Which type of program may impact the process for acquiring durable medical equipment / assistive technology.
T here are multiple types of Medicaid programs. Buying durable medical equipment online is usually the least expensive route. For less expensive items, some seniors choose to buy the item out-of-pocket rather than waiting months to gain approval. If denied, the individual should receive the reason why and notification of the process to appeal the decision.Ī s one might assume, this process can be rather lengthy. If approved, the item is delivered by the supplier with the bill sent directly to Medicaid. The Medicaid office approves or denies the purchase and notifies both the individual and the supplier of their decision. The supplier completes a Prior Approval (PA) application and sends it to the state Medicaid office for approval. They select a Medicaid-approved DME supplier and provide them with the medical justification letter. Individuals must obtain a medical justification letter for the durable medical equipment item from their doctor or therapist. 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. When this occurs, it is referred to as Home and Community Based Services or Waivers. Medicaid can be provided outside of nursing homes. And the individual is provided with the durable medical equipment item for which they have been approved. The acquisition and approval process occurs behind the scenes. W hen an individual resides in a Medicaid approved nursing home, the process of acquiring durable medical equipment is largely invisible to the care recipient. “At home” can include living in a family member’s home, in independent living or, in some cases, even in assisted living communities. It is worth noting that the definition of “at home” is more broadly interpreted by some states than others. The process and rules are different for those living at home vs. These processes largely depend on the location in which the individual resides and intends to use the item. Medicaid and the Beneficiary’s Place of Residence Impactĭespite there being hundreds of different Medicaid programs, most programs have similar processes for DME acquisition. However, the reader should be aware that nuances exist and not all states or organization agree on the differences. For the purposes of this article, we use the phrases interchangeably.
durable medical equipment … What is the difference? From a Medicaid perspective, most durable medical equipment falls under the broader category of assistive technology.
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.Īssistive technology vs. For example, it may be clear that it is a medical necessity for an aging or disabled individual to have a powered wheelchair. 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. 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. Instead, there are hundreds of different sets of rules depending on the state and the Medicaid program in which one is enrolled. Therefore, there is not a single set of rules governing Medicaid’s role in paying for durable medical equipment. Eligibility rules and benefits are determined at the program or waiver level by each individual state. Within each state, there are multiple Medicaid programs and several Home and Community Based Services Waivers. 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. 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.īefore discussing Medicaid’s role in paying for durable medical equipment (DME), it is helpful to briefly explain how Medicaid works.