How to Get and Pay for Assistive Equipment

The 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.

More Information on the NC Medicaid Program

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.

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.
   

   

   Supplier with a Medicare Billing Number

   

   
   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.
   

   

   Medicare's Durable Medical Equipment Center

   
   
   

   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.).
   

   

   Palmetto Government Benefits Administrator

   

    

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

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.

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.
  

  

  	Medicare's Durable Medical Equipment Center
  	Palmetto Government Benefits Administrator

  

• 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.

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.

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.

Full Circle of Care on SSI
Supplemental Security Income

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.

Family Benefits
Full Circle of Care on Disability Insurance
Social Security Disability Insurance