2000 Conference Proceedings

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 cash benefits):
1. Social Security Retirement Benefits under Title II of the Social Security Act; or
2. Federal Civil Service Retirement Benefits; or
3. The Railroad Retirement System; or
4. 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.
1. You are eligible for Medicare if you have received either of the following for at least 24 months:
2. - Social Security Disability Benefits under Title II of the Social Security Act; or
  - Railroad Retirement Disability Benefits.
  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 benefits.
3. 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 levels.
4. 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 period.
5. 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 facility services;
  - 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.
6. 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.
7. 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) unless:
  (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.
8. What items of durable medical equipment (DME) does Medicare provide?
  Medicare provides DME such as:
  - Iron lungs, respirators, intermittent positive pressure breathing machines, and oxygen-tents;
  - Hospital beds;
  - Wheelchairs including power chairs, customized chairs, and power vehicles (like triwheelers);
  - Crutches, canes, trapeze bars, or walkers;
  - Inhalators and nebulizers;
  - Commodes;
  - 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 seat-lift chair).
  Medicare will also pay for institutional dialysis services and supplies, and for home dialysis supplies and equipment. 42 U.S.C. Section 1395x(s).
  
  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 Section 2100.1.
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ACCESS TO ASSISTIVE TECHNOLOGY THROUGH MEDICARE