Summary
In addition to healthcare coverage, Medicaid Long Term Care also provides coverage for durable medical equipment like wheelchairs, home care supplies such as adult diapers and Personal Emergency Response Services. The amount of coverage (full or partial) and which medical goods are covered depend on your state of residence and your Medicaid Long Term Care program – Nursing Home, Home and Community Based Service (HCBS) Waivers or Aged, Blind and Disabled (ABD) Medicaid.
Most states define Durable Medical Equipment (DME) as equipment that can handle repeated use, serves a medical purpose, would be appropriate to use in a home setting and would not be useful for someone without an illness or injury. If a piece of equipment fits that definition, is cost-effective and is considered medically necessary for the Medicaid Long Term Care recipient, Medicaid will, in general, pay for that piece of equipment. “Cost-effective” in this case means that the equipment is the least expensive brand or version of the necessary DME that is available.
For Nursing Home Medicaid Long Term Care recipients, the facility where they live will handle the approval and acquisition process for durable medical equipment (DME). Medical professionals at the facility will help determine what type of DME is needed. The facility will then find the most cost-effective option, acquire it for the Medicaid Long Term Care recipient and oversee its use.
Home and Community Based Services (HCBS) Waivers recipients and Aged, Blind and Disabled (ABD) Medicaid recipients need to be more involved than Medicaid Nursing Home residents when it comes to obtaining durable medical equipment (DME). HCBS Waivers and ABD Medicaid recipients first need a letter from their medical professional (usually their doctor or therapist) justifying the medical need for the DME. Then the Medicaid recipient gives that letter to a Medicaid-approved DME supplier of their choice that has the equipment they need. That supplier then completes a Prior Approval (PA) application and submits it to the state Medicaid office for approval.
If the PA application is approved, the DME will be delivered to the recipient by the supplier and the bill will be sent directly to the state’s Medicaid offices. If the PA is denied, the Medicaid recipient should receive a notification explaining why it was denied and how they can appeal the decision.
Certain HCBS Waivers and some state’s ABD Medicaid programs have “Consumer Directed Care.” This provides the Medicaid recipient with a set amount of money each month to spend on health care items of their choice. Buying DME is an option with a Consumer Directed Care budget, as is upgrading a piece of equipment. For example, a state may be willing to cover a basic electric wheelchair, but the Medicaid recipient could upgrade to a more high-end model using their Consumer Directed Care budget.
The Medicaid recipient can also avoid the sometimes lengthy wait for PA application approval if they pay for DME using their Consumer Directed Care budget instead of going through the approval process.
Another way Medicaid will cover durable medical equipment (DME) is through its Money Follows the Person program. This program is meant to help Medicaid recipients currently living in a nursing home return to their home or somewhere in the “community,” like with a family member or in an assisted living facility. For many people making that transition, adding DME to their home will be necessary. Even with the addition of DME like wheelchair ramps, bathtub rails or hospital beds, caring for someone at home is less expensive than caring for them in a nursing home, so Medicaid is willing to pay for the needed DME through the Money Follows the Person program to make that possible.
Forty four states currently have a Money Follows the Person program. The six states that do not one are Alaska, Arizona, Florida, New Mexico, Utah and Wyoming.
Home care supplies are usually disposable, which is the biggest difference between them and durable medical equipment (DME), which are meant for repeated use. Home care supplies are sometimes called consumable medical supplies. Some examples of them are adult diapers, urological supplies, ostomy bags and diabetic test strips.
All three types of Medicaid Long Term Care will cover ostomy and diabetic supplies, and in most states they will also cover adult diapers and other incontinence supplies. Some states do have limits on which brand of home care supplies are covered and how many products will be covered per month. If this becomes a problem, using Consumer Directed Care is another possible option for purchasing, or upgrading, home care supplies.
Personal Emergency Response Services (PERS) include any type of technology that can alert caregivers, family members or emergency responders in the event of a medical emergency. This can be a pendant or a bracelet with a simple call button, a smart watch that monitors movement and vital signs, or an in-home network of sensors that monitors all activities. These can also be known as life alerts, medical alerts, fall monitors, telemonitoring or aging in place technologies.
Personal Emergency Response Services (PERS) are included as a standard benefit in some HCBS Waivers programs. While the coverage varies by state, PERS coverage ranges from $25 to $75 per month, and some states will also cover any installation or start-up fees with a one-time reimbursement that ranges from $40 to $200.
If your state or HCBS Waiver doesn’t include PERS as a standard benefit, it is also possible to pay for a personal emergency response service with a Consumer Directed Care budget.
In some states, Aged, Blind and Disabled (ABD) Medicaid includes Personal Care Attendant programs for recipients who demonstrate a need for such a program, and these programs can include Personal Emergency Response Services (PERS) coverage. This coverage spans the same ranges as the HCBS Waivers coverage for PERS: $25 to $75 per month and the one-time installment reimbursement of $40 to $200.
If your state or ABD Medicaid coverage does not have a Personal Care Attendant program that includes PERS as a benefit, paying for personal emergency response service with a Consumer Directed Care budget is another option.
Nursing home residents typically do not require PERS / medical alert devices as the infrastructure of the facility would make them redundant. However, for Nursing Home Medicaid recipients looking to return home, the Money Follows the Person program will cover Personal Emergency Response Services (PERS) expenses. This occurs when the recipient moves out of the facility and back to their home or another residence in the community – with a family member, for example.
Medicaid eligibility is complicated, and the application process is full of potential pitfalls. Families should consider working with a Medicaid Planning professional when applying. These fee-based experts help people become eligible, while streamlining the application process and preserving assets for spouses and family members.
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