.
Advocates for Medicare Patients
Legal Services for the Elderly
P. O. Box 2723
Augusta, ME 04338
Phone: 207 621-0087
Fax: 207 621-0742
Toll free Hotline: 800 750-5353 (for individuals 60 years of age and older)