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Marci's Medicare Answers (online only)
December 2011
By Medicare Rights Center

Dear Marci,

I was recently diagnosed with Chronic Obstructive Pulmonary Disease (COPD). Are there any plans that can help with my specific needs?—Wind

Dear Wind,

Yes, there are Medicare Advantage (MA) plans called Special Needs Plans (SNPs). A SNP is a Medicare Advantage plan (private health plan) that exclusively serves at least one of the following groups:

  • People who live in a nursing home or Intermediate Care Facility for the Mentally Retarded (either specific nursing homes or those in a certain area) and people who live in the community but require an institutional level of care;
  • People who have both Medicare and Medicaid (dual eligibles);
  • People who have a specific chronic, severe or disabling condition defined by the plan (such as diabetes or heart disease).

SNPs provide Medicare-covered health care and services that are designed to meet the special needs of people in the groups they serve. In your case you would choose a SNP that is designed for individuals with COPD. Be sure to call the plan and ask about the additional services they will provide to help you manage your condition. You should also compare the costs of the SNP plan to your Original Medicare costs to see what works best for you.

SNPs must include drug coverage (Medicare Part D) as part of their benefits packages. —Marci

 Dear Marci,

Will Medicare pay to replace my walker? —Trudy

Dear Trudy,

Generally, Medicare will replace your walker or any other piece of Durable Medicare Equipment (DME) if the item has been in your possession its whole lifetime and your doctor certifies that you still need it. The definition of lifetime varies depending on the type of equipment but is never fewer than five years from the date that you began using the equipment. In addition, the item must be so worn down from being used on a day-to-day basis that it can no longer be fixed.

However, if you lose equipment that you rent or own, if it is stolen, or if it suffers irreparable damaged in an accident or a natural disaster, Medicare should cover a new piece of equipment with proof of the damage or theft.

“Replacement” refers to the replacement of one item with an identical or nearly identical item (for example, one manual wheelchair for another, not to switch from a manual wheelchair to an electric wheelchair or a motorized scooter). —Marci

 Dear Marci,

I have been an inpatient in a hospital for a week and am being transferred to a skilled nursing facility for admission. Will Medicare cover the cost of my ambulance transport? —Larry

Dear Larry,

Medicare will pay for ambulance transport only if you are confined to your bed or your health requires transport by an ambulance. Your trip from the hospital to the skilled nursing facility (SNF) is considered a non-emergency ambulance service because your health is not in immediate danger. Medicare Part B covers emergency and non-emergent ambulance services differently. An emergency is when your health is in serious danger and every second counts to prevent your health from getting worse. Medicare will generally cover emergency transport because during most emergencies, ambulance is the only safe way to transport you.

Medicare may cover non-emergency ambulance services if

  • you are confined to your bed (unable to get up from bed without help, unable to walk, and unable to sit in a chair or wheelchair); or
  • you need vital medical services during your trip that are available only in an ambulance, such as administration of medications or monitoring of vital functions.

It is important to remember that if you are receiving SNF care under Part A, any ambulance transport should be paid for by the SNF. The SNF should not bill Medicare for this service.

For SNF residents who have exhausted their Part A benefits, Medicare may cover regular, scheduled ambulance trips. For Medicare to cover these trips your doctor must send the ambulance supplier a written order ahead of time to show that your health requires ambulance transport. For unscheduled or irregular non-emergency trips, a doctor’s order may be required within 48 hours after the transport if you live in a SNF.

You should also note that lack of access to alternative transportation alone will not justify Medicare coverage. Medicare will never pay for ambulette services. An ambulette is a wheelchair-accessible van that provides non-emergency transportation for people with disabilities.

If covered, Medicare will pay for 80 percent of its approved amount for the ambulance service. You or your supplemental insurance policy will be responsible for the remaining 20 percent. All ambulance providers must accept Medicare assignment, meaning they must accept the Medicare-approved amount as payment in full.  —Marci

Marci’s Medicare Answers is a service of the Medicare Rights Center (www.medicarerights.org), the nation’s largest independent source of information and assistance for people with Medicare. To speak with a counselor, call (800) 333-4114. To subscribe to “Dear Marci,” the Medicare Rights Center’s free educational e-newsletter, simply e-mail dearmarci@medicarerights.org. To learn more about the services that Medicare will cover and how to change plans, log on to Medicare Interactive Counselor at the Medicare Rights Center’s website at www.medicareinteractive.org.

 

  

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>>Marci's Medicare Answers (online only)
  

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