Who qualifies for Medicare benefits?
- Individuals 65 years of age or older
- Individuals under 65 with permanent kidney failure (beginning three months after dialysis begins), or
- Individuals under 65, permanently disabled and entitled to Social Security benefits (beginning 24 months after the start of disability benefits)
The Different Benefits of Traditional Medicare
- Medicare Part A benefits cover hospital stays, home health care and hospice services.
- Medicare Part B benefits cover physician visits, laboratory tests, ambulance services and home medical equipment.
- While oftentimes you do not have to pay a monthly fee to have Part A benefits (you only have to pay money when you use the services), the Part B program requires a monthly premium to stay enrolled (even if you do not use the services). In 2016 that premium will be between $121.80-389.80 per month (but could be less) depending on your income. Typically, this amount will be taken from your Social Security check.
- Medicare Part C is coverage offered through various insurance companies that offer Medicare Advantage Plans. These plans are offered as an alternative to Medicare Part B. Medicare Advantage Plans cover the same benefits as your Part B plan but often have limited provider networks and may require authorization for services prior to making payment. Premiums and deductibles vary by plan. Some plans offer perks like gym memberships as a participation benefit.
- Medicare Part D offers optional program benefits that cover prescription drugs.
- For more information about your benefits or making coverage decisions, you can visit the official website for Medicare benefits at www.medicare.gov.
What Can You Expect to Pay for Medicare Part B Services?
- In 2016, in addition to your monthly premium, you will have to pay the first $166 of covered expenses out-of-pocket for Part B services, and then 20 percent of all approved charges if the supplier agrees to accept Medicare payments.
- Unfortunately, your medical equipment supplier cannot automatically waive this 20 percent or your deductible without suffering penalties from Medicare.
- They must attempt to collect the coinsurance and deductible if those charges are not covered by another insurance plan; however, certain exceptions can be made if you meet qualifying financial hardships established by your supplier.
- If you have a supplemental insurance policy, that plan may pick up this portion of your responsibility after your supplemental plan’s deductible has been satisfied.
- If your medical equipment supplier does not accept assignment with Medicare you may be asked to pay the full price up front, but they will file a claim on your behalf to Medicare. In turn, Medicare will process the claim and mail you a check to cover a portion of your expenses if the charges are approved.
Other possible costs:
- Medicare will pay only for items that meet your basic needs. Oftentimes you will find that your supplier offers a wide selection of products that vary slightly in appearance or features. You may decide that you prefer the products that offer these additional features. Your supplier should give you the option to allow you to privately pay a little extra money to get the product that you really want.
- To take advantage of this opportunity, a new form has been approved by the Centers for Medicare and Medicaid Services (CMS) that allows you to upgrade to a piece of equipment that you like better than the other standard option you may otherwise qualify for. This form is known as the Advance Beneficiary Notice or ABN.
- The ABN form that your supplier completes for you must detail how the products differ, and requires a signature to indicate that you agree to pay the difference in the retail costs between two similar items. Your supplier will typically accept assignment on the standard product and apply that cost toward the purchase of the fancier item, thus requiring less money out of your pocket.
Purpose of ABN
- The Advance Beneficiary Notice of Non Coverage will also be used to notify you ahead of time that Medicare will probably not pay for a certain item or service in a specific situation, even if Medicare might pay under different circumstances. The form should be detailed enough that you understand why Medicare will probably not pay for the item you are requesting.
- The purpose of the form is to allow you to make an informed decision about whether or not to receive the item or service knowing that you may have additional out-of-pocket expenses.
Durable Medical Equipment (DME) Defined
- In order for any item to be covered under Medicare, it typically has to meet the test of durability. Medicare will pay for medical equipment when the item:
- Withstands repeated use (which excludes many disposable items such as underpads)
- Is used for a medical purpose (meaning there is an underlying condition which the item should improve)
- Is useless in the absence of illness or injury (which excludes any item that is preventive in nature such as bathroom safety items used to prevent injuries)
- Used in the home (which excludes all items that are needed only when leaving the confines of the home setting)