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Medicare Information

 Reimbursement

 

General Medicare Information
Overview

Medicare is a federally funded health insurance program, designed to provide health insurance to people age 65 and over and certain people with disabilities. The Health Care Financing Administration (HCFA) runs the Medicare program, and the Social Security Administration helps by enrolling qualified participants into the program.

Medicare has two parts. Part B is the medical insurance part of Medicare that pays for Durable Medical Equipment (DME). In order for Part B carriers to be reimbursed for DME, two conditions must be met. First, the DME must be necessary and reasonable either in the treatment of an injury or illness, or in improving the function of an impaired body part. Second, the DME must be for use in the individualís home. The necessary part of the first requirement is met by obtaining a doctorís prescription that includes the diagnosis and prognosis for that individual, the reasons behind prescribing the DME, and the length of time that DME will be needed. The requirements for reasonableness is much more complex. The guidelines the Part B carrier can use in determining reasonableness include weighing the expense against the anticipated therapeutic benefits, investigating less costly alternatives, and determining if the DME will serve the same purpose as equipment readily available to the individual. If the DME fails the reasonableness test, reimbursement in full is usually denied.

Eligibility Requirements

Medicare is health insurance coverage for those persons who are either 65 years of age or older, who are blind, totally and permanently disabled, and have been receiving Social Security disability payments for 24 months, or who have end-sage renal disease. Many Medicare recipients are also eligible for Medicaid benefits. In those cases Medicaid will pay the Part B insurance premiums plus the co-insurance and deductible amounts and other charges sponsored by Medicaid, but not covered by Medicare.

Application Process

You can apply for Medicare at the local offices of the Social Security Administration.

Social Security

Power Wheelchair Chair Reimbursement

Most power wheelchairs are recognized and qualify for potential reimbursement under Medicare and other Health Care Insurance Companies.

If you need a power chair for mobility and you meet your insuranceís coverage guidelines, they may pay for all or part of the cost of the power chair. Coverage criteria and payment amounts will vary depending on the type of insurance you have. Most health care insurance companies, including Medicare, have minimum requirements that need to be met before they will purchase a power chair for you.

 

Motorized/Power Wheelchair

Medicare Coverage Criteria

A power wheelchair is covered when all of the following criteria are met:

  1. The patientís condition is such that without the use of a wheelchair the patient would otherwise be bed or chair confined; and,
  2. The patientís condition is such that a wheelchair is medically necessary and the patient is unable to operate a wheelchair manually; and,
  3. The patient is capable of safely operating the controls for the power wheelchair.

A patient who requires a power wheelchair usually is totally nonambulatory and has severe weakness of the upper extremities due to a neurologic or muscular disease/condition. If the documentation does not support the medical necessity of a power wheelchair the power wheelchair will be denied as not medically necessary. Options that are beneficial primarily in allowing the patient to perform leisure or recreational activities are noncovered. A power wheelchair is covered if the patientís condition is such that the requirement for a power wheelchair is long term (at least six months). Payment is made for only one wheelchair at a time. Backup chairs are denied as not medically necessary. Reimbursement for the power wheelchair includes all labor charges involved in the assembly of the wheelchair and all covered additions or modification. Reimbursement also includes support services, such as emergency services, delivery, set-up, education, and on-going assistance with use of the wheelchair.

If you feel you meet these requirements, you may be eligible to receive the most stylish, best performing and most reliable power chair available on the market today at little or no money out of pocket.

Beneficiary Information

Power Wheelchair

Dear Medicare Beneficiary,

You may be eligible to receive a portion of your money back from Medicare when you purchase a power wheelchair. To qualify you must have Medicare Part B coverage and meet certain medical coverage criteria as determined by your physician.

Here are some common questions regarding Medicare Reimbursement.

Will Medicare pay for a Power Wheelchair?

If you qualify, Medicare will pay for a portion of your power wheelchair.

If I qualify, how much will Medicare pay towards the purchase of a power wheelchair?

Medicare will pay 80% of a set allowable for a power wheelchair. The amount depends on the type of power wheelchair you choose and on your state of residence. On average the amount reimbursed by Medicare is around $4,000.00.

How do I know if I qualify?

Medicare has certain medical criteria that need to be met before Medicare will pay for a power wheelchair. Medicare requires a Certificate of Medical Necessity, also knows as a CMN, to be completed by your physician.

How do I submit a claim to Medicare? What other information needs to be sent?

Once a completed CMN signed by the physician is obtained we will submit a claim along with the CMN to Medicare on your behalf. Medicare will process your claim and inform you of their payment decision in about 30-45 days.

Can I find out if I medically qualify before I purchase the Power Wheelchair?

At this time, Medicare offers Advance Determination of Medicare Coverage (Prior Authorization) for certain types of power wheelchairs. The power wheelchairs eligible for this are those that come with a power tilt or power recline seating system or those that come with some type of specialty control device. If your physician prescribes a power wheelchair with one of these options, we can send a request to Medicare to see if you qualify in advance. Medicare will let you know within 30 days if you medically qualify.

Motorized Scooter Reimbursement

Most Scooters or Power Operated Vehicles (POVs) are recognized and qualify for potential reimbursement under Medicare and other Health Care Insurance Companies as a power operated vehicle or (P.O.V.).

If you need a scooter for mobility and you meet your insuranceís coverage guidelines, they may pay for all or part of the cost of the scooter. Coverage criteria and payment amounts will vary depending on the type of insurance you have. Most health care insurance companies, including Medicare, have minimum requirements that need to be met before they will purchase a scooter for you.

Power Operated vehicles (POVs)/Scooters

Medicare Coverage Criteria

A power operated vehicle (POV) is covered when all of the following criteria are met:

  1. The patientís condition is such that a wheelchair is required for the patient to get around in the home,
  2. The patient is unable to operate a manual wheelchair,
  3. The patient is capable of safely operating the controls of the POV,
  4. The patient can transfer safely in and out of the POV and has adequate trunk stability to be able to safely ride in the POV, and
  5. It is ordered by a physician who is one of the following specialties:

Physical Medicine, Orthopedic Surgery, Neurology, or Rheumatology. Exceptions: When such a specialist is not reasonably accessible (e.g., more than one dayís round trip from the beneficiaryís home or the patientís condition precludes such travel), an order from the beneficiaryís physician my be acceptable.

Most POVs are ordered for patients who are capable of ambulation within the home, but require a power vehicle for movement outside the home. POVs will be denied as not medically necessary in these circumstances. If you feel you meet these requirements, you may be eligible to receive the most stylish, best performing and most reliable scooter available on the market today at little or no out of pocket.

Beneficiary Information

Motorized Scooter

Dear Medicare Beneficiary,

You may be eligible to receive a portion of your money back from Medicare when you purchase a scooter. To qualify you must have Medicare Part B coverage and meet certain medical coverage criteria as determined by your physician.

Here are some common questions regarding Medicare Reimbursement.

Will Medicare pay for a Scooter?

If you qualify, Medicare will pay for a portion of your scooter.

If I qualify, how much will Medicare pay towards the purchase of scooter?

Medicare will pay 80% of a set allowable for a scooter. The amount depends on your state of residence. On average the amount reimbursed by Medicare is around $1440.00.

How do I know if I qualify?

Medicare has certain medical criteria that need to be met before Medicare will pay for a scooter. Medicare requires a Certificate of Medical Necessity, also known as a CMN, to be completed by a physician who is a specialist in: Physical Medicine, Rheumatology, Orthopedics, or Neurology.

How do I submit a claim to Medicare? What other information needs to be sent?

Once a completed CMN signed by the physician is obtained and after you purchase the scooter, we will submit a claim along with the CMN to Medicare on your behalf. Medicare will process your claim and inform you of their payment decision in about 30-45 days.

Can I find out if I medically qualify before I purchase the scooter?

No, Medicare does not have a Prior Authorization process available at this time.

Seat Lift Chair Reimbursement

Most Seat Lift Chairs are recognized and qualify for potential reimbursement under Medicare and other Health Care Insurance Companies.

If you need a lift chair and you meet your insuranceís coverage guidelines, they may pay for all or part of the cost of the lift chair. Coverage criteria and payment amounts will vary depending on the type of insurance you have. Most health care insurance companies, including Medicare, have minimum requirements that need to be met before they will purchase a lift chair for you.

Seat Lift Chairs

Medicare Coverage Criteria

A seat lift mechanism is covered if all of the following criteria are met:

  1. The patient must have severe arthritis of the hip or knee or have a severe neuromuscular disease.
  2. The seat lift mechanism must be part of the physicianís course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in the patientís condition.
  3. The patient must be completely incapable of standing up from a regular armchair on any chair in their home. (The fact that a patient has difficulty or is even incapable of getting up from a chair, particularly a low chair, is not sufficient justification for a seat lift mechanism.

    Almost all patients who are cable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.

  4. One standing, the patient must have the ability to ambulate.

Coverage of seat lift mechanisms is limited to those types which operate smoothly, can be controlled by the patient, and effectively assist a patient in standing up and sitting down without other assistance. Excluded from coverage is the type of lift which operated by spring release mechanism with a sudden, catapult-like motion and jolts the patient from a seated to a standing position. Coverage is limited to the seat lift mechanism, even if it is incorporated into a chair.

If you feel you meet these requirements, you may be eligible to receive the most stylish, best performing and most reliable lift chair available on the market today.

Beneficiary Information

Seat Lift Chair

Dear Medicare Beneficiary,

You may be eligible to receive a portion of your money back from Medicare when you purchase a Seat Lift Chair. To qualify to must have Medicare Part B coverage and meet certain medical coverage criteria as determined by your physician.

Here are some common questions regarding Medicare

Will Medicare pay for a Seat Lift Chair?

If you qualify, Medicare will pay for a portion of your Seat Lift Chair. The portion that Medicare will pay for is the seat lift mechanism that is incorporated into a Seat Lift Chair.

 

What is a seat lift mechanism?

The seat lift mechanism is the portion of the lift chair that gently lifts you to a standing position. It includes the metal frame on which the chair rests, the lift motor, the scissors mechanisms and the hand control unit.

If I qualify, how much will Medicare pay towards the purchase of a Seat Lift Chair?

Medicare will pay 80% of a set allowable for a seat lift mechanism. The amount depends on your state of residence. On average the amount reimbursed by Medicare is around $250.00.

How do I know if I qualify?

Medicare has certain medical criteria that need to be met before Medicare will pay for a seat lift mechanism. Medicare requires a Certificate of Medical Necessity, also known as CMN, to be completed by your physician based on your medical condition. Generally, Medicare will only pay for the seat lift mechanism if the patient has a neuromuscular disease or severe arthritis of the hip or knee that completely prevents the patient from standing up from a regular armchair or any chair in their home. Medicare also requires that once standing the patient must have the ability to ambulate. Additionally, the seat lift mechanism must be part of the physicianís course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in the patientís condition.

How do I submit a claim to Medicare? What other information needs to be sent?

Once you have a completed CMN signed by your physician and after you purchase the Seat Lift Chair, we will submit a claim along with the CMN to Medicare on your behalf. Medicare will process your claim and inform you of their payment decision in about 30-45 days.

 

Medicare Carrier by State

If you reside in:

CT, DE, ME, MA, NH, NJ, NY, PA, RI, VT

Your Medicare Carrier is:

HealthNow NY

Region A DMERC

P.O. Box 6800

Wilkes-Barre, PA 18773

Phone: (800)842-2052

 

 

If you reside in:

DC, IL, IN, MD, MI, MN, OH, VA, WV, WI

Your Medicare Carrier is:

AdminiStar Federal

Region B DMEC

P.O. Box 7031

Indianapolis, IN 46207

Phone: (800)270-2313

 

 

If you reside in:

AL, AR, CO, FL, GA, KY, LA, MS, NM, NC, OK, SC, TN, TX

Your Medicare Carrier is:

Palmetto GBA

Region C DMERC

P.O. Box 100141

Columbia, SC 29202-3235

Bene Call Center 1-800-583-2236

TTY/TDD line 1-800-223-1296

 

 

If you reside in:

AZ, AK, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY

Your Medicare Carrier is:

CIGNA

DMERC Region D

P.O. Box 690

Nashville, TN 37202

Phone: (800)899-7095

 

 

 

 

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e-mail  Doug Hartley @ m1 medical.com
Phone  919. 601. 9053

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