Medicare vs. Medicaid: Program Comparison
April 2001

Lewis Golinker, Esq.
Director, Assistive Technology Law Center
202 East State Street, Suite 507
Ithaca, New York 14850
607-277-7286 (voice)
607-277-5239 (fax)
lgolinker@aol.com (e-mail)

To learn more about Medicaid click on this article.
Introduction to Medicaid: Eligibility, Federal Mandates, Hearings and Litigation

                                                                       Medicare                                               Medicaid

Enacted by Congress                                           1965                                                       1965

Alternate Program Name                                 Title XVIII                                                Title XIX

Eligibility                                                 Not Income Based: Age (all                          Income based; all
                                                              Persons 65 and older are                               ages are eligible
                                                              eligible); younger persons
                                                              are eligible based on disability
                                                              or specific condition,

                                                             [Dual Eligibility for both programs is possible]

Premium Required for
Enrollment                                              Yes ($ 50.00/month) for                                  No for some
                                                               Medicare Part B services,                               individuals,
                                                               which include durable                                      others have a spend-
                                                               medical equipment                                          down" requirement
                                                                                                                                     each month to be eligible

Administered by                                      Federal Government with                                 State Governments
                                                             sub-contractors who make                                subject to federal
                                                             claims decisions for medical                               regulations and
                                                             services (fiscal intermediaries)                            guidelines
                                                             and for DME and prosthetic
                                                             devices (regional carriers).

                                                            Also uses managed care                                      Also uses managed
                                                            organizations                                                       care organizations

Are AAC Evaluations
Covered?                                              Yes, as an SLP service                                      Yes, for all children
                                                                                                                                     who are eligible -
                                                                                                                                     nationwide; adult
                                                                                                                                     coverage of
                                                                                                                                     evaluations depends
                                                                                                                                     on whether states
                                                                                                                                     cover SLP services
                                                                                                                                     for adults
                                                                                                                                     (optional benefit)

Are AAC Devices
Covered?                                              Yes, as durable medical                                    Yes, as durable
                                                            equipment                                                          medical equipment
                                                                                                                                    or as a prosthetic
                                                                                                                                    device, or under the
                                                                                                                                    SLP services benefit

Is AAC Training
Covered?                                              Yes, as an SLP service                                     Yes, for all children
                                                                                                                                    who are eligible --
                                                                                                                                    nationwide; adult
                                                                                                                                    coverage of evaluations
                                                                                                                                    depends on whether states
                                                                                                                                    cover SLP services for
                                                                                                                                    adults (an optional benefit)

Is AAC Device Repair
Covered?                                             Yes, after expiration of warranty                        Yes, after expiration
                                                                                                                                    of warranty

What documents are
required as part of a claim?                   SLP report; doctor's prescription;                       SLP report and
                                                           payment or co-payment from                               doctor's
                                                           beneficiary; other forms also                                 prescription
                                                           required

Claims are submitted by:                       manufacturer/supplier                                           manufacturer/supplier

Claims Processing                                Claims filed for reimbursement                             Claims filed for
                                                          after device is delivered and                                  "prior approval"
                                                          charges are incurred                                              before device is deliverd
                                                                                                                                     and charges are
                                                                                                                                     incurred

Payments                                            Made to beneficiary or to                                      Made to
                                                         manufacturer/supplier                                             manufacturer/ supplier

Amount of Payments                          Fee schedules were created                                    Usually payment is
                                                         for devices with technological                                  full price or a per-
                                                         similarities, i.e., in "codes"                                       centage of retail price
                                                        Medicare will pay 80% of a                                     for every device
                                                        fee schedule amount, or 80%
                                                        of the actual charge for a device,
                                                        whichever is lower

Co-Payments by
Beneficiaries)                                     Required                                                                 None in most states;
                                                                                                                                      if required, must be
                                                                                                                                      minimal

Amounts of co-payments                   Will be one of these 3 amounts:                               Not applicable, see
                                                                                                                                     above
                                                        20 % of actual charge, when
                                                        the device's actual charge is the
                                                        same or less than the fee schedule
                                                        amount for the device

                                                        20 % of the fee schedule amount,
                                                        when the mfr/supplier will "accept
                                                        assignment" from Medicare

                                                        Full actual charge, when the mfr/
                                                        supplier refuses to "accept
                                                        assignment" from Medicare

Administrative Appeals                      5-step administrative procedure                                 1 or 2 step
                                                                                                                                        administrative
                                                                                                                                        procedure

Judicial Review                                  Available in Federal court                                          Available in state
                                                                                                                                        court or in federal court

2003 National AT Conference Handouts  

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