In the medical insurance arena, AT devices are often referred to as DME- Durable Medical Equipment and P&O - Prosthetics and Orthotics. For approval for purchase, the device must meet the “medically necessary” criterion.

Government Health Insurance

Medicare (http://www.cms.hhs.gov/medicare/)

Medicare was originally designed in 1965 to provide medical insurance to persons over 65 years old or to persons who have been out of the work force for more than two years due to a disability. This federal program has two parts - Part A: Hospitalization, Part B: Physician services and Durable Medical Equipment. If a medically necessary service or piece of equipment is needed, the service or device is provided, andthen Medicare is billed using codes for each service/device which was rendered. In 2005 the DME benefit for a Medicare beneficiary is limited to “in the home” needs only.

Medicare uses two types of coding systems. The CPT (Common Procedure Terminology) describes a wide variety of healthcare services provided and covered under Part A. DME is coded under the Healthcare Common Procedure Cosing System (HCPCs). HCPCs is a series of narrative descriptions of products Most codes have a pre-determined "customary and regular" fee assigned to that code. Medicare pays 80% of that fee; the remaining 20% comes from another source. A Certified Rehab Technology Supplier (CRTS ®) (http://www.nrrts.org) or a DME supplier in your area can give you direct support and guidance, when working with a person for whom Medicare is the primary payer.

Medicaid (http://www.cms.hhs.gov/medicaid/)

Medicaid is a federally mandated insurance program for persons who are determined to be “medically indigent”. A financial “means-test” is applied to each recipient, prior to qualifying for the program. (Details differ from state to state.) While federally mandated, Medicaid (unlike Medicare) is administrated at the state level, resulting in large variations from state to state regarding eligibility and items which are covered. Equipment must be "prior approved" before it can be dispensed. A prior approval form is often accompanied by a letter of justification, which outlines the medical necessity of the requested items. A denial of a prior approval request can be appealed through a process known as a fair hearing, where both the Medicaid personnel and the client have an opportunity to explain the need and the decision in front of a neutral third party.

The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program is set of mandatory federal Medicaid services required from the states as a condition of receiving federal Medicaid money. These services may include AT that would ordinarily not be provided to an adult Medicaid recipient. This means that advocates for children seeking AT from Medicaid may point to EPSDT as a basis for covering any medically necessary AT -- whether or not that AT is listed as covered in Medicaid regulations or billing instructions.