Assistive Technology Public Funding
Assistive Technology Public Funding
MEDICARE - "MC"
What agency runs the program?
The Social Security Administration ("SSA") runs the
Medicare program. Medicare is a health insurance program for
people who receive Social Security benefits. Private insurance
companies work with SSA to provide Medicare insurance coverage.
Blue Cross and Blue Shield of Rhode Island provides most of
the medical coverage in Rhode Island for Medicare. Metrahealth
(formerly Travelers Insurance Company) provides insurance coverage
for most durable medical equipment and other AT devices in
Rhode Island.
Most people will not have to apply for Medicare benefits: SSA
will notify you when you become eligible. If you have questions
about your eligibility, you can contact the SSA office nearest
you. There are three Social Security Offices in Rhode Island:
Providence Voice (401) 528-4501
Pawtucket Voice (401) 724-9611
Warwick Voice (401) 822-1463
All offices Voice (800) 772-1213
TDD (800) 325-0778
Who can get services from the program?
Generally, you must receive either Social Security Disability
("SSDI") or Retirement benefits in order to get Medicare.
Your Medicare coverage will begin:
- as soon as you start receiving Retirement benefits, or - two years after you start receiving SSDI benefits.
What kinds of AT help can the program provide?
There are two kinds of insurance coverage provided by Medicare.
Part A Medicare covers inpatient hospital services, some nursing
facility services and home health services, and hospice care.
Part B Medicare includes doctor's visits and other outpatient
care, e.g., home health services, durable medical equipment,
rehabilitation services, physical, speech and occupational
therapy. Both Part A and Part B services can be a source of
AT.
As a general rule, Medicare will only cover services that promote
your "recovery" and are "reasonable and necessary
to the diagnosis or treatment" of your illness or condition.
Medicare currently pays for AT devices, which are traditionally
considered "medical", such as artificial limbs and
other prosthetics, hospital beds, wheelchairs, and walkers.
Other AT devices, such as heat lamps, pressure and floatation
mattresses, will be covered only if you need them for a therapeutic
purpose.
Under current law, Medicare will not pay for some AT devices, such as hearing aids, eyeglasses or orthopedic shoes.
What is the cost for AT?
Medicare does not cover the entire cost of health services. You
will be required to pay a monthly fee or "premium" for
Part B coverage ($46.10 in 1995). There are deductibles and
coinsurance for some kinds of medical care. You will be responsible
to pay coinsurance for many AT devices. Medicare will only
pay 80% of the price of the AT device, and you will be required
to pay the remaining 20% of the cost (the "coinsurance").
Medicare determines what is a "reasonable" price
for AT devices. Just because Medicare says the price is reasonable
does not mean that you will be able to find an AT provider
willing to accept that price. An AT provider can charge you
a much higher price than Medicare will allow for the AT device
you need. If you buy the device from the AT provider, you will
only get reimbursed 80% of the Medicare "reasonable" price.
You will then end up paying much more than 20% of the Medicare "reasonable" price
for your AT. On the other hand, an AT provider may be willing
to accept the Medicare "reasonable price" as
payment in full. (This is often called "accepting assignment").
If the AT provider does this, Medicare will send 80% of the "reasonable
price" to the AT provider, and you will only be responsible
for the remaining 20%.
If you are also eligible for Medicaid ("MA"), then MA will pick up some or all of the costs not covered by Medicare (i.e., the Part B premiums, deductibles and coinsurance). Although being eligible for both programs may help you pay for the AT you need, it often creates long delays in getting an AT device. If you receive both MA and Medicare and face a delay in getting the AT device you need, you should get legal help.
How can I make a request for AT?
To get Medicare to pay for an AT device or service, you will
need a doctor to prescribe the device or service for you. A
doctor may recommend certain AT devices as part of an overall
plan of care within a hospital or nursing home, or as part
of your home health care plan. If you do not have this kind
of care plan, you will need to obtain a doctor's prescription
on your own.
Providers of AT services and devices who accept Medicare will help you process forms for Medicare reimbursement. As mentioned above, providers may be willing to accept "assignment" of the Medicare reimbursement for some AT devices. If an AT provider is not certain of the cost of an AT device, there is a procedure for requesting a price quote (called a "prior authorization") from Medicare. Some AT providers may be unwilling to seek prior authorization from Metrahealth because they believe the agency will not provide it. If you are interested in pursuing a prior authorization, you should seek legal help.
How can I appeal a denial of AT?
There are several different processes for appealing a denial
of Medicare funding for an AT device or service. There is a
process for appealing Part A hospital service decisions, non-hospital
Part A decisions, and Part B service decisions. The level of
review you will be entitled to, often depends on the dollar
amount of the service in dispute.
Most appeals of Part A hospital services must first be reviewed
by a Professional Review Organization (PRO) which is a statewide
organization of physicians. For disputes above a specific dollar
amount, further appeals of Part A hospital benefits are available
using the SSA administrative appeals procedure, and finally
federal court review.
Initial decisions involving non-hospital Part A services will
generally be issued by Blue Cross and Blue Shield of Rhode
Island. If your dispute is above a specific dollar amount,
you can obtain review of Blue Cross' decision through the SSA
administrative process and federal court.
A dispute involving Part B services must be brought to the appropriate insurance carrier. For disputes involving many AT devices, this will be Metrahealth. Further review depends upon the cost of the device or service in dispute.
The notices which you receive from Medicare should explain how to appeal Medicare's decision.
Where can I get legal help?
The Rhode Island Disability Law Center, Inc., (formerly RIPAS)
can provide free legal services if you have questions or need
help getting Medicare payment for an AT device or service.
For more information or help contact:
349 Eddy Street
Providence, Rhode Island 02903
Voice (401) 831-3150 TDD (401) 831-5335
(800) 733-5332
Website: http://www.ridlc.org/
E-mail: info@ridlc.org
Return to the AT Public Funding Source Home Page: AT Public Funding Source Guide