Medicaid’s Benefits for Durable Medical Equipment (DME) & Assistive Technology (AT)

Medicaid Overview

 There is not a single set of rules regarding Medicaid’s role in paying for durable medical equipment instead there are hundreds of different sets depending on one's state and Medicaid sub-program.

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 with low incomes (and usually limited assets), primarily the elderly or disabled but also some adults and children. Within each state, there are multiple Medicaid programs and several “Home and Community Based Services 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 governing 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 it is determined to be medically necessary, cost effective and meet their strict definition of what is 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.

Assistive technology vs. durable medical equipment? What is the difference? From a Medicaid perspective, most durable medical equipment falls under the broader category of assistive technology. For the purposes of this article, we use the phrases interchangeable. However, the reader should be aware that nuances exist and not all states or organization agree on the differences.

 Medical alert services, called PERS by Medicaid, are a unique category of medical equipment. Our organization has written a detailed article specifically about Medicaid coverage of medical alert services.

 

Medicaid and the Beneficiary’s Place of Residence Impact

Despite there being hundreds 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.  The process and rules are different for those living at home vs. in a nursing home.  It is worth noting that the definition of “at home” is more broadly interpreted by some states than others.  At home can include living in a family member’s home, in independent living or in some cases even in assisted living communities.

Skilled Nursing Homes

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)

Medicaid can be provided outside of nursing homes, when this occurs it is referred to as Home and Community Based Services 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 must 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.  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.

 

Types of Medicaid Programs

There are multiple types of Medicaid programs and which type of program may impact the process for acquiring durable medical equipment / assistive technology.

Regular Medicaid

Often called Medicaid State Plan, this is the program most people think of when they hear the term Medicaid. Of the Medicaid programs, this will have the most restrictive eligibility requirements and the narrowest definition of durable medical equipment / assistive technology.

HCBS Waivers

Also called Home and Community Based Services or 1915 Waivers, these are limited enrollment programs that help Medicaid beneficiaries to reside outside of nursing homes. Most (but not all) waivers will cover a broad range of durable medical equipment / assistive technology. Some waivers allow for Consumer Direction (sometimes referred to as Cash and Counseling), which means that the participants are allocated 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 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. A complete list of waivers covering DME / AT is available at the bottom of this page.

Money Follows the Person

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 forty-four states.  The following six states do not have MFP programs: Alaska, Arizona, Florida, New Mexico, Utah and Wyoming. Read more about the Money Follows the Person Program. Readers should be aware that while forty-four states have MFP programs, the programs may be referred to using different names in different states.

 

List of Medicaid Waivers / Programs Covering DME / AT

This list includes both HCBS Waivers, 1915 Waivers and some programs with consumer direction. It was last updated April 2018. There are also many non-Medicaid programs that cover DME.

Medicaid Programs Covering Medical Equipment of Assistive Technology

Alabama SAIL Waiver

Alabama Community Transition (ACT) Waiver

Alaskans Living Independently

Alaska Adults with Physical & Developmental Disabilities Waiver

Arizona LTC Services

Arizona Self Directed Attendant Care (SDAC)

Arkansas Independent Choices Program

California Medi-Cal Multipurpose Senior Services Program Waiver (MSSP)

California Medi-Cal Home and Community-Based Alternatives (HCBA) Waiver

Connecticut Personal Care Assistance (PCA)

Delaware Diamond State Health Plan Plus

Florida Statewide Managed Long Term Care

Idaho HCBS Aged & Disabled Waiver

HealthChoice Illinois
Illinois Medicaid-Medicare Alignment Initiative

Indiana Aged and Disabled Waiver (A&D)

Indiana Structured Family Caregiving / Caregiver Homes

Iowa HCBS Elderly Waiver

Kansas HCBS Frail and Elderly (HCBS/FE) Waiver

Kentucky Supports for Community Living Waiver

Louisiana Community Choices Waiver

Maine Older Adults and Adults with Disabilities

Maine Consumer Directed Attendant Services

Maryland Community Options Waiver for Older Adults

Maryland Community Personal Assistance

Maryland Increased Community Services Program

Michigan Choice Waiver Program

Michigan Health Link Program

Minnesota Elderly Waiver

Minnesota Community Access for Disability Inclusion Waiver

Mississippi Independent Living Waiver

Montana HCBS Waiver

Nebraska Aged & Disabled Waiver

Nevada HCBW for Persons with Physical Disabilities

New Hampshire’s Choices For Independence Program

New Jersey Personal Preference Program

New York Managed Long Term Care Program Waiver (MLTC)

New York Community First Choice Option

North Carolina Community Alternatives Program for Disabled Adults Waiver (CAP/DA)

North Dakota Aged and Disabled Waiver

Ohio PASSPORT Waiver

Ohio MyCare Plan

Oklahoma ADvantage Program Waiver

Oregon K Plan

Pennsylvania Department of Aging (PDA) Waiver

Pennsylvania Services My Way

Pennsylvania HealthChoices Program

Rhode Island Global Consumer Choice Compact Waiver

South Carolina Community Choices Waiver

South Dakota Hope Waiver 

Tennessee CHOICES in Long-Term Care

Texas Star Plus Waiver

Utah Aging Waiver for Individuals Age 65 or Older

Utah Medicaid New Choices Waiver

Vermont Global Commitment to Health Waiver

Vermont CFC Moderate Needs Group Services Program

Virginia Commonwealth Coordinated Care Plus Waiver

Washington Community Options Program Entry System Waiver (COPES)

Washington New Freedom Program

Washington Medicaid Alternative Care (MAC) Program

Wisconsin Family Care and Partnership

Wisconsin IRIS Program

 

 

Additional Resources
  • Eligibility - More information regarding Medicaid eligibility is available here.
  • Assistance Qualifying - A discussion of the public and private assistance options which help person to qualify for Medicaid is available here.