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FAQ20: Getting into Medicare??

MEDICARE is part of a program funded by the federal government (using the salary deductions and taxes paid by the citizens) to help provide Medical needs for those who are retired, disabled or have low income. For years the major program was called HCFA but is now called CMS (which stands for Centers for Medicare and Medicaid Services).

The rules for MEDICARE in general are the same from state to state, so the booklet mentioned will be good for everyone of retirement age with Social Security. Medicare covers many medical products for people on Social Security, regardless of income, as long as they have signed up for Medicare part B.

HOWEVER, there are always complications! For some reason, the amount allowed for some of the equipment - particularly artificial larynges - differs considerably depending on the state where you live. For ALs it currently ranges from $698.01 in Washington, DC. and neighboring states down to $525 in the Midwest and other variations around the country, with Hawaii and Alaska the lowest at $488.20 and $456.56. There is quite a bit of variation for TEP prostheses, too.

Fortunately, the laryngectomee related items that have been accepted for coverage in just the last few years, such as the HMEs (Heat Moisture Exchangers) and Voice Amplifiers, have little or no variation from state to state.

In any case, Medicare will pay 80% of the amount it allows.

EXCEPT - there is another complication! Medicare claims paperwork is usually handled by companies that have contracted directly with the federal government. However some people have an HMO insurance plan that has taken over the administration of their Medicare - but it may not provide exactly the same coverage as the regular Medicare program would. For some reason, these independent HMO plans do not have to follow the exact guidelines of the main government program about what they cover for who for how much. In most cases there will probably be similar coverage, but it is much more iffy and may require a lot more paperwork and documentation and sometimes a whole additional layer of paperwork for preapproval, which is why a lot of us suppliers find it very difficult or impossible to work with them.

MEDICAID is a different part of the CMS program. It covers only people with very low income. (Some people of retirement age may have both Medicare and Medicaid.) Medicaid coverage is paid for by a combination of state funds and federal CMS funds, but the programs are administered by the individual states. Medicaid is intended to assure that low-income people have their basic health needs covered, but the idea of what is a medical necessity varies considerably from state to state. Each state has its own coverages, rules, regulations, procedures and forms. Medicaid programs are notoriously very difficult, expensive and time consuming to work with and it is pretty impossible for most of the laryngectomee suppliers, who sell by mail order to all 50 states, to keep up with the different programs in each state - they would have to hire a lot more people and prices would go up. On the other hand, many local medical supply stores or pharmacies handle Medicaid for their own state(s) routinely and are set up to deal with it much more easily since they only have to have forms and remember the procedures for one or two states. Many laryngectomee suppliers will work, if at all possible, with a local supplier of your choice to provide equipment for people on Medicaid.

Sorry this is all so complicated - hope this will help a little getting these programs sorted out.

Best wishes,
Dorothy Lennox
Luminaud, Inc

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