Medicaid’s Coverage of Durable Medical Equipment
Medicaid and Home Medical Equipment: Background and Overview
Prior to discussing Medicaid’s role in paying for durable medical equipment (DME), it is helpful to briefly explain how Medicaid works. Medicaid is an insurance program for Americans, primarily the elderly or disabled, that have both low incomes and extremely limited assets. Within each state, there are multiple Medicaid programs and “waivers”.
Eligibility rules and benefits are determined at the program or waiver level by each individual state. Therefore there is not a single set of rules regarding Medicaid’s role in paying for durable medical equipment instead there are 100’s of different sets of rules depending on the state and the Medicaid program in which one is enrolled.
Given there are many different sets of rules, generally speaking, Medicaid will pay for medical equipment when they are determined to be medically necessary, cost effective and meet their definition of durable medical equipment. Most states define DME as “equipment that can withstand repeated use, is primarily used to serve a medical purpose, is appropriate for home use and is not useful to a person without an illness or injury.”
“Cost-effective” usually means that Medicaid will pay for the most basic level of equipment only. For example, it may be clear that it is a medical necessity for an aging or disabled individual to have a powered wheelchair. However Medicaid may determine that the individual only needs a less-expensive, rear-powered chair instead of a center-powered chair that has a tighter turning radius.
Medicaid and the Beneficiary’s Place of Residence
Despite there being 100s of different Medicaid programs, most programs have similar processes for DME acquisition. These processes largely depend on the location in which the individual resides and intends to use the item.
Skilled Nursing Homes and DME
When an individual resides in a Medicaid approved nursing home, the process of acquiring durable medical equipment is largely invisible to the care recipient. The acquisition and approval process occurs behind the scenes and the individual is provided with the durable medical equipment item for which they have been approved.
Medicaid at Home (HCBS) and DME
Medicaid can be provided outside of nursing homes, when this occurs it is referred to as Home and Community Based Service or Waivers. Individuals participating in a Medicaid Waiver program typically have a higher degree of personal involvement in the acquisition of DME than Medicaid Nursing Home residents.
Individuals obtain a medical justification letter for the durable medical equipment item from their doctor or therapist. They select a Medicaid approved, DME supplier and provide them with the medical justification letter. The supplier completes a Prior Approval (PA) application and sends it to the state Medicaid office for approval. The Medicaid office approves or denies the purchase and notifies both the individual and the supplier of their decision. If approved, the item is delivered by the supplier with the bill sent directly to Medicaid. If denied, the individual should receive the reason why and notification of the process to appeal the decision.
As one might assume, this process can be rather lengthy and for less expensive items, some seniors choose to purchase the item out-of-pocket rather than waiting months to gain approval. Buying durable medical equipment online is usually the least expensive route.
Consumer Direction (Cash and Counseling) and DME
Certain types of Medicaid Waivers allow for Consumer Direction (sometimes referred to as Cash and Counseling), which means that participating individuals are given a budget and the flexibility to manage their own care providers and suppliers. Individuals’ care needs are assessed and they are allocated the financial resources to pay for all of their care services, medical equipment and supplies. Since these individuals are working within a defined budget and have the freedom to allocate it as they see fit, they have significant incentive to purchase inexpensive durable medical equipment and supplies to preserve their budget for other purposes. Click here to learn more about Consumer Direction and Medicaid Waivers
Money Follows the Person (MFP Programs) and DME
This is special Medicaid program designed to help individuals that currently reside in nursing homes to return to their homes or to living in the community. To make this possibly, the program will purchase some durable medical equipment to enable participants to live at home, such as hospital beds and wheelchair lifts. There are currently MFP Programs in 42 states (the following 8 states do not have MFP programs: AL, AK, AZ, MT, SC, SD, UT and WY). Read more about the Money Follows the Person Program
Learn more about qualifying for Medicaid
and the programs available in your state