It can sometimes be hard 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 all of this means for a person with limb loss.
1. What is Medicare?
Medicare is federally funded healthcare coverage for people who are 65 years old or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called 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 Benefits.
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 five things you should know.
Medicare provides an online Eligibility and Premium Calculator to help you find out if you are eligible.
You can find the answers to common questions about Medicare on their Frequently Asked Questions page.
Medicare provides information on how Medicare is funded, and what it pays for.
You can learn how the Affordable Care Act (Obamacare) affects Medicare by visiting their https://www.cms.gov/Medicare/Eligibility-and-Enrollment/Medicare-and-the-Marketplace/Overview1.html.
You can contact Medicare by calling 800/MEDICARE (800/633-4227) or by writing to:
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244-1850
2. What Coverage does Medicare Offer for People with Limb Loss?
Medicare Part B (Medical Insurance) covers these items as durable medical equipment (DME):
- Orthotics, as long as you go to a supplier that’s enrolled in Medicare.
- Artificial limbs and eyes.
- Arm, leg, back and neck braces.
- Orthopedic shoes (only when they’re a necessary part of a leg brace).
- Therapeutic shoes or inserts for people with diabetes who have severe diabetic foot disease.
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.
For more information about the Medicare-approved amount, visit the Your Medicare Coverage page.
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 aren’t enrolled, Medicare won’t pay the claims submitted by them. It’s 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 aren’t “participating,” they may choose not to accept assignment. If suppliers don’t accept assignment, there’s no limit on the amount they can charge you.
Competitive Bidding Program: If you live in or visit certain areas, you may be affected by Medicare’s Competitive Bidding Program. In most cases, if you have Original Medicare and get competitively bid equipment and supplies in competitive bidding areas, Medicare will only help pay for such equipment and supplies if they’re provided by contract suppliers. Contract suppliers can’t charge you more than the 20 percent coinsurance and any unmet yearly deductible for any equipment or supplies included in the Competitive Bidding Program.
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’ll 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.
3. 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.You have ALS (amyotrophic lateral sclerosis, also called Lou Gehrig’s disease).You live in Puerto Rico and get benefits from Social Security or the RRB.||You aren’t getting Social Security or RRB benefits (for example, because you’re 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 https://www.medicare.gov/newcard in the mail three months before your 65th birthday or your 25th month of disability.
When you’re 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.
4. 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, 2015 to December 7, 2015
- You can apply for Medicaid and the Children’s Health Insurance Program (CHIP) any time of year. If you qualify, you can enroll immediately.
5. What is the Penalty for Not Having Health Insurance?
Each year, the tax penalties for not enrolling in health insurance increase. To avoid these penalties, be sure to enroll in a health insurance plan during the open enrollment period.
|2014||$95 per adult, $47.50 per child (up to $285 per family) or 1% of annual income, whichever is greater.|
|2015||$325 per adult, $162.50 per child (up to $975 per family) or 2% of annual income, whichever is greater.|
|2016||$695 per adult, $347.50 per child (up to $2,085 per family) or 2.5% of annual income, whichever is greater.|
6. 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’re requesting a redetermination and the specific date(s) of service
- An explanation of why you don’t agree with the initial determination
- Your signature; if you’ve 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. 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, order the Amputee Coalition’s Insurance Coverage and Reimbursement Guide.
7. Links in This Fact Sheet
Find out if you should get Part B: http://www.medicare.gov/sign-up-change-plans/get-parts-a-and-b/should-you-get-part-b/should-i-get-part-b.html
Part B Application: http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS017339.html
Part B Application in Spanish: http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-S.pdf
Your Medicare Benefits: http://www.medicare.gov/Pubs/pdf/10116.pdf
How Medicare works with other insurance: http://www.medicare.gov/supplement-other-insurance/how-medicare-works-with-other-insurance/how-medicare-works-with-other-insurance.html
If you are retired or have coverage from former employer: http://www.medicare.gov/supplement-other-insurance/retiree-insurance/retiree-insurance.html
Medicare’s Eligibility and Premium Calculator: http://medicare.gov/eligibilitypremiumcalc/
Medicare’s FAQs: https://questions.medicare.gov/
How Medicare is Funded: https://www.medicare.gov/about-us/how-is-medicare-funded
The Affordable Care Act and Medicare: https://www.cms.gov/Medicare/Eligibility-and-Enrollment/Medicare-and-the-Marketplace/Overview1.html
Part B Coverage of Orthotics and Artificial Limbs: http://www.medicare.gov/coverage/orthotics-and-artificial-limbs.html#1435
The Medicare Competitive Bidding Program: https://www.medicare.gov/what-medicare-covers/what-part-b-covers/competitive-bidding-program
Example of a Medicare Card: https://www.medicare.gov/newcard
Medicare Redetermination Request Form: http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS20027.pdf
Medicare Summary Notice (MSN): http://www.medicare.gov/forms-help-and-resources/mail-about-medicare/medicare-summary-notice-msn.html
8. Additional Resources
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.
For more information about how to navigate the health insurance system as a person living with limb loss, you can also order the Amputee Coalition’s resource guide, Insurance Coverage and Reimbursement: How to Be Your Own Advocate.
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.