Howard Houghton, Coordinator Fairfax County VICAP Program
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Howard referred to Medicare’s Competitive Bidding Program for durable medical equipment (DME), prosthetics, orthotics, and supplies (DMEPOS) at our meeting. He sent me some documents that explain the process as well as press releases dated January 30, 2013 about Round 2 of the bidding. These documents appear to be geared towards “partners” who work in the program, but you may still find some of it useful. If you have any questions on this topic, please contact Howard’s office.
Please click on the links below to read each document:
1) Medicare’s DMEPOS Competitive Bidding Program – Frequently Asked Questions
2) The Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program – What You Need to Know
3) Medicare Announces Substantial Savings for Medical Equipment Included in the Next Round of Competitive Bidding Program
4) Expansion of Competitive Bidding Program Will Increase Competition, Maintain Quality, and Save Medicare Billions
Howard showed us several websites and you’ll find a wealth of knowledge in them:
There are 127,000 Medicare beneficiaries in Fairfax County. Howard and his staff of 16 volunteers are there to assist them.
VICAP = Virginia Insurance Counseling and Assistance Program
is a health insurance counseling program administered by the Fairfax Area Agency on Aging. VICAP assists senior citizens and persons with disabilities that need help understanding Medicare, Medicare health plans, Medicare supplemental insurance plans and prescription assistance plans, including Medicare Part D. The program also offers guidance with purchasing long-term care insurance, sorting medical bills or forms and assistance with Medicaid problems.
Program counselors are volunteers who have received special training on health insurance issues and have been certified by the Virginia Department for the Aging and the State Corporation Commissions’ Bureau of insurance. They are not connected with any insurance company and their services are entirely free. Their purpose is to serve you objectively and confidentially.
Counselors can assist you by explaining policy benefits and help you to understand, file or resolve health insurance claims. Depending on your needs, counseling can be provided by telephone, in the program’s Fairfax office or in your home.
The VICAP website
It contains a list of outreach events, an electronic tool box to assist you with most related issues, and a list of podcasts that explain certain issues.
On the Medicare website, www.medicare.gov,
you can search for health and drug plans. You can also search for suppliers of medical equipment. It is recommended that you choose companies that participate in Medicare – they will have a “P” in a green circle next to their name. It is also advisable to get an order from your doctor and for large equipment you may need a certificate of medical necessity. You will need these documents prior to the purchase in order to be reimbursed. To read the brochure, “A Quick Look at Medicare” click here.
is a great website, highly recommended by Howard, with information for about options for free or discounted drugs and other financial assistance including:
– drug discount card
– Patient Assistant Program (for brand and generic medications)
– diagnostic based assistance. For example, some organizations can help cover co-pays if you can’t afford it. Click here for the Parkinson’s page.
– much more!
Medicare Participation Physicians/Suppliers Directory
Click here to go to the Novitas Solutions webpage to find physicians and suppliers participating in Medicare, but when you choose a physician, call their office to confirm that they participate in Medicare and are accepting new patients.
Virginia Senior Medicare Patrol Project (SMP)
“help Medicare and Medicaid beneficiaries avoid, detect, and prevent health care fraud.” Click here for more info.
Prior to our meeting, we sent Howard some questions from our group which were raised in discussions at our support group meetings, or by individuals.
Q. What is meant by the 3 day hospital stay which Medicare requires for rehab coverage post hospital?
A. 3 night stay in hospital is required to qualify for Medicare to cover rehab and/or care in a Skilled Nursing Facility (SNF).
Q. What is an observational stay/admission to the hospital? How would I know if I am in observational status rather than a regular admission?
A. If you are under observation while in hospital, even if it’s for 3 nights, and you are then sent to a SNF, you would pay out of pocket for the SNF. While under observation only Medicare Part B expenses are covered – not Part A or Part D.
For more information, click here to read the booklet entitled “Are You a Hospital Inpatient or Outpatient?”
Q. What happens when there is a readmission to the hospital? For example, hospital stay followed by admission to nursing home/rehab followed by readmission to hospital with no discharge to home along the way? Do we still need to be concerned whether the hospitalizations are observational stay or admission? Does post hospital care come under the rules of the original admission?
A. It depends on how long you were away from the hospital and where you were (home or SNF). Read the Medicare Handbook for more information, and if you need help understanding it all, call the VICAP office for assistance.
Q. Is durable medical equipment covered by Medicare if I have not had a hospital admission? Are there guidelines about what DME is covered, for example the type of wheelchair or walker?
A. Important point – Use a participating Medicare provider as identified by the Medicare website with a “P” by their name or you may be dealing with a number of issues. Non participating providers (no P by their name) can determine what they will charge you whereas participating providers (P by their name) have an agreement with Medicare regarding the charge and cannot charge you more than that. Medicare pays 80% and you will be responsible for 20% for equipment approved by Medicare when purchased from a participating provider.
Q. Physical therapy and speech therapy are often needed by folks with PD who have not had a hospital stay. Can Medicare cover this?
A. Yes, if the therapy is provided at a hospital or clinic, then there is no limit for the amount that Medicare will cover. If it’s provided in the home, the limit that Medicare will cover is $1,900/year. In home services must meet the criteria that you are essentially homebound and often include other services as well.
Q. Does Medicare cover home health care? Hospice? Do you need a hospital stay first?
A. Yes, Medicare will cover home health care but not for 24/7 care. It will cover skilled services and may also include custodial care if you are receiving skilled care covered by a Medicare and you are restricted to your home.
Click here to read the official Medicare booklet, “Medicare and Home Health Care”.
Medicare Part A covers hospice care and you do not have to be hospitalized first.
Click here to go to the Medicare web page about Medicare Part A coverage-hospice.
Q. Are there any benefits for folks with Parkinson’s under 65 through Medicare?
A. Yes, Medicare may provide the same benefits as it will for people over 65 years if approved. Application must be made and once approved for coverage there is a two year wait before the benefits actually begin.
The Medicare Summary Notice (MSN) is your “Explanation of Benefits”. If there aspects to it that you don’t agree with, for example, an item is denied for coverage, you have right to file an appeal. You need to note the information on the MSN about the deadline for filing the appeal and follow the instructions carefully. If you have problems with this, call Howard’s office at VICAP for assistance. Seventy percent of appeals are decided in favor of the Medicare recipient.
If you are covered by Medicare and Tricare for Life, you don’t need additional insurance.