2000 Conference Proceedings
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ACCESS TO ASSISTIVE TECHNOLOGY THROUGH MEDICARE
Protection and Advocacy, Inc.
100 Howe Avenue, Suite 235N, Sacramento, CA 95825
Tel: (916) 488-9950/Fax: (916) 488-9960
- What is Medicare?
Medicare is a federal health insurance program for people
who are elderly or who have disabilities. Private insurance
companies (carriers) administer the program locally. Employer
and employee payroll taxes fund the Medicare program. To
receive Medicare, you need to apply for benefits at a local
Social Security office. Social Security should answer any
questions you have about benefits as well. The number to call
for information is (800) 772-1213.
- What does Medicare cover?
Medicare benefits are divided into Part A, Part B and Part
- Part A covers hospital care, nursing home, and home
health care services for some people.
- Part B covers outpatient hospital care, physician
services, physical therapy, medical transportation,
durable medical equipment (DME), prostheses, and home
health care for most people.
- Part C plans are supposed to provide most Part A and
part B services including assistive technology. They also
provide any other services specified in the Medicare part
- Since most assistive technology devices and services
fall under part B, this chapter will focus on Part
Medicare Health Maintenance Organizations (HMOs) also
provide Medicare. They are now classified as Medicare
part C plans. They still operate the same as before.
Medicare part C appeals apply to HMOs. See Question 28
for more information.
- How would I know if I am eligible for Medicare?
To be automatically eligible for Medicare, without any
premium for Part A hospital insurance, you must qualify under
one of the following categories.
- Age-based eligibility
You must be 65 years of age or older and be eligible
for one of the following (even if not actually get
- Social Security Retirement Benefits under Title
II of the Social Security Act; or
- Federal Civil Service Retirement Benefits;
- The Railroad Retirement System; or
- Enough quarters of Medicare coverage from
either employment covered by
Social Security or Medicare-qualified government
employment, or both.
42 U.S.C. Section 1395c; 42 C.F.R. Section 406.15.
How many quarters of coverage you need vary
depending upon the year you retire. 42 C.F.R.
Sections 406.11, 407.10.
- Disability-based eligibility.
- You are eligible for Medicare if you have
received either of the following for at least 24
- Social Security Disability Benefits under
Title II of the Social Security Act; or
- Railroad Retirement Disability
If you are a disabled widow or widower, you
can receive Medicare with a waiting period as
short as 12 months if you can show that you
fulfill all of eligibility requirements up to 12
months before you applied for disability
You are eligible for Medicare if you are in
the Qualified Disabled and Working Individuals
program, received Social Security benefits
before, and are below certain income and resource
You are eligible for Medicare if you have
end-stage renal disease.
Medicare benefits can continue for up to two
years after you stop receiving disability
benefits because you successfully completed a
trial work period. If you become disabled again
within five years after completing a trial work
period, your Medicare begins immediately. You do
not need to go through a second two-year waiting
Which Medicare Part do I need to get assistive
technology devices and services?
When Medicare covers assistive technology devices
and services, it will generally be under Part B.
Part B services include:
- Physicians' services;
- Outpatient hospital services;
- Rural health clinic services;
- Comprehensive outpatient rehabilitation
- Physical and occupational therapy;
- Speech pathology services;
- Prosthetic devices;
- Durable medical equipment (DME); and
- Diagnostic tests.
If you are under institutional care, you can get
the technology you need under Part A as part of
the Medicare payment for institutional care
services. This may include prosthetics,
orthotics, durable medical equipment, and other
devices also covered under Part B. The criteria
for coverage is generally the same.
What does Medicare not provide?
Medicare does not cover routine or preventative
services, such as:
- Routine physical examinations;
- Most dental care (except for emergency
restorative services or where the jaw or bone
supporting the teeth is involved);
- Routine eye examinations, eyeglasses or
contact lenses (except when associated with eye
disease or injury;
- Hearing aids and related examinations;
- Orthopedic shoes (except when you need them
for symptoms of diabetes, or they are an
integral part of leg braces); and
- Some immunizations.
How does Medicare decide when to provide
benefits such as assistive technology?
Medicare will only pay for services and equipment
that it finds to be reasonable and necessary. 42
U.S.C. Section 1395y(a)(1)(A); 42 C.F.R. Section
411.15(k). The provider's report must justify the
need for the item by describing your condition
and how the recommended item will help you.
Medicare expects carriers to refer to lists of
approved and disapproved devices when deciding if
an equipment or service is medically necessary.
If an item is on the approved list, Medicare can
pay it if you can establish a need for it. If an
item is on the disapproved list, carriers will
not approve its purchase. The only recourse is to
appeal, but it will be hard to win. Federal
courts have upheld such Medicare rulings. If the
requested item does not appear on either an
approved or disapproved list, you can make a case
for its medical necessity. The carrier may
approve. If not, you can appeal. See Questions 23
and 28-29 below on appeals. DME suppliers know
whether a particular item is on an approved or
disapproved list. You should talk with them
before you buy anything.
Under Medicare, health care providers cannot bill
for services that Medicare denied on the basis
that they are not reasonable and necessary
pursuant to 42 U.S.C. Section 1395y(a)(1)
(1) the provider did not know and could not be
reasonably expected to know that Medicare would
not pay for the services on this basis; or
(2) the physician gave you notice before
providing the service that Medicare was not
likely to pay for the specific service, and after
receiving the notice, you signed a statement
agreeing to pay the provider for the service.
Medicare Carriers Manual Section 7330.
What items of durable medical equipment (DME)
does Medicare provide?
Medicare provides DME such as:
Medicare will also pay for institutional dialysis
services and supplies, and for home dialysis
supplies and equipment. 42 U.S.C. Section
- Iron lungs, respirators, intermittent
positive pressure breathing machines, and
- Hospital beds;
- Wheelchairs including power chairs,
customized chairs, and power vehicles (like
- Crutches, canes, trapeze bars, or
- Inhalators and nebulizers;
- Suction machines;
- Traction equipment;
- Heart pacemakers;
- Infusion pumps;
- Whirlpool baths;
- Blood-testing strips and blood glucose
monitors (if you are diabetic); and
- A seat-lift mechanism (not including the
Items such as hospital beds and wheelchairs are
presumed to be medical in nature. Medicare
Carriers Manual Section 2100.1. Equipment which
is generally used for nonmedical purposes is
presumed to be nonmedical. Medicare will not pay
for nonmedical equipment. This is true even
though the item has some medically related use.
For example, an air filter may be necessary if
you have severe allergies. An air conditioner may
be necessary if you have difficulty controlling
internal body temperature. Medicare does not
consider either item as medical equipment because
the primary and customary use of a filter or an
air conditioner is a nonmedical one. Medicare
Carriers Manual Section 2100.1.
Some items that Medicare will not provide
include: all environmental control devices
including items such as air filters and
humidifiers (not medical in nature); braillers
and braille texts (educational in nature); all
exercise equipment (not primarily medical in
nature); eyeglasses and contacts, except one pair
after cataract surgery; and telephones and
television set rental fees during hospital stays.
Medicare Coverage Issues Manual Section 2100.1,
Bedford County General Hospital v. Heckler, 574
F. Supp. 943 (E.D. Tenn. 1983).
Obviously, many of these items do perform a
medical function by helping you overcome the
impact of a disability. Medi-Cal may consider
some items as medically necessary which Medicare
does not. In some cases, you should ask for an
administrative hearing to challenge a denial.
Strong advocacy has resulted in the purchase of
items which a carrier or Medicare initially found
to be nonmedical in nature. In one case, Medicare
approved a computer to help a stroke victim
communicate. The man could not speak or write
legibly. The Medicare Appeals Council found the
computer to be a prosthetic device that replaced
the injured portion of his brain.
Medicare may cover a few special items even
though they are useful in the absence of illness
or disability. These include gel pads, and
pressure and water mattresses (when prescribed
because you are susceptible to bedsores) and heat
lamps (if you have an established medical need
for heat therapy). Medicare Carriers Manual
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