Is there a straight forward way to look up Medicare reimbursement for a PAL?

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Buckhorn

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I hate to bother people with what I am sure is a question that is asked often. However, I have "googled" and used the search function on this forum but I am not having great success with this. I am looking for a web-site (hopefully more concise than Medicare's own site) which will enlighten me, and others, as to what Medicare will pay for and when. I do have some idea...... For instance, I think Medicare only pays for a PWC every (5?) years. Or, maybe they only pay for one w/c period, so it is best to purchase the manual / push w/c outright, reserving Medicare payment for the more expensive w/c. It has been my experience that MC will only pay for a cane or a walker, so of course, purchase the cane outright. If I am wrong about this, well then I will appreciate your input. I have read many posts on this forum, including all the stickies. These have been VERY helpful. I have been especially thankful for Tillie's sticky on anticipatory planning. I whole heartedly agree with her post, but I am not sure when Medicare will pay for DME that I am fairly certain we will need.

I realize that there is no "one size fits all" reimbursement system with Medicare, and it depends upon whether a PAL has a managed care plan (like Humana, etc.) or just straight Medicare. For the record, my PAL has straight Medicare as primary and Blue Shield as his secondary insurance, and has had this in effect since he was 65. We are very fortunate (and thankful) to have such good coverage.

Our second ALS clinic appointment has not been scheduled yet, but is supposed to be later this month. I am sure that case management/social services and the clinic nurse will be able to provide more detailed information. However, the petition posted by rkn50a under the General Discussion tab (asking the CEO of the ALS assoc. to improve home care for PALS), sheds light upon some inadequacies regarding the education of some ALS clinic and chapter support personnel regarding coverage for DME for PALS.

Thank you!
 
I hope someone can help you sort this out. Asking questions here is never a bother, this is a support forum, we are here purely for lots of questions :)

My understanding from reading elsewhere of CALS actively working to try and get understanding is that too many people who should be advising you in the US don't have a clue. To me this means that others here who have recently figured it all out just may be able to give the most accurate and up-to-date assistance.

I don't know how often rules change for you guys over there, but we have had some huge shifts in rules for what people are entitled to here over the past nearly 2 years since Chris passed and I wouldn't even be able to tell fellow aussies which way is up with our system.

I truly hope there is some help to navigate this for you!
 
Thanks Tillie. I'm hoping to get information during the 2nd clinic appt., however, it would be great to have more input as well. I'm especially concerned about the w/c issue, and as you have noted previously, it is best not to wait until the need arises.
 
I believe the 5 year one mobility device is accurate so yes people pay for manual chairs and also scooters to save the one chance for a pwc
Interesting about walker/ cane. I suppose it is the same " reasoning".
 
I'm hoping to get more information during the clinic visit. Just wishing there was a way to double check what I am told.
 
There are Medicare regions that may reimburse differently. I think there are 10 general regions but different regions for DME (Durable Medical Equipment), others for Medicare Part B, Medicare Part D, Medicare Advantage Plans and probably more. So you would have to determine which region you are in for which service and then try to find a website for them. And they probably won't list specific dollar amounts, only tell you your reimbursement will be 80% of the allowed amount. This is so frustrating because getting even a ballpark figure of what your 20% copay will be is unlikely!
The "one wheelchair per five years" rule isn't set in stone. You can get a new one sooner if changes in your condition require modifications that cannot be done on your current chair. The approval process will take more documentation and time, but it is possible. I believe that Lemon Laws also apply. And if the chair recommended to you by a certified wheelchair specialist turns out to be totally wrong for you, you can get it replaced after a fight with the provider!
 
Thanks Diane. My husband does not need a w/c just yet, but I want to plan ahead for things like that. I will be having a ramp put in to enter the house and several "mini-ramps" / threshold ramps built, probably by my neighbor. I would like to get a lightweight, push w/c to begin with, but not if Medicare will only pay for one w/c. If that is indeed true then we will pay for the manual w/c out of pocket and save the motorized one for Medicare.
 
Buckhorn, check to see if your local ALS Association has push and/or power wheelchairs that you can borrow before you get yours. My husband is occasionally using a loaned power w/c that has hand controls that he can barely use anymore. One has been ordered for him with chin controls. He got a lot of help figuring out what was the right set of features from his PT and a representative from the company that sells them.

Janis
 
Thanks Janis - we will look into that.
 
Buckthorn,
Are you in traditional Medicare or a Medicare Advantage plan (the latter is recommended if an option for you)?

As to when Medicare pays for things, you are correct that you want to pay for yourself/have a manual wheelchair loaner and have Medicare pay for the PWC. As for other things, they pay for them when medical criteria are met and documented. Those criteria are available on line and are applied nationally.
 
Laurie,

Douglas has traditional Medicare plus a medigap Plan F insurance that covers almost all co-pays, plus a Medicare Part D (prescription) plan. Together they are a much better deal for us than my COBRA plan for my last job, and a friend who counsels people about Medicare recommended it for us. We Medicare Advantage plans available to us. Of course, this all seems to vary from state to state.

Janis
 
Dave has the straight up (traditional) Medicare plan but also has an excellent Blue Shield plan as the secondary insurance. With the traditional Medicare plan he can go wherever he wants for care, and our Blue Shield plan has been great to pay for medications (after deductible of $500 is met). The BS plan also pays 100% for generic medications for me, because I am not on Medicare. Dave has never needed any medical equipment of any kind, so I'm not sure what our expensess will be. I am fairly certain that Medicare pays 80% for most DME with a script of medical necessity (but you can't replicate items, such as walking aides, etc. - they will pay for one) but we have no idea yet what BS will pay for. We will call BS to find out how the deductible applies to DME. We count ourselves very fortunate with the coverage that we have.
 
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