Medicare

Medicare

Centers for Medicare and Medicaid Services

Purpose

Medicare is a federal health insurance plan administered by the Centers for Medicare Services (CMS) for persons age 65 and older, and for eligible individuals with disabilities. The Social Security Administration (SSA) helps CMS by enrolling people in Medicare and by collecting Medicare premiums. Eligibility is NOT based on need or income/asset limits.

Medicare - Part A covers hospital and related health care.

Medicare - Part B is a voluntary medical insurance program that provides assistive technology (AT) purchased as Durable Medical Equipment (DME) and must be “necessary and reasonable.”

Medicare - Part D is a voluntary insurance for prescription drugs.

Contact(s)

For information about applying for Medicare, eligibility, or replacing a lost Medicare card contact the Social Security
Administration:
(800) 772-1213
www.medicare.gov

For general Medicare information call the Medicare Hotline: (800) 633-4227

For questions regarding general information contact the Senior Health Insurance Counseling Program (SHIP) which is a non-profit organization helping to inform the public about Medicare and other senior health insurance issues. This division provides accurate and objective counseling, assistance, and advocacy relating to Medicare, Medicaid, Medicare supplements, Medicare Advantage, long-term care, and other related health coverage plans for Medicare beneficiaries, their representatives, or persons soon to be eligible for Medicare.

Senior Helpline:
(800) 763-2828

Financial Criteria

  • none

Eligibility

  • Individuals 65 years of age or older;
  • have been receiving Social Security Disability Insurance (SSDI) payments for twenty-four months as a result of being blind or have a permanent disability;
  • have End Stage Renal Disease; or
  • Amyotrophic Lateral Sclerosis (ALS).

AT Services Provided/Covered

  • Assessments & Evaluations
  • Maintenance & Repairs

AT Devices Provided/ Covered

  • Aids for Daily Living
  • Mobility/Seating & Positioning
  • Speech Communication
  • Aids for Vision Impaired

Application Process

  • Applications for a Medicare health insurance card are taken at all local offices of the Social Security Administration. For eligibility information and to locate the Social Security Office nearest you, call the Social Security information hotline at (800) 772-1213.
  • Apply on-line at www.medicare.gov

Dispute Resolution Process

  1. If Medicare makes a decision you disagree with, you can file an appeal. If you disagree with the decision made at any level of the process, you can generally go to the next level. After each level, you will be given instructions on how to proceed to the next level of appeal.
  2. Level 1 is a redetermination by the company that handles claims for Medicare. A redetermination is a second look at a claim. If you disagree with the decision made on your claim, you must request a redetermination within 120 days from the date you got your Medicare Summary Notice (MSN). Follow the directions on the MSN to do this. You will get a response called a “Medicare Redetermination Notice” about 60 days after the company gets your appeal request.
  3. If you disagree with the redetermination decision in level 1, you have 180 days after you get your decision to ask for a reconsideration. This is the second level of appeal.
  4. Level 2 is a reconsideration by the Qualified Independent Contractor (QIC).
  5. To check the status of your reconsideration you can call 1-800-Medicare (800 633-4227).
  6. For assistance, contact the Senior Health Insurance Counseling Program (SHIP) at (800) 763-2828 (in state only) or (405) 521-6628 (out of state).

Pieces of the Puzzle

  • Anyone who has Medicare Part B can have Medicare help pay for the rental or purchase of durable medical equipment, as long as the equipment is “medically necessary”. Medical equipment is prescribed by a doctor (or qualified nurse practitioner, physician assistant, or clinical nurse specialist) for use in the home.
  • Most people will pay the Medicare Part B premium of $104.90 in 2015 unless according to their IRS income tax return they earn above a certain amount, in which case they may have an increase in the premium as a result of an Income Related Monthly Adjustment Amount.
  • Individuals with low income may qualify for additional financial assistance to help pay for Part B premiums, deductible and co-payments. To apply for the Qualifying Medicare Benefits Program or Specified Low-Income Medicare Beneficiary Programs, go to the local Oklahoma Department of Human Services County Office.
  • Oklahoma is part of the DME competitive bidding program, which changes the amount Medicare pays suppliers for certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). Under this program, suppliers submit bids to provide certain medical equipment and supplies at a lower price. Medicare uses these bids to set the amount it will pay for that equipment and supplies under the competitive bidding program. Qualified, accredited suppliers with winning bids are chosen as Medicare contract suppliers.
  • If the equipment or supplies ordered by the doctor are included in the competitive bidding program, individuals must get their equipment or supplies from a Medicare contract supplier for Medicare to pay for the item(s).
  • Medicare covers power-operated vehicles (scooters and wheelchairs), walkers, and manual wheelchairs as DME that your doctor prescribes for use in your home. Before Medicare helps pay for a power wheelchair you must have a face-to-face examination and a written prescription from a doctor or other treating provider.
  • Medicare covers Speech Generating Devices (SGDs) as DME even though the device can perform other functions as long as it is used solely by the patient with the severe speech impairment and are used primarily for the generation of speech.  Medicare recipients may choose to purchase accompanying services for the SGD such as phone, text or internet.
  • The Gleason Act was signed into law on July 31, 2015. This law ends Capped Rental for Speech Generating Devices (SGDs) on October 1, 2015 and will include eye control as an accessory for SGDs after January 1, 2016.
  • Medicare beneficiaries who have their diabetic testing supplies delivered to thier home will have to get their supplies from a contract supplier in order for Medicare to help pay. Medicare will help pay for supplies if individuals use a mail-order contract supplier or go to their local pharmacy. Local stores don’t have to be Medicare contract suppliers unless they’re also offering diabetic supplies through the mail.
  • The Medicare website, www.medicare.gov/ is very informational. The website also has a directory to look up DME suppliers and physicians online at: www.medicare.gov/