Specialty Medicare Coverage..
DME Durable Medical Equipment, Chiropractic, Hearing Aids, Physical Therapy, Ambulance, 

#Durable1 medical equipment (DME)

Medicare Coverage of Durable Medical Equipment Publication  11045

• Medicare covers items like oxygen equipment and supplies, wheelchairs, walkers, and hospital beds ordered by a doctor or other health care provider enrolled in Medicare for use in the home. Some items must be rented.  You pay 20% of the Medicare-approved amount, and the Part B deductible applies. If you have a Medi Gap plan, that should pay the 20%!   Medicare Advantage, check the summary of benefits or EOC Evidence of Coverage.
• Make sure 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 they submit. 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 (that is, they’re limited to charging you only coinsurance and the Part B deductible for the Medicare-approved amount). If suppliers aren’t participating and don’t accept assignment, there’s no limit on the amount they can charge you.
• Prosthetic Limbs – Medical Necessity?   Kff.org  *
  • Why Insurance Companies are denying coverage for Prosthetic Limbs  Kff.org  *
• To find suppliers who accept assignment, visit Medicare.gov/supplier directory or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. You can also call 1-800-MEDICARE if you’re having problems with your DME supplier, or you need to file a complaint. ^{Copied from Medicare & You – see link in side panel}

What about Stair Lifts?

• acorn stair lifts.com
• Medical Necessity of Stair Lifts & Lifting devices Clinical Bulletin?
• Durable Medical Equipment
• Seat Life Mechanisms
• Pride Mobility.com Steps to get Medicare to pay
• hhs.gov research 1989

Guide Dog or Other Service Animal

You can include in medical expenses [but apparently not as durable medical expense] the costs of buying, training, and maintaining a guide dog or other service animal to assist a visually impaired or hearing disabled person, or a person with other physical disabilities. In general, this includes any costs, such as food, grooming, and veterinary care, incurred in maintaining the health and vitality of the service animal so that it may perform its duties.  irs.gov/

• Maybe you can get a grant?
  • us service animals.org/grants-resources/
  • disability-benefits-help.org/service-animals

Resources & Links

• Justice in Aging DME for CA Advocates Fact Sheet
  • An Advocate’s Guide to Medi-Cal Services January 2020 Chapter X: Durable Medical Equipment, Orthotics and Prosthetics, and Other Non-Pharmaceutical Items  Health Law.org * 
• CMS discontinues medical device forms to ease physician administrative burdens Fierce Health Care  * Rev Cycle Intelligence *
• Biden repeals Trump rule  that expedited coverage for “breakthrough technology”  ^{Modern Health Care *  9.13.2021 prior article * Federal Register 42 CFR Part 405 [CMS-3372-P2] RIN 0938-AT88 *} 
• Wheelchair users can face hefty costs not covered by insurance, under age 65…  ^{LA Times 11.15.2021} *
  • statnews.com/medicare-needs-to-update-its-wheelchair-coverage-for-the-21st-century
• Coverage for catheters?
• wikipedia.org/Certificate_of_medical_necessity
• Adult Diapers?
•  

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#Chiropractic coverage in Medicare

• VIDEO explanation Chiropractic
• Here’s how Medicare A & B and the a Typical MAPD Plan. and Medi Gap would pay the 20% that Medicare allows, but leaves as a co payment.
• Medicare Part B pays 80% for spinal manipulation  if medically necessary.   Thus, Medi Gap and Medicare Advantage only pay, if Medicare does.
• Medicare doesn’t cover other services or tests ordered by a chiropractor, including X-rays, massage therapy, and acupuncture. If you think your chiropractor is billing Medicare for chiropractic services that aren’t covered, you can report suspected Medicare fraud   ^Medicare.gov *

Medical Necessity get’s quite complicated.
Here’s more detailed definitions:

• Here’s a Medicare Fact Sheet, something a little easier to read for the lay person.
• 
• For chiropractic services, medically necessary means the patient must have “a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct, therapeutic relationship to the patient’s condition and provide a reasonable expectation of recovery or improvement of function. The patient must have a subluxation of the spine, as demonstrated by x-ray or physical exam.”
• Treatment by means of manual manipulation of the spine to correct a subluxation  (incomplete or partial dislocation of a joint or organ.^{[1] Wikipedia} )  (that is, by use of the hands).
• Patient must require treatment by means of manual manipulation.
  Manipulation services rendered must have direct therapeutic relationship to the patient’s condition.
  There must be a reasonable expectation of recovery or improvement of function resulting from the planned treatment.    ^CMS.gov *
• Medicare Exclusions from Coverage
• Note that the specimen Medicare Advantage policy we used to analyze coverage has exclusions on page 115  for chiropractic, they only cover what Medicare covers, nothing extra!
• For those of you who think that “Medicare for All” will be the solution to every health problem and that Medicare pays everything, take a look at this NINE page bulletin on the the Medicare records required from your chiropractor.
• 
• Sample Medicare Advantage Plan
  • Use Ctrl F & Search adobe.com/searching-pdfs
• Sample Medi Gap EOC  Plan G
  • Medi Gap will provide coverage for the coinsurance amount or, in the case of hospital outpatient Services, the copayment amount of Medicare Eligible Expenses under Part B …, subject to the Medicare Part B Deductible provided the Subscriber is receiving concurrent benefits from Medicare for the same Services. ^{Blue Shield EOC} * 

FAQ  Chiropractor

• Does blue shield 65 plus  cover any chiropractor care as basic Medicare does?
  • How do I find a Chiropractor for the Inspire Plan?
    .
• Here’s our webpage on what Medicare offers for chiropractic.  If you have further questions, please post in the ask a question section on that page.   MAPD plans are required to offer at least as much coverage as Medicare does.
  •  See the summary of benefits for the Blue Shield plan you are interested.
  • See link at top of page to enroll. No extra charge for our help.
  • call ASH American Specialty Health Network customer service at (800) 678-9133