How to Get and Pay for Assistive Equipment

 

The best way to access and pay for assistive equipment may be through your state Assistive Technology Program.

 

Paying Bills

 

Assistive Technology Programs

State Assistive Technology Programs offer a variety of services. Examples are:

  • device loan programs
  • equipment exchange and recycling programs
  • device demonstration, education, and training
  • alternative financing programs
  • assistive technology specialists to help

They often know of other national or local resources for both finding equipment and paying for it.

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Medicaid

US DHHS Logo
Medicare & Medicaid Logo

 

Please note that Medicaid is different from state to state. Contact your state Medicaid office or the agency that handles Medicaid to find out what equipment may be covered and what eligibility criteria are in place.

 

NCThe North Carolina Medicaid Program is handled by the North Carolina Division of Medical Assistance. Medicaid information for North Carolina is available on their website.

If you would like to apply for Medicaid, the NC Division of Medical Assistance website can provide general information and your local Department of Social Services will take your application and discuss your eligibility.

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Medicare

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Medicare & Medicaid Logo

1-800-MEDICARE (1-800-633-4227)

 

Medicare (Part B) covers assistive technology devices if the device meets the standard for Durable Medical Equipment or a prosthesis and medical necessity. Durable Medical Equipment coverage requires prior approval.

Durable Medical Equipment
Defined as: being able to withstand repeated use; is primarily or customarily used to serve a medical purpose; generally is not useful to an individual in the absence of illness or injury; and is appropriate for use in the home. Home includes your own home or apartment, relative's home and most institutional settings except a hospital and skilled nursing facility.


Prosthetic or Orthotics Devices
Defined as: replacing all or part of a body organ; leg, arm, back and neck braces and artificial legs, arms, and eyes. Items are not covered if they are seen as convenience items. The denial will state that the item is not used primarily to serve a medical purpose, can be used by someone who is not ill or injured, or cannot be used in the home. The device must be provided by a supplier with a Medicare billing number and be either reasonable or necessary for the treatment of illness or injury or to improve the functioning of a malformed or malfunctioning body part or organ system.

 

Process for Submitting a Claim

  1. Get a Certificate of Medical Necessity (CMN) from your Doctor. The CMN is the Doctor's prescription for the device. It must state the diagnosis, prognosis, the reason the device is required and an estimate of the length of time the device will be needed. It is critical to have a complete and comprehensive CMN when dealing with special features of equipment and if your Medicare claim is denied. Customized and deluxe features are covered only if shown, through documentation, to be medically necessary for functioning in the home environment.

  2. Take the CMN to a supplier with a Medicare billing number. You purchase the equipment from the supplier and the supplier submits the claim and the CMN to Medicare for reimbursement.


    Make sure the supplier is in good standing with Medicare. It would also be useful to pre-determine what the Medicare reimbursement will be before you purchase. To find out this type of information, you will need to contact the regional carriers that handle the Part B claims for Medicare - the Durable Medical Equipment Regional Carrier.


    NC The one for NC is Palmetto Government Benefits Administrators in South Carolina. Information from the regional carrier can be obtained by going to their website or by calling 1-800-583-2236 (Press 1 for English or 0 for a person.).

     

  3. The Claim is reviewed by the Durable Medical Equipment Regional Carrier for Medicare who will send you an Explanation of Medical Benefits.

 

Payment for Assistive Technology Under Medicare

  1. For claims that are accepted, you have to pay the yearly deductible of $100.

  2. Medicare pays 80% of the "approved amount" listed on the Explanation of Medical Benefits.

  3. If the supplier "accepts assignment" which is the Medicare approved amount as payment in full, you will pay the remaining 20% of the Medicare approved amount.

  4. If the supplier does not "accept assignment", you must pay the remaining 20% plus any amount charged by the supplier above the Medicare approved amount.

 

If Your Claim is Denied

If Medicare does not pay, usually you are liable for payment unless the supplier knew or should have known that the claim would be denied and didn't tell you.

 

The Appeals Process

  • If the claim was not filed correctly, ask the doctor or supplier to resubmit.

  • If the claim was filed correctly, send a copy of the Explanation of Medical Benefits (that was sent to you containing the denial information) back to Medicare within six months with a signed note asking for a review by the Durable Medical Equipment Regional Carrier.

  • If you lose the review, you have six months to request a fair hearing by the Durable Medical Equipment Regional Carrier.

  • If you lose the fair hearing, you can request within sixty days a hearing with an administrative law judge. It may take at least a year to reach this level. During this time, you may have to pay the full cost of the item and wait for possible reimbursement.

  • The final step is having the case heard in federal court.
*Information on Medicare courtesy of the NC Assistive Technology Program.

Please note that the Social Security Administration handles Medicare eligibility and enrollment. You can contact the Social Security Administration at 1-800-772-1213 to enroll in Medicare or to ask questions about whether you are eligible. You can also visit their website.

 

Want to Enroll for Medicare Benefits?

 

Want More Information on Medicare?

 

Personalized Assistance With Medicare

For questions and assistance understanding the many complexities of Medicare, most states offer a Seniors Health Insurance Information Program (the name of the program may vary from state to state). They offer the help of trained volunteers to answer your questions and to offer counseling.

These programs were established in 1990 and are funded by grants from the U.S. Department of Health and Human Services and/or funding from state government. They are authorized by federal law to provide information, referrals, and counseling to Medicare beneficiaries and their caregivers on a wide range of health access and insurance matters. They are typically administered by either the state aging agency or the state Division of Insurance. Services are provided locally through the trained volunteer network.

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Supplemental Social Security and/or Disability Insurance

Social Security Card

The Social Security Administration provides financial assistance to eligible people who are blind and/or disabled. Though not specifically designed to help pay for assistive technology, qualifying for financial assistance might allow you to be able to afford technology that you otherwise could not afford.

SSI - Supplemental Security Income
SSI is a Federal income supplement program. It is designed to help aged, blind, and disabled people, who have little or no income. It provides cash to meet basic needs for food, clothing, and shelter. Blind means you are either totally blind or have very poor eyesight. Disabled means you have a physical or mental problem that keeps you from working and is expected to last at least a year or to result in death. Sometimes, a person whose sight is not poor enough to qualify for benefits as a blind person may be able to get benefits as a disabled person if his or her condition prevents him or her from working.

You are considered blind under Social Security rules if your vision cannot be corrected to better than 20/200 in your better eye, or if your visual field is 20 degrees or less, even with corrective lenses. If you do not meet the legal definition of blindness, you still may qualify for benefits if your vision, coupled with other health problems, prevents you from doing substantial work.

 

SSDI - Disability Insurance
SSDI provides for payment of disability benefits to individuals who are "insured" under the Act by virtue of their contributions to the Social Security trust fund through the Social Security tax on their earnings, as well as to certain disabled dependents of insured individuals.

 

Red Phone
If you prefer to talk to a Social Security representative, their toll-free number is 1-800-772-1213.

 

 

To follow are direct links to helpful resources on the Social Security website.

  • Social Security Homepage
    providing access to a wealth of information about Social Security and the various programs offered.

  • Social Security Disability Programs
    a comprehensive page of the Social Security website that offers descriptions of the disability programs, who is eligible, how to apply, etc.

  • Benefit Eligibility Screening Tool
    a screening tool designed to help you identify all the benefits you may be eligible for from the different benefit programs offered.

  • Disability Planner -
    explains the benefits available, how you can qualify, and who can receive benefits on your earnings record. It will also explain how to apply for the benefits and what happens when your application is approved.

  • Representative Payee
    "More than six million people who get monthly Social Security or Supplemental Security Income (SSI) benefits, or both, need someone to help them manage their money. When a person needs this kind of help, the Social Security Administration--after a careful investigation--appoints a relative, friend or another interested party to serve as the beneficiary's "representative payee." The person's Social Security or SSI benefits are then paid in the representative payee's name on the beneficiary's behalf."
    *Social Security

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Private Foundations/Sources

Some private foundation or grant sources may fund projects that include assistive technology. The projects are for a limited term, usually have defined goals about who is to be served and what outcome is desired, and are usually administered by a local nonprofit agency. Check with your local agencies such as Area Agency on Aging, Council on Aging, Department of Social Services, Department of Health, etc. to see if they know of any current projects for which your need would qualify.

Churches and local civic groups also work to secure private funding for projects. They sometimes are awarded grants but many times the money comes from private donations and/or the efforts of a church or organization to raise dollars through community service efforts. Sometimes, due to the size of the effort, the organization must restrict those they can assist. But, they may not. Be alert to notices in the local newspapers. And, the state agencies that coordinate efforts to help the deaf and hard of hearing, blind and visually impaired, and/or the disabled often know of community resources.

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Private Insurance

Check the insurance policy(s) that covers the family member needing the assistive technology. Durable Medical Equipment may be covered. The equipment needed may be covered under the category of "Orthotics and Prosthetics". Be sure to check to see if a medical necessity criteria must be met and if there are any exclusions. Also, check to see if prior approval is needed by the insurer before purchase.

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Veterans

If the person you are caring for is a Veteran and is eligible for VA benefits, check with the Department of Veterans Affairs. Services may include medical related home improvements, prosthetics and durable medical equipment (canes, walkers, etc.), home health including physical and occupational therapy, and more.

 

Red Phone
VA Benefits
1-800-827-1000

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Personalized Assistance

Specialist

The state where you need assistance may have Assistive Technology Specialists available.

 

 

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