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 & 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 the individual, the reasons behind prescribing the DME, and the length of time that the DME will be needed. The requirement 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-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.

Application Process

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


The Centers for Medicare and Medicaid Services: cms.gov

Social Security Administration: ssa.gov

Durable Medical Equipment Medicare Administrative Contractors:

DME Jurisdiction A - Noridian Healthcare Solutions
CT, DE, MA, ME, MD, NH, NJ, NY, PA, RI, VT, Washington D.C.: med.noridianmedicare.com/web/jadm

DME Jurisdiction B - CGS Medicare
IL, IN, KY, MI, MN, OH, WI: www.cgsmedicare.com/jb/index.htm

DME Jurisdiction C - CGS Medicare
AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, PR, SC, TN, TX, U.S. Virgin Islands, VA, WV: www.cgsmedicare.com/jc/index.html

DME Jurisdiction D - Noridian Healthcare Solutions
Am. Samoa, Guam, N. Mariana Is., Is., AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY: med.noridianmedicare.com/web/jddme/