It can sometimes be difficult to understand what your options are under Medicare. This fact sheet will explain what Medicare is, what each Medicare plan offers, how to get covered, and what it all means for a person with limb loss.
What is Medicare?
Medicare is federally funded healthcare coverage for people who are 65 years old or older, certain younger people with disabilities, people with Amyotrophic Lateral Sclerosis (ALS), and people with End-Stage Renal Disease (ESRD).
There are two main ways to get Medicare coverage: Original Medicare (Parts A and B) or a Medicare Advantage Plan (Part C). Some people get additional coverage, such as Medicare prescription drug coverage (Part D) or Medicare Supplement Insurance (Medigap).
|Part A (Hospital Insurance)||Covers inpatient hospital stays, care in a skilled nursing facility, hospice care and some home healthcare.|
|Part B (Medical Insurance)||Covers certain doctors’ services, outpatient care, medical supplies and preventive services.
Visit the Medicare Web site to determine if you should sign up for Part B.
If you choose to enroll in Part B, you can download the application from the Medicare Web site.
|Part C (Medicare Advantage Plans)||A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits.
Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.
|Part D (Prescription Drug Coverage)||Adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans.
These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.
- For more information, read Your Medicare Coverage Choices.
- If you have other health insurance, Medicare can answer your questions about how Medicare works with other insurance.
- If you’re retired and have coverage from a former employer, there are four things you should know.
- Medicare provides an online Eligibility and Premium Calculator to help you find out if you are eligible.
- Medicare provides information on how Medicare is funded, and what it pays for.
- You can learn how the Affordable Care Act affects Medicare by visiting their Affordable Care Act page.
- You can contact Medicare by calling 800/MEDICARE (800/633-4227) or by writing to:
Medicare Contact Center Operations
PO Box 1270
Lawrence, KS 66044
What Coverage Does Medicare Offer for People With Limb Loss?
Medicare Part B (Medical Insurance) covers these items as durable medical equipment (DME):
- Arm, leg, back, and neck braces if deemed medically necessary.
- Artificial limbs and eyes when your doctor orders them.
- Orthopedic shoes (only when they are a necessary part of a leg brace).
- Orthotics, if a doctor has deemed it medically necessary and, the doctor and orthotic supplier are enrolled and participate in Medicare.
- Therapeutic shoes or inserts for people with diabetes who have severe diabetic foot disease.
Who is eligible?
All people with Medicare are covered.
Your costs in Original Medicare:
You pay 20 percent of the Medicare-approved amount. Medicare pays for different kinds of DME in different ways. Depending on the type of equipment, you may need to rent the equipment, you may need to buy the equipment, or you may be able to choose whether to rent or buy the equipment.
Medicare will only cover your DME if your doctors and DME suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If your doctors or suppliers are not enrolled, Medicare will not pay the claims submitted by them. It is also important to ask your suppliers if they participate in Medicare before you get DME. If suppliers are participating suppliers, they must accept assignment. For more information on this, visit the Your Medicare Coverage page.
If suppliers are enrolled in Medicare but are not “participating,” they may choose not to accept assignment. If suppliers do not accept assignment, there is no limit on the amount they can charge you.
Note: To find out how much your specific test, item, or service will cost, talk to your doctor or other healthcare provider. The specific amount you will owe may depend on several things such as, other insurance you may have, how much your doctor charges, whether your doctor accepts assignment, the type of facility, and the location where you get your test, item, or service.
How Do I Enroll in Medicare?
Some people will get Medicare Parts A and B automatically, and others will need to sign up. Find out which category you fall into:
|You will be enrolled in Medicare Parts A and B automatically if:||You must sign up for Medicare Parts A and B if:|
|You are already getting benefits from Social Security or the Railroad Retirement Board (RRB).
You are under 65 and have a disability after you get one of these:
You have ALS (amyotrophic lateral sclerosis, also called Lou Gehrig’s disease).
|You are not getting Social Security or RRB benefits (for example, because you are still working).
You qualify for Medicare because you have end-stage renal disease (ESRD).
You live in Puerto Rico and want to sign up for Part B (you automatically get Part A). You must already have Part A to apply for Part B. If you choose to apply, you can download and complete an Application for Enrollment in Part B (CMS-40B).
The application and instructions to complete it are also available in Spanish.
If you get Medicare automatically, you’ll get your red, white, and blue Medicare card in the mail three months before your 65th birthday or your 25th month of receiving disability.
When you are first eligible for Medicare, you have a seven-month Initial Enrollment Period to sign up for Part A and/or Part B. For example, if you’re eligible when you turn 65, you can sign up during the seven-month period that begins three months before the month you turn 65, includes the month you turn 65, and ends three months after the month you turn 65.
Medicare provides an online Eligibility and Premium Calculator to help you find out if you are eligible.
If you didn’t sign up for Parts A and B when you were first eligible, you can sign up between January 1 and March 31 of each year, or you can sign up during a Special Enrollment Period.
What is Open Enrollment and When Does It Happen?
Medicare open enrollment is a period of time in which individuals and families can enroll in health insurance coverage.
- Medicare Open Enrollment: October 15, 2020 to December 7, 2020
Note: You can apply for Medicaid and the Children’s Health Insurance Program (CHIP) any time of year. If you qualify, you can enroll immediately.
How Do I Appeal a Medicare Denial for Payment of a Prosthesis?
There are three ways to file an appeal with Medicare:
- Fill out a Medicare Redetermination Request Form (CMS-20027) and send it to the address on the Medicare Summary Notice (MSN) that you receive in the mail every three months.
- Follow the instructions on the back of the MSN. You must send your request for redetermination to the company that handles claims for Medicare (their address is listed in the “Appeals Information” section of the MSN.)
- Circle the item(s) and/or services you disagree with on the MSN.
- Explain in writing why you disagree with the decision or write it on a separate piece of paper, along with your Medicare number, and attach it to the MSN.
- Include your name, address, phone number and Medicare number on the MSN and sign it.
- Include any other information you have about your appeal with the MSN. Ask your doctor, other healthcare provider, or supplier for any information that may help your case.
- Send a written request to the company that handles claims for Medicare (their address is listed in the “Appeals Information” section of the MSN). Your request must include:
- Your name and Medicare number
- The specific item(s) and/or service(s) for which you are requesting a redetermination and the specific date(s) of service
- An explanation of why you do not agree with the initial determination
- Your signature: if you have appointed a representative, include the name and signature of your representative.
Note: Write your Medicare number on all documents you submit with your appeal request. Also, keep a copy of everything you send to Medicare as part of your appeal.
For more information on the appeals process, visit Medicare’s File an Appeal page.
For tips on how to be your own advocate and to make the appeals process go smoothly, contact the National Limb Loss Resource Center at 888/267-5669 or online to request a free copy of the Amputee Coalition’s Insurance Coverage & Reimbursement Guide: How to Be Your Own Advocate.
To learn more about Medicaid and CHIP programs, visit the Healthcare.gov Getting Health Coverage Outside Open Enrollment page.
To learn how to sign up for Medicare if you already have coverage through the insurance marketplace, visit the Medicare Special Conditions page.
The Medicare Improvements for Patients and Providers Act (MIPPA) provides information about subsidies that may help you save on Medicare costs.
Healthcare.gov provides information about health insurance coverage for American Indians and Alaska Natives.
For further information on open enrollment, your state’s insurance marketplace, and coverage for prosthetic devices and DME under various health insurance options, take a look at the Amputee Coalition’s Fact Sheet on Open Enrollment for Insurance Coverage.
It is not the intention of the Amputee Coalition to provide specific medical or legal advice but rather to provide consumers with information to better understand their health and healthcare issues. The Amputee Coalition does not endorse any specific treatment, technology, company, service or device. Consumers are urged to consult with their healthcare providers for specific medical advice or before making any purchasing decisions involving their care.
National Limb Loss Resource Center, a program of the Amputee Coalition, located at 900 East Hill Ave., Suite 390, Knoxville, TN 37915 | 888/267-5669
© Amputee Coalition. Local reproduction for use by Amputee Coalition constituents is permitted as long as this copyright information is included. Organizations or individuals wishing to reprint this article in other publications, including other World Wide Web sites must contact the Amputee Coalition for permission to do so.