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Medicare Information

Medicare 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.

Medicare 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-stage 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.

Medicare Application Process

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

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 has changed the coverage criteria and documentation requirements for Power Mobility Devices for dates of service on or after May 5, 2005. Medicare has modernized the policy and replaced the "Bed or Chair Confined" requirements with consideration now given to the beneficiary's ability to safely and in a reasonable time frame participate in one or more Mobility Related Activities of Daily Living (MRADLs).

A face-to-face examination with your referring physician is required prior to any PMD being prescribed.

Medicare looks for the following information from your physician:

  1. What is the patient's mobility limitation and how does it interfere with the performance of activities of daily living?
  2. Why can't a cane or walker meet the patient's mobility needs in the home?
  3. Why can't a manual wheelchair meet the patient's mobility needs in the home?
  4. Why can't a POV meet the patient's mobility needs in the home?
  5. Does the patient have the physical and mental abilities to operate a power wheelchair in the home?

Medicare Beneficiary Information

Power Wheelchair

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

Medicare has changed the coverage criteria and documentation requirements for Power Mobility Devices for dates of service on or after May 5, 2005. Medicare has modernized the policy and replaced the "Bed or Chair Confined" requirements with consideration now given to the beneficiary's ability to safely and in a reasonable time frame participate in one or more Mobility Related Activities of Daily Living (MRADLs).

A face-to-face examination with your referring physician is required prior to any PMD being prescribed.

Medicare looks for the following information from your physician:

  1. What is the patient's mobility limitation and how does it interfere with the performance of activities of daily living?
  2. Why can't a cane or walker meet the patient's mobility needs in the home?
  3. Why can't a manual wheelchair meet the patient's mobility needs in the home?
  4. Does the patient have the physical and mental abilities to operate a power wheelchair in the home?

POVs will be denied as not medically necessary if the chair is to be used only outside the home. 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 expense.

Medicare Beneficiary Information

Motorized Scooter

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:

  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 physician's course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in the patient's 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 capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.
  4. 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

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 Reimbursement

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

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




Notice: Information on the MobilityBasics.ca web site is for informational purposes only and not meant to be a substitute for the advice provided by physicians, therapists or other medical professionals. All information is general in nature and may not necessarily apply to everyone as individual needs may vary. For more information see our terms.

Products displayed or discussed on this web site are presented to provide examples of products discussed and are not specifically endorsed by mobilitybasics.ca. We do not receive any compensation for displaying or presenting any products.

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