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Durable Medical Equipment

For its durable medical equipment program, Medicare divides the country into four regions, each served by different insurance companies, known as durable medical equipment regional carriers or DMERCs. (See "Resources.")

"The four regions work very, very diligently to be coordinated among themselves. Coverage is coverage, but the frequency or quantities may vary," says Jacqueline Burress, public relations manager for HealthNow of New York Inc., DMERC for the Northeast region.

A much greater variation is the difference in coverage between vendors (suppliers) that accept Medicare assignment and those that don't. A participating Medicare vendor accepts the amount the program allows as payment in full, while those that are only registered with the program may charge any price. Participating suppliers also bill Medicare directly, requesting only a 20 percent copayment from consumers.

Attorney Suzanne Levin, client services director of the Medicare Rights Center, explains: "Let's say Medicare says a wheelchair should cost $100. The Medicare participating suppliers charge $100 and Medicare pays 80 percent or $80, and the beneficiary would pay $20."

As many as two-thirds of the equipment suppliers registered with the program don't accept assignment. In such cases, Levin says, "Medicare still pays them the 80 percent of the $100, but [the supplier] can charge the beneficiary whatever they want. So if the wheelchair costs $500, Medicare's going to pay $80 and the beneficiary's going to have to pay $420."

Burress adds, "If it's a financial hardship case, many nonparticipating suppliers on a case-by-case basis may choose to accept assignment for that particular beneficiary's claim."

'Homebound'
No More

David Jayne relies on home health care for managing his tracheostomy tube, his feeding tube and many other needs. Photos by Rich Addicks, Atlanta Journal-Constitution.

David Jayne, 40, of Rex, Ga., is a long-term survivor of amyotrophic lateral sclerosis who's known as an online mentor and a champion of issues concerning people with ALS.

In his latest battle, Jayne has been the driving force behind reintroduction of federal legislation to increase access to in-home health care for all Medicare beneficiaries. The Homebound Clarification Act, H.R. 1490, was introduced in the House of Representatives this year. (The bill is endorsed by MDA.)

The new legislation aims to remove long-standing restrictions on the frequency, length and purpose of excursions from home by Medicare recipients who require skilled nursing care and in-home assistance covered by the program.

Under traditional regulations, those whose home health care is covered by Medicare could leave home only for visits that were "brief, infrequent and medically necessary."

Jayne, a former stockbroker and outdoorsman who now uses a ventilator, received an ALS diagnosis 13 years ago. His situation could be a textbook case for a new standard that he espouses: that an individual is considered homebound if leaving home usually requires "considerable or taxing effort."

He can blink his eyes and twitch three fingers — everything else involving movement or communication calls for assistance. Since 1997, he's received services for two hours almost every morning from a personal care attendant provided by Medicare.

Once fed and groomed, Jayne uses adaptive devices to stay as active as possible, including attending MDA ALS support group meetings, and activities of his children, Hannah, 12, and Hunter, 10. Such trips don't fit Medicare's definition of "homebound."

Jayne takes his dog, Red, for a walk.

"I was always at risk of being discharged [from home health care services] and that was a terrible feeling. I felt I was being deceitful just trying to be a part of my family," says Jayne.

Late last year he challenged his home health company and Medicare by openly discussing his occasional outings in an Atlanta Journal-Constitution profile, including a rare overnight trip to his college's football game. Shortly after, his in-home assistance, provided by Healthfield Home Health, was suspended. After he contacted both his congressman, Michael "Mac" Collins, a member of the House Ways and Means Committee, and Healthfield CEO Tony Strange, Jayne's in-home care was reinstated.

"I knew Healthfield would discharge me after reading the article, but I wanted this punitive restriction known," says Jayne via e-mail.

As a result of the experience, Jayne formed the National Coalition to Amend the Medicare Homebound Restriction for Americans with Significant Chronic Illness. He also authored a petition circulated by Internet that has garnered thousands of signatures.

A new law effective in December, the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act (known as BIPA), expanded the activities its "homebound" clients are "allowed" to undertake without risking benefits. It allows regular visits to adult day-care programs and attendance at religious services. (SCHIP is a children's insurance program.)

BIPA also continues suspension of the limit for outpatient therapy payments. Before, there was an annual cap of $1,500 for occupational and physical therapy combined and a separate limit of $1,500 for speech-language pathology services.

"It makes a huge difference because $1,500 doesn't get you very far," says Suzanne Levin, director of client services for the Medicare Rights Center in New York. "They tell the physical therapist how much they can charge. If it's medically necessary for you to continue beyond what would normally cost $1,500, you can continue beyond that."