Day 5 Chapter 6 – Claims/Appeals/Fraud

Topics to Highlight

□ Medicare Summary Notice □ Coordination of benefits

□ Mass Ban on Balance Billing Law vs. other states

□ Stress importance of time limit for appeals

□ Stress importance of using MAP

Handouts/Case Studies □ MSN A & B examples and How to Read a MSN Guide

□ Advanced Beneficiary Notice of Noncoverage (ABN)

□ MAP’s information / Brochures (Not included)

□ Appeals Process Flow Chart

□ Case Study – Felix DeKatt (Podiatry coverage for diabetic)

□ Case Study – Cal Asthenik (Wheelchair coverage-not doctor ordered)

□ Case Study – Fran Tikk (Pt. B late enrollee appeal – MAP)

□ Case Study – Demi Gogg (PA eligible)

□ Claims Processing/Appeals/Fraud/Abuse Quiz

□ Case Study – Jack R. Abbot (Insurance denial of payment)

□ Case Study – Perry Scope (Discontinue PT services)

□ Case Study – Pam Purr (LIS eligible)

□ Case Study – Barbie Que (Gap downgrade)

□ Case Study – Al Falfa (LIS eligible)

□ Case Study – Jen Teal (PA eligible)

□ Medicare Coverage of Durable Medical Equipment and Other Devices

□ Medicare’s Wheelchair and Scooter Benefit

□ Homework: Read Chapter Seven – Public Benefits

Medicare Summary Notice Guide

How to Read Your Medicare Summary Notice (MSN) - Part A

Below is a sample Medicare Summary Notice (MSN) for Part A services and information on how to read it. The MSN is not a bill.Do not send money to Medicare or to the provider until you get a bill.

1. Date: Date MSN was sent.

2. Customer Service Information: Who to contact with questions about the MSN. Provide your Medicare number (3), thedate of the MSN (1), and the date of the service you have a question about (7).

3. Medicare Number: The number on your Medicare card.

4. Name and Address: If incorrect, contact the company listed in (2), and the Social Security Administration immediately.

5. Be Informed: Messages about ways to protect yourself and Medicare from fraud and abuse.

6. Part A Hospital Insurance - Inpatient Claims: Type of service. See the back of MSN for additional information.(Please Note: For outpatient services, this section is called "Part B Medical Insurance - Outpatient Facility Claims.")

7. Claim Number: Number that identifies this specific claim.

3

8.

9.

Benefit Days Used: Shows the number of days used in the benefit period. See the back of your MSN for an explanationof benefit periods. (Please Note: For outpatient services, this column is called "Amount Charged."

10.

Non-Covered Charges: Shows the charges for services denied or excluded by the Medicare program for which youmay be billed.

11.

Deductible and Coinsurance: The amount applied to your deductible and coinsurance.12.

You May Be Billed: The total amount the provider may bill you, including deductibles, coinsurance, and non-coveredcharges. Medicare supplement (Medigap) policies may pay all or part of this amount.

13.

See Notes Section: If letter appears, refer to (15) for explanation.14.

Provider's Name and Address: Facility's name and billing address. The referring doctor's name will also be shown.The address shown is the billing address, which may be different from where you receive the service(s).

15. Notes Section: Explains letters in (14) for more detailed information about your claim.

16. Deductible Information: How much of your deductible you have met for the benefit period.

17. General Information: Important Medicare news and information.

18. Appeals Information: How and when to request an appeal.

Dates of Service: Dates service was provided. You may use these dates to compare with the dates shown on yourhospital bill.

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Medicare Summary Notice Guide

How to Read Your Medicare Summary Notice (MSN) - Part B

Below is a sample Medicare Summary Notice (MSN) for Part B services and information on how to read it. The MSN is not a bill.Do not send money to Medicare or to the provider until you get a bill.

1. Date: Date MSN was sent.

2. Customer Service Information: Who to contact with questions about the MSN. Provide your Medicare number (3), thedate of the MSN (1), and the date of the service you have a question about (7).

3. Medicare Number: The number on your Medicare card.

4. Name and Address: If incorrect, contact the company listed in (2), and the Social Security Administration immediately.

5. Be Informed: Messages about ways to protect yourself and Medicare from fraud and abuse.

6. Part B Medical Insurance - Assigned Claims: Type of service. See the back of MSN for information aboutassignment. (Please Note: For unassigned services, this section is called "Part B Medical Insurance - UnassignedClaims.")

7.

8.

Claim Number: Number that identifies this specific claim.

Provider's Name and Address: Doctor (may show clinic, group, and/or referring doctor) or provider's name and billingaddress. The referring doctor's name may also be shown if the service was ordered or referred by another doctor. Theaddress shown is the billing address, which may be different from where you received the services.

9. Dates of Service: Date service or supply was received. You may use these dates to compare with the dates shown onthe bill you receive from your doctor.

5

Services Provided: Brief description of the service or supply received.

10. Amount Charged: Amount the provider billed Medicare.

11. Medicare Approved: Amount Medicare approves for this service or supply.

12. Medicare Paid Provider: Amount Medicare paid to the provider. (Please Note: For unassigned services, this column iscalled "Medicare Paid You.")

13. You May Be Billed: The total amount the provider may bill you, including deductibles, coinsurance, and non-coveredcharges. Medicare supplement (Medigap) policies may pay all or part of this amount.

14. See Notes Section: If letter appears, refer to (16) for explanation.

15.

16. Notes Section: Explains letters in (14) for more detailed information about your claim.

17. Deductible Information: How much of your yearly deductible you have met.

18. General Information: Important Medicare news and information.

19. Appeals Information: How and when to request an appeal.

Medicare & You provides more information about coverage and other services. For a free copy, call 1-800-Medicare(1-800-633-4227) or visit the website www.medicare.gov.

Also, please note that you will receive a separate Explanation of Benefits (EOB) directly from your plan or providerfor your Medicare Part D prescriptions.

The Indiana SMP Project is supported by grant number 90AM3074 from the Administration on Aging, the Centers for Medicareand Medicaid Services (CMS), Washington, D.C. 20201. Grantees undertaking projects under government sponsorship areencouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily representofficial Administration on Aging policy.

6

Medicare Summary Notice

BENEFICIARY NAMESTREET ADDRESSCITY, STATE ZIP CODE

CUSTOMER SERVICE INFORMATION

Your Medicare Number: 111-11-1111A

If you have questions, write or call:Medicare (#12345)555 Medicare Blvd., Suite 200Medicare BuildingMedicare, US XXXXX-XXXX

Call: 1-800-MEDICARE (1-800-633-4227)Ask for Hospital ServicesTTY for Hearing Impaired: 1-877-486-2048

BE INFORMED: Beware of “free” medicalservices or products. If it sounds too good tobe true, it probably is.

This is a summary of claims processed from 05/15/2006 through 08/10/2006.

PART A HOSPITAL INSURANCE – INPATIENT CLAIMS

Dates Benefit Non- Deductible You Seeof Days Covered and May Be Notes

Service Used Charges Coinsurance Billed Section

Claim Number: 12435-84956-84556-45621 aCure Hospital, 213 Sick Lane,

Dallas, TX 75555Referred by: Paul Jones, M.D.04/25/06 – 05/09/06 14 days $0.00 $876.00 $876.00 b, c

Claim Number: 12435-84956-845556-45622Continued Care Hospital, 124 Sick Lane,

Dallas, TX 75555Referred by: Paul Jones, M.D.05/09/06 – 06/20/06 11 days $0.00 $0.00 $0.00

PART B MEDICAL INSURANCE – OUTPATIENT FACILITY CLAIMS

Dates Non- Deductible You Seeof Amount Covered and May Be Notes

Service Services Provided Charged Charges Coinsurance Billed Section

Claim Number: 12435-8956-8458 dMedicare Hospital, 123 Medicare Lane,

Dallas, TX 75209Referred by: Paul Jones, M.D.04/02/06 L.V. Therapy (Q0081) $33.00 $0.00 $6.60 $6.60

Lab (3810) 1,140.50 0.00 228.10 228.10Operating Room (31628) 786.50 0.00 157.30 157.30Observation Room (99201) 293.00 0.00 58.60 58.60Claim Total $2,253.00 $0.00 $450.60 $450.60

(continued)

THIS IS NOT A BILL – Keep this notice for your records.

Page 1 of 2

July 1, 2006

Your Medicare Number: 111-11-1111A

Notes Section:

a The amount Medicare paid the provider for this claim is $XXXX.XX.

b $776.00 was applied to your inpatient deductible.

c $30.00 was applied to your blood deductible.

d The amount Medicare paid the provider for this claim is $XXXX.XX.

Deductible Information:

You have met the Part A deductible for this benefit period.

You have met the Part B deductible for 2006.

You have met the blood deductible for 2006.

General Information:

You have the right to make a request in writing for an itemized statement which details eachMedicare item or service which you have received from your physician, hospital, or any otherhealth supplier or health professional. Please contact them directly, in writing, if you would likean itemized statement.

Compare the services you receive with those that appear on your Medicare Summary Notice. Ifyou have questions, call your doctor or provider. If you feel further investigation is needed dueto possible fraud and abuse, call the phone number in the Customer Service Information Box.

Appeals Information – Part A (Inpatient) and Part B (Outpatient)

If you disagree with any claims decisions on either Part A or Part B of this notice, your appealmust be received by November 1, 2006. Follow the instructions below:

1) Circle the item(s) you disagree with and explain why you disagree.

2) Send this notice, or a copy, to the address in the “Customer Service Information” box on Page 1. (You may also send any additional information you may have about your appeal.)

3) Sign here _______________________________ Phone number ______________________

Revised 08/06

Page 2 of 2July 1, 2006

PART A HOSPITAL INSURANCE (INPATIENT) helpspay for inpatient hospital care, inpatient care in a skillednursing facility following a hospital stay, home health careand hospice care. Inpatient services are measured in benefitperiods. A benefit period begins the first time you receiveMedicare covered inpatient hospital care and ends whenyou have been out of the hospital or skilled nursing facilityfor 60 consecutive days. There is no limit to the number ofbenefit periods you may have.

THE AMOUNT YOU MAY BE BILLED for Part Aservices includes:

• an inpatient hospital deductible once during each benefit period,

• a coinsurance amount for the 61st through the 90th days of a hospital stay during each benefit period,

• a coinsurance amount for each Lifetime ReserveDay, which can be used if you have to stay in the hospital more than 90 days in one benefit period. Lifetime Reserve Days may be used only once,

• a blood deductible for the first three pints of unreplaced blood furnished to you in a calendar year in some states,

• an inpatient coinsurance for the 21st through the 100th days of a Medicare covered stay in a skilled nursing facility,

• charges for services or supplies that are not coveredby Medicare. You may not have to pay for certain denied services. If so, a NOTE on the front will tell you.

PART B MEDICAL INSURANCE (OUTPATIENT FACILITIES) helps pay for care provided by certifiedmedical facilities, such as hospital outpatient departments,renal dialysis facilities, and community health centers.

THE AMOUNT YOU MAY BE BILLED for Part Bservices includes:

• an annual deductible, taken from the first Medicare Part B charges each year,

• after the deductible has been met for the year,depending on services received, a coinsurance amount (20% of the amount charged), or a fixed copayment for each service,

• charges for services or supplies that are not covered by Medicare. You may not have to pay for certain denied services. If so, a NOTE on the front will tell you.

If you have supplemental insurance, it may help to pay theamounts you may be billed. If you use this notice to claimsupplemental benefits from another insurance company,make a copy for your records.

WHEN OTHER INSURANCE PAYS FIRST: All Medicarepayments are made on the condition that you will payMedicare back if benefits could be paid by insurance that isprimary to Medicare. Types of insurance that should paybefore Medicare include employer group health plans, no-fault insurance, automobile medical insurance, liabilityinsurance and workers’ compensation. Notify us right awayif you have filed or could file a claim with insurance that isprimary to Medicare.

YOUR RIGHT TO APPEAL: If you disagree with whatMedicare approved for these services, you may appeal thedecision. You must file your appeal within 120 days of thedate you receive this notice. Unless you show us otherwise,we assume you received this notice 5 days after the date ofthis notice. Follow the appeal instructions on the front of thelast page of the notice. If you want help with your appeal, afriend or someone else can help you. Also, groups such aslegal aid services may provide free assistance. To contactus for the names and telephone numbers of groups in yourarea, please see our Customer Service Information box onthe front of this notice.

HELP STOP MEDICARE FRAUD: Fraud is a false representation by a person or business to get Medicare payments. Some examples of fraud include:

• offers of goods or money in exchange for your Medicare Number,

• telephone or door-to-door offers for free medical services or items, and

• claims for Medicare services/items you did not receive.

If you think a person or business is involved in fraud, youshould call Medicare at the Customer Service telephonenumber on the front of this notice.

INSURANCE COUNSELING AND ASSISTANCE:Insurance Counseling and Assistance programs are locatedin every State. These programs have volunteer counselorswho can give you free assistance with Medicare questions,including enrollment, entitlement, Medigap, and premiumissues. If you would like to know how to get in touch withyour local Insurance Counseling and Assistance ProgramCounselor, please call us at the number shown in theCustomer Service Information box on the front of this notice.

IMPORTANT INFORMATION YOU SHOULD KNOW ABOUT YOUR MEDICARE BENEFITS

For more information about services covered by Medicare, please see your Medicare Handbook.

Centers for Medicare & Medicaid Services

Medicare Summary Notice

BENEFICIARY NAMESTREET ADDRESSCITY, STATE ZIP CODE

CUSTOMER SERVICE INFORMATION

Your Medicare Number: 111-11-1111A

If you have questions, write or call:Medicare (#12345)555 Medicare Blvd., Suite 200Medicare BuildingMedicare, US XXXXX-XXXX

Call: 1-800-MEDICARE (1-800-633-4227)Ask for Doctor ServicesTTY for Hearing Impaired: 1-877-486-2048

BE INFORMED: Beware of telemarketersoffering free or discounted medicare itemsor services.

This is a summary of claims processed from 05/10/2006 through 08/10/2006.

PART B MEDICAL INSURANCE – ASSIGNED CLAIMS

Dates Medicare You Seeof Amount Medicare Paid May Be Notes

Service Services Provided Charged Approved Provider Billed Section

Claim Number: 12435-84956-84556Paul Jones, M.D., 123 West Street, a

Jacksonville, FL 33231-0024Referred by: Scott Wilson, M.D.04/19/06 1 Influenza immunization (90724) $5.00 $3.88 $3.88 $0.00 b04/19/06 1 Admin. flu vac (G0008) 5.00 3.43 3.43 0.00 b

Claim Total $10.00 $7.31 $7.31 $0.00

Claim Number: 12435-84956-84557ABC Ambulance, P.O. Box 2149, a

Jacksonville, FL 3323104/25/06 1 Ambulance, base rate (A0020) $289.00 $249.78 $199.82 $49.9604/25/06 1 Ambulance, per mile (A0021) 21.00 16.96 13.57 3.39

Claim Total $310.00 $266.74 $213.39 $53.35

PART B MEDICAL INSURANCE – UNASSIGNED CLAIMS

Dates Medicare You Seeof Amount Medicare Paid May Be Notes

Service Services Provided Charged Approved You Billed Section

Claim Number: 12435-84956-84558William Newman, M.D., 362 North Street a

Jacksonville, FL 33231-002403/10/06 1 Office/Outpatient Visit, ES (99213) $47.00 $33.93 $27.15 $39.02 c

THIS IS NOT A BILL – Keep this notice for your records.

Page 1 of 2

July 1, 2006

Your Medicare Number: 111-11-1111A

Notes Section:

a This information is being sent to your private insurer. They will review it to see if additional benefits can be paid. Send any questions regarding your supplemental benefits to them.

b This service is paid at 100% of the Medicare approved amount.

c Your doctor did not accept assignment for this service. Under Federal law, your doctor cannot charge more than $39.02. If you have already paid more than this amount, you are entitled to a refund from the provider.

Deductible Information:

You have met the Part B deductible for 2006.

General Information:

You have the right to make a request in writing for an itemized statement which details eachMedicare item or service which you have received from your physician, hospital, or any otherhealth supplier or health professional. Please contact them directly, in writing, if you would likean itemized statement.

Compare the services you receive with those that appear on your Medicare Summary Notice. Ifyou have questions, call your doctor or provider. If you feel further investigation is needed dueto possible fraud and abuse, call the phone number in the Customer Service Information Box.

Appeals Information – Part B

If you disagree with any claims decisions on this notice, your appeal must be recieved by November 1, 2006. Follow the instructions below:

1) Circle the item(s) you disagree with and explain why you disagree.

2) Send this notice, or a copy, to the address in the “Customer Service Information” box on Page 1. (You may also send any additional information you may have about your appeal.)

3) Sign here _______________________________ Phone number ______________________

Revised 08/06

Page 2 of 2July 1, 2006

MEDICARE PART B MEDICAL INSURANCE: MedicarePart B helps pay for doctors’ services, diagnostic tests,ambulance services, durable medical equipment, and otherhealth care services. Medicare Part A Hospital Insurancehelps pay for inpatient hospital care, inpatient care in askilled nursing facility following a hospital stay, homehealth care and hospice care. You will be sent a separatenotice if you received Part A services or any outpatientfacility services.

MEDICARE ASSIGNMENT: Medicare Part B claims maybe assigned or unassigned. Providers who acceptassignment agree to accept the Medicare approvedamount as total payment for covered services. Medicarepays its share of the approved amount directly to theprovider. You may be billed for unmet portions of theannual deductible and the coinsurance. You may contactus at the address or telephone number in the CustomerService Information box on the front of this notice for a listof participating providers who always accept assignment.You may save money by choosing a participating provider.

Doctors who submit unassigned claims have not agreed to accept Medicare’s approved amount as payment in full.Generally, Medicare pays you 80% of the approvedamount after subtracting any part of the annual deductibleyou have not met. A doctor who does not accept assignmentmay charge you up to 115% of the Medicare approvedamount. This is known as the Limiting Charge. Somestates have additional payment limits. The NOTES sectionon the front of this notice will tell you if a doctor hasexceeded the Limiting Charge and the correct amount topay your doctor under the law.

YOUR RESPONSIBILITY: The amount in the You MayBe Billed column is your share of cost for the servicesshown on this notice. You are responsible for:

• annual deductible: taken from the first Medicare Part B approved charges each calendar year,

• coinsurance: 20% of the Medicare approved amount, after the deductible has been met for the year,

• the amount billed, up to the limiting charge, for unassigned claims, and

• charges for services/supplies that are not covered by Medicare. You may not have to pay for certain denied services. If so, a NOTE on the front will tell you.

If you have supplemental insurance, it may help you paythese amounts. If you use this notice to claim supplementalbenefits from another insurance company, make a copy foryour records.

WHEN OTHER INSURANCE PAYS FIRST: All Medicarepayments are made on the condition that you will payMedicare back if benefits could be paid by insurance that isprimary to Medicare. Types of insurance that should paybefore Medicare include employer group health plans, no-fault insurance, automobile medical insurance, liabilityinsurance and workers’ compensation. Notify us right awayif you have filed or could file a claim with insurance that isprimary to Medicare.

YOUR RIGHT TO APPEAL: If you disagree with whatMedicare approved for these services, you may appeal thedecision. You must file your appeal within 120 days of thedate you receive this notice. Unless you show us otherwise,we assume you received this notice 5 days after the date ofthis notice. Follow the appeal instructions on the front of thelast page of the notice. If you want help with your appeal, afriend or someone else can help you. Also, groups such aslegal aid services may provide free assistance. To contactus for the names and telephone numbers of groups in yourarea, please see our Customer Service Information box onthe front of this notice.

HELP STOP MEDICARE FRAUD: Fraud is a false representation by a person or business to get Medicare payments. Some examples of fraud include:

• offers of goods or money in exchange for your Medicare Number,

• telephone or door-to-door offers for free medical services or items, and

• claims for Medicare services/items you did not receive.

If you think a person or business is involved in fraud, youshould call Medicare at the Customer Service telephonenumber on the front of this notice.

INSURANCE COUNSELING AND ASSISTANCE:Insurance Counseling and Assistance programs are locatedin every State. These programs have volunteer counselorswho can give you free assistance with Medicare questions,including enrollment, entitlement, Medigap, and premiumissues. If you would like to know how to get in touch withyour local Insurance Counseling and Assistance ProgramCounselor, please call us at the number shown in theCustomer Service Information box on the front of this notice.

IMPORTANT INFORMATIONABOUT YOUR MEDICARE PART B MEDICAL INSURANCE BENEFITSFor more information about services covered by Medicare, please see your Medicare Handbook.

Centers for Medicare & Medicaid Services

(A) Notifier(s): (B) Patient Name: (C) Identification Number:

ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN)NOTE: If Medicare doesn’t pay for (D)_____________ below, you may have to pay.

Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the (D)_____________ below.(D) (E) Reason Medicare May Not Pay: (F) Estimated

Cost:

WHAT YOU NEED TO DO NOW:� Read this notice, so you can make an informed decision about your care.� Ask us any questions that you may have after you finish reading. � Choose an option below about whether to receive the (D)_____________listed above.

Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

(G) OPTIONS: Check only one box. We cannot choose a box for you.

�� OPTION 1. I want the (D)__________ listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.

�� OPTION 2. I want the (D)__________ listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.

�� OPTION 3. I don’t want the (D)__________listed above. I understand with this choiceI am not responsible for payment, and I cannot appeal to see if Medicare would pay.

(H) Additional Information:

This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).Signing below means that you have received and understand this notice. You also receive a copy.

(I) Signature: (J) Date:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Form CMS-R-131 (03/08) Form Approved OMB No. 0938-0566

MASSACHUSETTS SENIOR LEGAL

HELPLINE 1-866-778-0939

The Helpline provides FREE legal information, advice and referral services for Massachusetts senior citizens (60 years or older) in most areas of civil law, including: • Social Security/SSI • Guardianship • Veterans Benefits • Mass Health • Medicare • Consumer issues • Public Benefits • Unemployment • Foreclosures

• Powers of Attorney • Bankruptcy • Evictions • Landlord/Tenant • Utilities • Family law • Nursing Home

We provide interpretation services in many languages.

If you get our voicemail, please leave your name, telephone number and the town where you reside and we will return your call within 2 business days. The Massachusetts Senior Legal Helpline is a project made in collaboration with the Massachusetts Office of Elders Affairs, the Legal Advocacy & Resource Center, the Massachusetts Justice Project and the Massachusetts legal services providers. This project is made possible with a grant from the U.S. Department of Health and Human Services, Administration on Aging.

Comparison of the Parts A, B, C, and D Appeal Processes

1Starting in 2005, the AIC requirement for an ALJ hearing and Federal District Court will be adjusted in accordance with the medical care component of the consumer price index.

AIC = Amount in controversy ALJ = Administrative Law Judge Contractor = Fiscal Intermediary, Carrier or Medicare Administrative Contractor (MAC) IRE = Independent Review Entity

MA-PD = Medicare Advantage-Prescription Drug MMA = Medicare Prescription Drug, Improvement & Modernization Act of 2003 PDP = Prescription Drug Plan QIC = Qualified Independent Contractor

Initial Decision

SecondLevel ofAppeal

ThirdLevel ofAppeal

FourthLevel ofAppeal

Final Appeal

Level

FirstLevel ofAppeal

ContractorDetermination

Contractor Redetermination60 day time limit

120 days to file

60 days to file

60 days to fileMAC may decline review

60 days to file

Quality ImprovementOrganization

Redetermination72 hour time limit

Standard ProcessPart A and B

Expedited Process(Some Part A only)

Notice of Dischargeor Service Termination

Qualified IndependentContractor

Reconsideration60 day time limit

Qualified IndependentContractor

Reconsideration72 hour time limit

180 days to file

Noon the next calendar day

Noon the next calendar day

Office of Medicare Hearings and Appeals

AIC=> $12090 day limit

Medicare Appeals Council90 day time limit

for processing

Federal District CourtAIC=> $1,220

Parts A & B (Fee-for Service) Process

60 days to file

60 days to fileMAC may decline review

60 days to file

OrganizationDetermination

Part C (MA) Process

MA Org. ReconsiderationPre Service: 30 day time limitPayment: 60 day time limit

60 days to file

IRE ReconsiderationPre Service: 30 day limitPayment: 60 day limit

Automatic IRE review if MA

Org. upholds denial

MA Org. Reconsideration72 hour time limit

Pre Service: 14 day time limit

Payment: 60 day time limit

IRE Reconsideration 72 hour time limit

Expedited ProcessStandard Process

72 hour time limit

Office of MedicareHearings and Appeals

AIC=> $120No statutory time limit for processing

Medicare Appeals CouncilNo statutory time limit

for processing

Federal District CourtAIC=> $1,220

Part D (Drug) Process

IRE Reconsideration 72 hour time limit

60 days to file

CoverageDetermination

60 days to file

72 hour time limit 24 hour time limit

MA-PD/PDPRedetermination7 day time limit

60 days to fileMA-PD/PDP

Redetermination72 hour time limit

IRE Reconsideration7 day time limit

60 days to file

60 days to file

Medicare Appeals CouncilNo statutory time limit

for processing

Federal District CourtAIC=> $1,2201

Office of MedicareHearings and Appeals

AIC=> $120No statutory time limit for processing

Expedited ProcessStandard Process

Case Study — Mr. Felix DeKatt Felix has diabetes and has been seeing a podiatrist for the past three months for foot care. Recently Felix changed doctors and was asked to pay $75 for the office visit. Felix was sure that Medicare paid for these services since he had never received a bill from his previous podiatrist. When Felix questioned the billing clerk in the doctor’s office, he was told that Medicare does not cover routine foot care. How would you help him?

Day 5 – 2012 1

Case Study — Mr. Cal Asthenik

Cal was having a hard time walking. He received a call from a company that sells wheelchairs. He ordered a wheelchair after the salesperson assured him that Medicare would reimburse him for the expense. He was surprised to find that Medicare would not pay for it. What would you tell him about the procedure for getting a wheelchair under Medicare? How would you help him with this situation?

Day 5 – 2012 2

Case Study — Fran Tikk

Fran comes to see you at the SHINE office. She is 71 years old and on a federal employee group retiree plan with Blue Cross/Blue Shield (BCBS) for which she is paying a premium of over $150/month. She has had numerous health problems in the past few years, and her plan does not provide full coverage. When Fran turned 65 in 2005, she called Social Security to see about enrolling in Medicare. She was told that she was not eligible for Medicare because she had not worked under Social Security. In 2007 a rep at her federal BCBS plan told her she would be eligible for Medicare under her spouse who had worked under Social Security. (They had been married for more than 10 years.) Fran then went to her local SS office to inquire. The SS worker confirmed that she indeed was eligible under her former spouse but would now face a penalty for not signing up back in 2005. Fran refused Medicare at that point because she could not afford it with the penalty. (Fran’s gross income is under $1000/month, and over the past few years she has spent down her savings on medical bills.) Fran was recently told by member services at her federal BCBS plan that if she could get Medicare A&B, her BCBS would act as a supplement providing full coverage at a lower cost. She could then drop down to a plan that would cost far less than what she is currently paying.

Day 5 – 2012 3

Case Study — Demi Gogg

Demi meets with you to see if she can get any help with the costs of her Medicare Prescription Drug Program. She is enrolled in a Part D plan (Wellcare Signature) that covers all of her drugs except Lorazepam. She pays $55.90/month for a premium and, after she met the deductible, co-pays for her meds. Demi lives in her own home and has a gross monthly income of $1,560 and savings of $15,000. She is getting help through the fuel assistance program with her heating costs, but still finds the Part D costs hard to meet. How would you assist her?

Day 5 – 2012 4

Claims Processing, Appeals, Fraud & Abuse Quiz

1. While driving to work Josephine has a minor traffic accident. As a precaution Josephine was transported to the hospital in an ambulance and was examined by a physician in the emergency room. Josephine gave the emergency room clerk her Medicare and Medigap insurance information. Several weeks later Josephine received a denial from Medicare for the services. Who pays first?

□ Insurance □ Health Plan □ Medicare □ Employer Health Plan

2. Harriet has been in the hospital for 4 days recovering from gall bladder surgery. The hospital staff has informed her that she is being discharged the following day. Harriet does not feel strong enough to return home and wants to appeal this discharge. To whom should she direct her appeal?

□ Medicare Advocacy Project □ Medicare Part B □ Mass PRO □ Surgeon General

3. What are the guidelines for an Expedited Appeal? 4. Mary Jones bas been receiving home health services for the past 6 weeks. She calls you because the home health agency informed her today that she will be discharged from receiving these services next week. Mary feels she still needs physical therapy. How would you help her?

Day 5 – 2012 5

Case Study — Jack R. Abbot Mr Abbot is retired and having problems with his insurance covering his medical bills. He keeps getting denial notices for many of the services he receives. He wants to meet with you to get some help with resolving the situation. What information would you ask Mr. Abbot to bring to your meeting? How would you help him?

Day 5 – 2012 6

Case Study — Mr. Perry Scope Mr. Scope fell and broke his hip. Since his discharge from the hospital he has been receiving physical therapy services in his home. He was told by his physical therapist, however, that the therapy will end next week. Mr. Scope thinks that he needs more therapy. How would you help him?

Day 5 – 2012 7

Case Study - Pam Purr

Pam Purr and her husband, Cass, meet with you. Cass receives a Social Security check for $950 and Pam receives a check for $650. They sold their house years ago and have spent down most of the money from that. They now have $19,000 in the bank. They live in senior housing and own a car. They both have only Medicare A & B. They tell you they are relatively healthy and see the doctor infrequently. They didn’t sign up for Part D because they didn’t take medication until recently. Cass has two prescriptions that cost $125 per month and Pam has one prescription that costs $55 per month. They do have bills beyond what Medicare covers, but said these are taken into account in calculating their rent for senior housing. They heard some of their neighbors talking about programs that help with medication and other health care costs and want to find out if they might be eligible. How would you help them?

Day 5 – 2012 8

Case Study — Barbie Que

Barbie calls you at the SHINE office. She tells you she has been covered under Blue Cross/Blue Shield’s Medex Gold plan because she takes a lot of medications. She is very satisfied with the Gold plan but is finding it difficult to pay the premium on top of the expenses she has maintaining her home. Barbie looked into the program through Social Security that helps pay for prescription costs, but tells you her monthly income of $1,725 and assets of $40,000 make her ineligible. How would you help her?

Day 5 – 2012 9

Case Study — Al Falfa

Al meets with you at the SHINE office. He will be 65 next month and is retiring. He has just returned from Social Security and will receive Medicare A and B. His neighbor has a Medigap Supplement 1 plan, so he also signed up effective on the first of next month when his Medicare begins. He has three prescriptions: one is a brand, Advair, and the other two are generics. He has heard negative things about Part D, so he tells you he may just pay for his prescriptions out of pocket. His only income will be $11,900/year from Social Security, and he currently has $8000 in the bank. How would you help him?

Day 5 – 2012 10

Case Study - Jen Teal

Jen meets with you to talk about her prescription coverage. She joined a Part D plan last year but wants to find out if there is a better plan she can join this year. She takes a few expensive brands which she paid for in full during the donut hole at a cost of several hundred per month. A friend told her she should have signed up for the plan that covers brands during the donut hole, so she wants to know if that’s what she should do this year. She explains that although her only income is Social Security of $1,450 per month, she has assets that make her ineligible for benefit programs. She lives in her own home and wants to stay there for as long as she can afford to. Although her assets prevent her from getting any assistance, she uses her assets to help with her prescription costs and to maintain her home. How would you help her?

Day 5 – 2012 11

★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★

CENTERS FOR MEDICARE & MEDICAID SERVICES

This official governmentbooklet explains the following:

★★ What durable medical equipment is

★★ Which durable medical equipment,prosthetic, and orthotic items are covered in Original Medicare

★★ Where to get help with your questions

Medicare Coverage of Durable MedicalEquipment andOther Devices

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Do you need durable medical equipment orother types of medical equipment? Medicare can help.This booklet explains Medicare coverage for durable medicalequipment, prosthetic devices, orthotic items, prostheses andtherapeutic shoes in Original Medicare (sometimes calledfee-for-service) and what you might need to pay. Durablemedical equipment includes things like the following:

• Home oxygen equipment

• Hospital beds

• Walkers

• Wheelchairs

This booklet also explains coverage for prosthetic equipment(like cardiac pacemakers, enteral nutrition pumps, andprosthetic lenses), orthotic items (like leg, neck, and backbraces) and prostheses (like artificial legs, arms, and eyes). It’simportant for you to know what Medicare covers and what youmay need to pay. Talk to your doctor if you think you needsome type of durable medical equipment.

If you have questions about the cost of durable medicalequipment or coverage after reading this booklet, call1-800-MEDICARE (1-800-633-4227). TTY users should call1-877-486-2048.

Note: The information in this booklet was correct when it wasprinted. Changes may occur after printing. For the most up-to-dateinformation, visit www.medicare.gov on the web, or call1-800-MEDICARE (1-800-633-4227). A customer servicerepresentative can tell you if the information has been updated.TTY users should call 1-877-486-2048.

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Table of Contents What is durable medical equipment? . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Does Medicare cover durable medical equipment? . . . . . . . . . . . . . . . . 3

When does Original Medicare cover durable medical equipment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

What if I need durable medical equipment and I am in a Medicare Advantage Plan? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3–4

If I have Original Medicare, how do I get the durable medical equipment I need? . . . . . . . . . . . . . . . . . . . . . . 4–5

Power wheelchairs and scooters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

What is covered, and how much does it cost? . . . . . . . . . . . . . . . . . . 6–7

What is “assignment” in Original Medicare, and whyis it important? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

How will I know if I can buy durable medical equipment or whether Medicare will only pay for me to rent it? . . . . . . . . . . . 8–9

New Rules for How Medicare Pays Suppliers for Oxygen Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10–11

Words to know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12–13 (Definitions of red words in text)

“Medicare Coverage of Durable Medical Equipment and Other Devices” isn’t a legaldocument. Official Medicare Program legal guidance is contained in the relevantstatutes, regulations, and rulings.

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What is durable medical equipment? Durable medical equipment is reusable medical equipment suchas walkers, wheelchairs, or hospital beds.

Does Medicare cover durable medicalequipment? Anyone who has Medicare Part B can get durable medicalequipment as long as the equipment is medically necessary.

When does Original Medicare cover durablemedical equipment? If you have Part B, Original Medicare covers durable medicalequipment when your doctor or treating practitioner (such as anurse practitioner, physician assistant, or clinical nurse specialist)prescribes it for you to use in your home. A hospital or nursinghome that is providing you with Medicare-covered care can’tqualify as your “home” in this situation. However, a long-termcare facility can qualify as your home.

Note: If you are in a skilled nursing facility and the facilityprovides you with durable medical equipment, the facility isresponsible for this equipment.

What if I need durable medical equipment andI am in a Medicare Advantage Plan? Medicare Advantage Plans (like an HMO or PPO) must coverthe same items and services as Original Medicare. Your costs willdepend on which plan you choose, and may be lower thanOriginal Medicare. If you are in a Medicare Advantage Plan andyou need durable medical equipment, call your plan to find outif the equipment is covered and how much you will have to pay. Words in red

are definedon pages12–13.

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What if I need durable medical equipment and I am in aMedicare Advantage Plan? (continued) If you are getting home care or using medical equipment and youchoose to join a new Medicare Advantage Plan, you should call the newplan as soon as possible and ask for Utilization Management. They cantell if your equipment is covered and how much it will cost. If youreturn to Original Medicare, you should tell your supplier to billMedicare directly after the date your coverage in the MedicareAdvantage Plan ends.

Note: If your plan leaves the Medicare Program and you are usingmedical equipment such as oxygen or a wheelchair, call the telephonenumber on your Medicare Advantage Plan card. Ask for UtilizationManagement. They will tell you how you can get care under OriginalMedicare or under a new Medicare Advantage Plan.

If I have Original Medicare, how do I get thedurable medical equipment I need? If you need durable medical equipment in your home, your doctor ortreating practitioner (such as a nurse practitioner, physician assistant,or clinical nurse specialist) must prescribe the type of equipment youneed. For some equipment, Medicare also requires your doctor or oneof the doctor’s office staff to fill out a special form and send it toMedicare to get approval for the equipment. This is called aCertificate of Medical Necessity. Your supplier will work with yourdoctor to see that all required information is submitted to Medicare.If your prescription and/or condition changes, your doctor mustcomplete and submit a new, updated certificate.

The chart on page 6 shows which items require a Certificate ofMedical Necessity.

Words in redare definedon pages12–13.

If I have Original Medicare, how do I get the durable medicalequipment I need? (continued) Medicare only covers durable medical equipment if you get itfrom a supplier enrolled in the Medicare Program. This meansthat the supplier has been approved by Medicare and has aMedicare supplier number.

To find a supplier that is enrolled in the Medicare Program, visitwww.medicare.gov and select “Find Suppliers of MedicalEquipment in Your Area.” You can also call 1-800-MEDICARE(1-800-633-4227) to get this information. TTY users should call1-877-486-2048.

A supplier enrolled in the Medicare Program must meet strictstandards to qualify for a Medicare supplier number. If yoursupplier doesn’t have a supplier number, Medicare won’t payyour claim, even if your supplier is a large chain or departmentstore that sells more than just durable medical equipment.

Power wheelchairs and scooters For Medicare to cover a power wheelchair or scooter, your doctormust state that you need it because of your medical condition.Medicare won’t cover a power wheelchair or scooter that is onlyneeded and used outside of the home.

Most suppliers who work with Medicare are honest. There are afew who aren’t honest. Medicare is working with othergovernment agencies to protect you and the Medicare Programfrom dishonest suppliers of power wheelchairs and scooters.

For more information about Medicare’s coverage of powerwheelchairs or scooters, view the publication “ProtectingMedicare’s Power Wheelchair and Scooter Benefit.” Visitwww.medicare.gov and select “Find a Medicare Publication.” Youcan also call 1-800-MEDICARE (1-800-633-4227). TTY usersshould call 1-877-486-2048.

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What is covered, and how much does it cost? The chart below and on page 7 shows some of the items Medicare covers and how muchyou have to pay for these items. This list doesn’t include all covered durable medicalequipment. For questions about whether Medicare covers a particular item, call1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If youhave a Medigap policy, it may help cover some of the costs listed below and on page 7.

Durable Medical Equipment

What Medicare Covers

• Air fluidized beds

• Blood glucose monitors

• Bone growth (or osteogenesis) stimulators*

• Canes (except white canes for the blind)

• Commode chairs

• Crutches

• Home oxygen equipment and supplies*

• Hospital beds

• Infusion pumps and some medicines used in them

• Lymphedema pumps/pneumatic compressiondevices*

• Nebulizers and some medicines used in them (if reasonable and necessary)

• Patient lifts*

• Scooters

• Suction pumps

• Traction equipment

• Transcutaneous electronic nerve stimulators (TENS)*

• Ventilators or respiratory assist devices

• Walkers

• Wheelchairs (manual and power)

What You Pay

Generally, you pay 20% of theMedicare-approved amount afteryou pay your Medicare Part Bdeductible for the year ($135 in2009). Medicare pays the other80%. The Medicare-approvedamount is the lower of the actualcharge for the item or the feeMedicare sets for the item.However, the amount you paymay vary because Medicare paysfor different kinds of durablemedical equipment in differentways. You may be able to rent orbuy the equipment.

* You must get a Certificate of Medical Necessity before you can get this equipment. See page 4.

Prosthetic and Orthotic Items

What Medicare Covers

• Arm, leg, back, and neck braces • Artificial limbs and eyes • Breast prostheses (including a surgical brassiere) after

a mastectomy • Ostomy supplies for people who have had a

colostomy, ileostomy, or urinary ostomy. Medicarecovers the amount of supplies your doctor says youneed based on your condition.

• Prosthetic devices needed to replace an internal bodypart or function

• Therapeutic shoes or inserts for people with diabeteswho have severe diabetic foot disease The doctor who treats your diabetes must certifyyour need for therapeutic shoes or inserts. Apodiatrist or other qualified doctor must prescribethe shoes and inserts. A doctor or other qualifiedindividual like a pedorthist, orthotist, or prosthetistmust fit and provide the shoes. Medicare helps payfor one pair of therapeutic shoes and inserts percalendar year. Shoe modifications may besubstituted for inserts.

What You Pay

You pay 20% of theMedicare-approved amount afteryou pay your Medicare Part Bdeductible for the year ($135 in2009). Medicare pays the other80%. These amounts may bedifferent if the supplier doesn’taccept assignment. See page 8.

Corrective Lenses What Medicare Covers

• Prosthetic Lenses —Cataract glasses —Conventional glasses and contact lenses after

surgery with an intraocular lens —Intraocular lenses An ophthalmologist or an optometrist mustprescribe these items. Important: Only standard frames are covered.Eyeglasses and cataract lenses are covered even ifyou had the surgery before you had Medicare.Payment may be made for lenses for both eyes evenif cataract surgery involved only one eye.

What You Pay

You are covered for one pair ofeyeglasses or contact lenses aftereach cataract surgery with anintraocular lens. You pay 20% ofthe Medicare-approved amountafter you pay the Medicare Part Bdeductible for the year ($135 in2009). Medicare pays the other80%. Costs may be different ifthe supplier doesn’t acceptassignment. See page 8. If youwant to upgrade the frames, youpay any additional cost.

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What is covered, and how much does it cost? (continued)

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What is “assignment” in Original Medicare and whyis it important? Assignment is an agreement between you (the person with Medicare),Medicare, and doctors or other health care providers, and suppliers of healthcare equipment and supplies (like durable medical equipment and prostheticor orthotic devices). Doctors, providers, and suppliers who agree to acceptassignment accept the Medicare-approved amount as full payment. After youhave paid the Part B deductible ($135 in 2009), you pay the doctor orsupplier the coinsurance (usually 20% of the approved amount). Medicarepays the other 80%.

Suppliers who agree to accept assignment on all claims for durable medicalequipment and other devices are called “participating suppliers.” If a durablemedical equipment supplier doesn’t accept assignment, there is no limit towhat they can charge you. In addition, you may have to pay the entire bill(Medicare’s share as well as your coinsurance and any deductible) at the timeyou get the durable medical equipment. The supplier will send the bill toMedicare for you, but you will have to wait for Medicare to reimburse youlater for its share of the charge.

Important Note: Before you get durable medical equipment, ask if thesupplier is enrolled in Medicare. If the supplier is not enrolled in Medicare,Medicare won’t pay your claim at all. Then, ask if the supplier is aparticipating supplier in the Medicare Program. A participating supplier mustaccept assignment. A supplier that is enrolled in Medicare, but isn’t“participating,” has the option whether to accept assignment. You will have toask if the supplier will accept assignment for your claim.

To find suppliers who accept assignment, visit www.medicare.gov and select“Find Suppliers of Medical Equipment in Your Area.” You can also call1-800-MEDICARE (1-800-633-4227). TTY users should call1-877-486-2048.

How will I know if I can buy durable medicalequipment or whether Medicare will only pay forme to rent it? If your supplier is a Medicare-enrolled supplier, they will know whetherMedicare allows you to buy a particular kind of durable medical equipment,or just pays for you to rent it. Medicare pays for most durable medicalequipment on a rental basis. Medicare only purchases inexpensive orroutinely purchased items, such as canes; power wheelchairs; and, in rarecases, items that must be made specifically for you.

Words in redare definedon pages12–13.

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How will I know if I can buy durable medical equipment orwhether Medicare will only pay for me to rent it?(continued) Buying equipment If you own Medicare-covered durable medical equipment andother devices, Medicare may also cover repairs and replacementparts. Medicare will pay 80% of the Medicare-approved amountfor purchase of the item. Medicare will also pay 80% of theMedicare-approved amount (up to the cost of replacing the item)for repairs. You pay the other 20%. Your costs may be higher if thesupplier doesn’t accept assignment.

Note: The equipment you buy may be replaced if it’s lost,stolen, damaged beyond repair, or used for more than thereasonable useful lifetime of the equipment.

Renting equipment If you rent durable medical equipment and other devices,Medicare makes monthly payments for use of the equipment. Therules for how long monthly payments continue vary based on thetype of equipment. Total rental payments for inexpensive orroutinely purchased items are limited to the fee Medicare sets topurchase the item. If you will need these items for more than afew months, you may decide to purchase these items rather thanrent them. Monthly payments for frequently serviced items, suchas ventilators, are made as long as the equipment is medicallynecessary. The payment rules for other types of rented equipment,called “capped rental items,” are on page 10. Medicare will pay80% of the Medicare-approved amount each month for use ofthese items. You pay the other 20% after you pay the MedicarePart B deductible ($135 in 2009).

The supplier will pick up the equipment when you no longerneed it. Any costs for repairs or replacement parts for the rentedequipment are the supplier’s responsibility. The supplier will alsopick up the rented equipment if it needs repairs. You don’t haveto bring the rented equipment back to the supplier.

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New Rules for How Medicare Pays Suppliers for OxygenEquipment Changes in law require Medicare to change the way it pays suppliers for oxygenequipment and supplies. You will still be able to get your oxygen equipment.However, you should know about the new rules that start January 1, 2009.Previously, the law stated that you would own the oxygen equipment after yourented it for 36 months. Under the new law, the rental payments will end after 36months, but the supplier continues to own the equipment. The new law thenrequires your supplier to provide the oxygen equipment and related supplies for 2additional years (5 years total), as long as oxygen is still medically necessary.

How does Medicare pay for oxygen equipment and related suppliesand what do I pay?The monthly rental payments to the supplier cover not only your oxygenequipment, but also any supplies and accessories such as tubing or a mouthpiece,oxygen contents, maintenance, servicing and repairs. Medicare pays 80% of therental amount, and the person with Medicare is responsible for any unpaid Part Bdeductible, and the remaining 20% of the rental amount.

What happens with my oxygen equipment and related services afterthe 36 months of rental payments?Your supplier has been paid over 36 months for furnishing your oxygen andoxygen equipment for up to 5 years, and your supplier is required to continue tomaintain the oxygen equipment (in good working order) and furnish theequipment and any necessary supplies and accessories, as long as you need it untilthe 5 year period ends. The supplier can’t charge you for performing these services.If you use oxygen tanks or cylinders that need delivery of gaseous or liquid oxygencontents, Medicare will continue to pay each month for the delivery of contentsafter the 36-month rental period. The supplier that delivers this equipment to youin the last month of the 36-month rental period must provide these items, as longas you medically need it, up to 5 years.

Will Medicare pay for any maintenance and servicing after the 36-month period ends?If you use an oxygen concentrator or transfilling equipment (a machine that fillsyour portable tanks in your home), for 2009 only, Medicare will pay for routinemaintenance and servicing visits every 6 months starting 6 months after the end ofthe 36-month rental period.

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New Rules for How Medicare Pays Suppliers for OxygenEquipment (continued)

What happens to my oxygen equipment after 5 years?At the end of the 5-year period, your supplier’s obligation to continuefurnishing your oxygen and oxygen equipment ends, and you may elect toobtain replacement equipment from any supplier. A new 36-month paymentperiod and 5-year supplier obligation period start once the old 5-year periodends and the new oxygen and oxygen equipment you require is furnished.

What if I’m away from home for an extended period of time or Imove to another area during the 36-month period?If you travel away from home for an extended period of time (several weeks ormonths) or permanently move to another area during the 36-month rentalperiod, ask your current supplier if they can help you find a supplier in thenew area. If your supplier can’t help you locate an oxygen supplier in the areawhere you are visiting or moving to, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

What if I’m away from home for an extended period of time or Imove to another area after the 36-month period? If you travel or move after the 36-month rental period ends, your supplier hasbeen paid for furnishing your equipment for 5 years and is generallyresponsible for ensuring that you are provided with oxygen and oxygenequipment in the new area. Your supplier may choose to make arrangementsfor a different supplier in your new area to provide the oxygen and oxygenequipment. However, a supplier may not charge you for the equipment,supplies, accessories or other services identified above that are provided afterthe 36-month rental payment period. The only exceptions to this rule arenoted above.

What if my supplier refuses to continue providing my oxygenequipment and related services as required by law?If your supplier is not following Medicare laws and rules, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. A customer service representative will refer your case to the appropriate area.

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Words to know

Assignment—An agreement between a person with Medicare, adoctor or supplier, and Medicare. Doctors or suppliers who acceptassignment from Medicare agree to accept the Medicare-approvedamount as full payment.

Capped rental item—Durable medical equipment (like oxygen,nebulizers, and manual wheelchairs) that costs more than $150,and is rented to people with Medicare more than 25% of the time.

Certificate of Medical Necessity—A form required by Medicarethat your physician must complete to get Medicare coverage forcertain medical equipment.

Coinsurance—An amount you may be required to pay for servicesafter you pay any plan deductibles. In Original Medicare, this is apercentage (like 20%) of the Medicare-approved amount. You haveto pay this amount after you pay the Part A and/or Part Bdeductible.

Deductible—The amount you must pay for health care orprescriptions, before Original Medicare or other insurance begins topay. For example, in Original Medicare, you pay a new deductiblefor each benefit period for Part A, and each year for Part B. Theseamounts can change every year.

Durable Medical Equipment—Medical equipment that is orderedby a doctor (or, if Medicare allows, a nurse practitioner, physicianassistant, or clinical nurse specialist) for use in the home. A hospitalor nursing home that mostly provides skilled care can’t qualify as a“home” in this situation. These medical items must be reusable,such as walkers, wheelchairs, or hospital beds.

Medically Necessary—Services or supplies that are needed for thediagnosis or treatment of your medical condition.

Medicare Advantage Plan (Part C)—A type of Medicare planoffered by a private company that contracts with Medicare toprovide you with all your Medicare Part A and Part B benefits. Alsocalled Part C, Medicare Advantage Plans are HMOs, PPOs, PrivateFee-for-Service Plans, or Medicare Medical Savings Account Plans.If you are enrolled in a Medicare Advantage Plan, Medicare servicesare covered through the plan, and are not paid for under OriginalMedicare.

Medicare-Approved Amount—In Original Medicare, this is theamount a doctor or supplier that accepts assignment can be paid.It includes what Medicare pays and any deductible, coinsurance,or copayment that you pay. It may be less than the amount adoctor or supplier charges for the item.

Medigap Policy—Medicare Supplement Insurance sold byprivate insurance companies to fill “gaps” in Original Medicarecoverage. Except in Massachusetts, Minnesota, and Wisconsin, allMedigap policies must be one of 12 standardized Medigappolicies labeled Medigap Plan A through Plan L. Medigappolicies only work with Original Medicare.

Nebulizers—Equipment that delivers medicine in a mist form toyour lungs.

Original Medicare—Original Medicare has two parts: Part A(Hospital Insurance) and Part B (Medical Insurance). It is afee-for-service health plan. After you pay a deductible, Medicarepays its share of the Medicare-approved amount, and you payyour share (coinsurance and deductibles).

Orthotics—Devices that correct or support the function of bodyparts. Examples include leg, arm, and neck braces.

Patient Lifts—Equipment designed to move a patient from abed or wheelchair.

Prostheses—Devices that substitute for a missing body part.Examples include artificial legs, arms, and eyes.

Prosthetic Devices—Medical equipment (other than dental)that replaces all or part of an internal body organ.

Words to know

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, Maryland 21244-1850

Official Business Penalty for Private Use, $300

CMS Publication No. 11045 Revised December 2008

To get this publication in Spanish, call1-800-MEDICARE (1-800-633-4227).TTY users should call 1-877-486-2048.

Para obtener este folleto en español,llame GRATIS al 1-800-MEDICARE(1-800-633-4227). Los usuarios de TTYdeben llamar al 1-877-486-2048.

Medicare’s Wheelchair and Scooter BenefitIf your doctor submits a written order stating that you have a medical need for awheelchair or scooter for use in your home, Medicare will help cover any of thetypes listed below. Generally, Medicare will pay 80% of the Medicare-approvedamount, after you have met the Part B deductible. You pay 20% of the Medicare-approved amount.

Wheelchairs (both manual and power) and scooters are also known as “mobilityassistive equipment.”

Medicare will help cover your wheelchair and scooter, if you meet all of the following conditions:

• You have a health condition that causes difficulty moving around in your home.

• You’re unable to do activities of daily living (like bathing, dressing, getting in orout of a bed or chair, or using the bathroom) even with the help of a cane, crutch,or walker.

• You’re able to safely operate, and get on and off the wheelchair or scooter, or havesomeone with you who is always available to help you safely use the device.

Also, the equipment must be usable within your home (for example, it’s not too bigfor your home or blocked by things in its path).

Types of Mobility Assistive Equipment:

Manual WheelchairIf you can’t use a cane or walker safely, you may qualify for a manual wheelchair. The manual wheelchair you choose can’t be a high strength, ultra-lightweight wheelchair that you could buy without renting first.

Rolling Chair/Geri-chairIf you need more support than a wheelchair can give, you may qualify for a rollingchair. These chairs have small wheels that are at least 5 inches in diameter. Therolling chair must be designed to meet your medical needs due to illness or otherimpairment.

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CENTERS FOR MEDICARE & MEDICAID SERVICES

Power-Operated Vehicle/ScooterIf you can’t use a cane or walker, or can’t operate a manual wheelchair, you may qualify for a power-operated scooter.

Power WheelchairIf you can’t use a manual wheelchair in your home, or if you don’t qualify for apower-operated scooter because you aren’t strong enough to sit up or to work thescooter controls safely, you may qualify for a power wheelchair.

Before you get either a power wheelchair or scooter, you must have a face-to-faceexam by your doctor. The doctor will review your needs and help you decide ifyou can safely operate the device. If so, the doctor will submit a written ordertelling Medicare why you need the device and that you’re able to operate it.

Remember, you must have a medical need for Medicare to cover a power wheelchairor scooter. Medicare won’t cover this equipment if it will be used mainly for leisure orrecreational activities, or if it’s only needed to move around outside your home.

Also, in some areas, you may need to get your power wheelchair or scooter from specific suppliers approved by Medicare. Visit www.medicare.gov/supplier or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users should call1-877-486-2048.

Note: If you don’t need a power wheelchair or scooter on a long-term basis, you maywant to rent the equipment to lower your costs. Talk to your supplier to find outmore about this option. Some wheelchairs must be rented first, even if you eventuallyplan to buy them.

FraudMost doctors, health care providers, suppliers, and private companies who work withMedicare are honest. However, there are a few who aren’t. For example, some suppliers of medical equipment try to cheat Medicare by offering expensive powerwheelchairs and scooters to people who don’t qualify for these items. Also, some suppliers of medical equipment may call you without your permission, even though“cold calling” isn’t allowed. Medicare is trying harder than ever to find and preventfraud and abuse by working more closely with health care providers, strengtheningoversight, and reviewing claims data.

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How to Spot Fraud and AbuseYou can help Medicare stop fraud and abuse by watching for the following examplesof possible Medicare fraud:

• Suppliers offer you a free wheelchair or scooter.

• Suppliers offer to waive your copayment.

• Someone bills Medicare for equipment you never got.

• Someone bills Medicare for home medical equipment after it has been returned.

What to Do if You Suspect Fraud and AbuseIf you suspect billing fraud, contact your health care provider to be sure the bill iscorrect. If your doctor, health care provider, or supplier doesn’t help you with yourquestions or concerns or if you can’t contact them, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

For More InformationMedicare is here for you 24 hours a day, every day. To get more information, visitwww.medicare.gov or call 1-800-MEDICARE. For more information aboutMedicare’s fraud and abuse activities, visit www.stopmedicarefraud.gov.

CMS Product No. 11046Revised January 2011