General Medicare Information
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 Centers for Medicare and Medicaid Services (CMS) 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
individual’s home. The necessary part of the first requirement is met by
obtaining a doctor’s 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 insurance’s 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:
- The patient’s condition is such that without the use of a wheelchair the
patient would otherwise be bed or chair confined; and,
- The patient’s condition is such that a wheelchair is medically necessary
and the patient is unable to operate a wheelchair manually; and,
- 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 patient’s 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 known 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 (POV).
If you need a scooter for mobility and you meet your insurance’s 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:
- The patient’s condition is such that a wheelchair is required for the
patient to get around in the home,
- The patient is unable to operate a manual wheelchair,
- The patient is capable of safely operating the controls of the POV,
- 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
- 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 day’s round trip from the beneficiary’s home or the patient’s
condition precludes such travel), an order from the beneficiary’s 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
$1600.00.
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 insurance’s 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:
- The patient must have severe arthritis of the hip or knee or have a severe
neuromuscular disease.
- The seat lift mechanism must be part of the physician’s course of
treatment and be prescribed to effect improvement, or arrest or retard
deterioration in the patient’s condition.
- 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 capable of ambulating can get out of an ordinary chair if the
seat height is appropriate and the chair has arms.
- Once 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 $260.00.
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 physician’s course of treatment and be prescribed
to effect improvement, or arrest or retard deterioration in the patient’s
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
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
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
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
ABC Mobility of N.E. Ohio Inc
Toll Free: 800-733-5145
96 E Bellmeadow LN
Chagrin Falls, OH 44022
E-Mail Us
The information contained on this website is for educational
purposes only.
We reserve the right to alter product specifications and models without prior
notice.
Please consult with your Authorized Pride Provider for full product information
and availability.
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