Medicaid of Delaware

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• Obtaining Equipment and/or Related Services
• The Importance of Medical Necessity
• Letter of Medical Necessity – Essential Elements
• Prescription & Claim Submission
• Durable Medical Equipment
• DMAP DME Access for Fee-For-Service Members and Diamond State Partners Members
• DME Access for First State Health Plan Members
• Obtaining Orthotics and Prosthetics
• Funding of Specific AT Categories

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Obtaining Equipment and/or Related Services

The Importance of Medical Necessity

Medicaid will purchase or rent various types of assistive devices for Medicaid beneficiaries if they are considered medically necessary. The first and most important step in developing an effective medical necessity justification for AT/DME is the completion of a thorough evaluation and assessment of the person's needs by an appropriately certified health care professional. Once a person's needs have been identified, the correct device or device system can be selected. The question of whether a given device is covered by Medicaid depends on the applicant's Medicaid eligibility status (eligibility criteria are outlined later in this section), and whether the item may be deemed medically necessary.

In order for an AT funding request to be successful, the following conditions must be met:

• The person's diagnosis must be consistent with the use of the requested AT
• The AT must be reasonable and necessary to maintain the person in the home
• A physician must prescribe the AT
• An enrolled AT provider must supply the item.

Delaware Medicaid's Definition of Medical Necessity

The State Plan, which governs both fee-for-service Medicaid as well as Medicaid MCO plans, defines medical necessity as essential medical care or services "prescribed by the beneficiary's primary physician care manager and delivered by or through authorized and qualified providers" that will meet all of the following criteria:

• Be directly related to the diagnosed medical condition or the effects of the condition on the beneficiary (the physical or mental functional deficits that characterize the beneficiary's condition), and be provided to the beneficiary only;
• Be appropriate and effective to the comprehensive profile (e.g., needs, aptitudes, abilities, and environment) of the beneficiary and the beneficiary's family;
• Be primarily directed to treat the diagnosed medical condition or the effects of the condition on the beneficiary, in all settings for normal activities of daily living, but will not be solely for the convenience of the beneficiary, the beneficiary's family, or the beneficiary's provider;
• Be timely, considering the nature and current state of the beneficiary's diagnosed condition and its effects, and will be expected to achieve the intended outcomes in a reasonable time;
• Be the least costly, appropriate, available health service alternative, and will represent an effective and appropriate use of program funds;
• Be the most appropriate care or service that can be safely and effectively provided to the beneficiary, and will not duplicate other services provided to the beneficiary;
• Be sufficient in amount, scope and duration to reasonably achieve its purpose;
• Be recognized as either the treatment of choice (that is, according to the prevailing community or statewide standard) or common medical practice by the practitioner's peer group, or the functional equivalent of other care and services that are commonly provided; be rendered in response to a life threatening condition or pain, or to treat an injury, illness, or other diagnosed condition, or to treat the effects of a diagnosed condition that has resulted in or could result in a physical or mental limitation, including loss of physical or mental functionality or developmental delay.

In addition, the device/service must be reasonably determined to address at least one of the following goals:

• diagnose, cure, correct, or ameliorate defects and physical and mental illnesses and diagnosed conditions or the effects of such conditions; or
• prevent the worsening of conditions or effects of conditions that endanger life or cause pain, or result in illness or infirmity, or have caused or threaten to cause a physical or mental dysfunction, impairment, disability, or developmental delay; or
• effectively reduce the level of direct medical supervision required or reduce the level of medical care or services received in an institutional setting or other Medicaid program; or
• restore or improve physical or mental functionality, including developmental functioning, lost or delayed as the result of an illness, injury, or other diagnosed condition or the effects of the illness, injury or condition; or
• Provide assistance in gaining access to needed medical, social, educational and other services required to diagnose, treat, or support a diagnosed condition or the effects of the condition.

Further, the medical necessity definition requires that a covered device or service should enable the beneficiary to attain or retain independence, self-care, dignity, self-determination, personal safety, and integration into all natural family, community, and facility environments and activities.

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Letter of Medical Necessity - Essential Elements

The State Medicaid Office will give individual consideration to any request for DME that is accompanied by a Letter of Medical Necessity (LMN). The LMN should address, but not be limited to, the following, as appropriate:

• Description of the client (name, age, residence, caretaker, occupation, measurements of height, weight, ideal body weight, etc.)
• List of all relevant diagnoses
• Description of the effects of the diagnoses on the functionality of the person in areas such as activities of daily living, positioning, ambulation, transfer, respiratory system, communication, range of motion, muscle strength, continence, nutrition, pressure relief, etc.
• Explanation of what is currently being done and why this is not appropriate or effective. Is there similar equipment in the home?
• Description of trial use with device
• Clear statement of expected therapeutic value of the requested item. How will this device/service improve functionality?
• Explanation of why the item needs to be replaced. Why can it not be repaired or modified?
• Discussion of any alternative related service that has been tried and failed and/or was considered inappropriate.
• Physician's treatment plan (medical, pharmacy, surgical, special therapies, nursing care, other durable medical equipment, school services, etc.)
• Consideration for supportive documentation from another specialist and/or therapist that could help explain or describe the medical need. If so, this may also be submitted with a physician's LMN.
• Address any specific policy coverage criteria.

Sample LMNs | PDF Version | Large Print Version | Text Version

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Prescription & Claim Submission

Currently, Medicaid will only pay for equipment if a physician prescribes it. The usual procedure for those enrolled in the fee-for-service plan is as follows:

• The patient is evaluated by a clinician (doctor or therapist) who identifies the patient's medical need for a given device.
• The patient receives a prescription (Rx) from the doctor for the necessary equipment. Certain equipment may require a specialist's Rx. For instance, under Delaware Medicaid regulations, only a neurologist, physiatrist, orthopedist, rheumatologist, or cardiac specialist may prescribe a motorized wheelchair. Medicare has similar requirements. However, there is an exception: Medicaid may approve DME prescribed by non-specialty physicians who routinely work with rehabilitation agencies to develop and monitor plans of care for physical rehabilitation and who have backgrounds or expertise in rehabilitative medicine.
• The patient takes the Rx to an equipment supplier. The supplier must be enrolled with Delaware Medicaid as a DME provider in order to bill and receive payment from DE Medicaid. In Delaware, the supplier may deliver the prescribed equipment anytime after receiving the Rx as long as the item is clearly defined in the DME provider manual and is known by the supplier to be a covered device/service.

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Durable Medical Equipment

Assistive devices may be purchased with Medicaid funds if they are medically necessary, can be considered durable medical equipment (DME), and are covered under Title XIX and the State Plan. A device does not have to be included in the State Plan to be covered under the children's (EPSDT) program.

The federal government defines DME as that which:

• Can withstand repeated use
• Is customarily used for a medical purpose
• Is generally not useful to a person in the absence of an illness, injury, or disability
• Is needed to maintain the person in his or her home.

The beneficiary owns DME purchased with Medicaid funds. The DMAP and each of its MCOs have policies that describe their DME-related procedures as well as examples of items generally covered and not covered. The policies are generally similar but some features of each are described below.

DMAP considers that presumptively medical DME, and therefore covered items, include hospital beds, wheelchairs, respirators, crutches, nebulizers, etc. It excludes coverage for DME that is "not primarily medical in nature." This includes physical fitness equipment, air conditioners, room heaters, humidifiers attached to home heating systems, and generally aids for daily living (ADL) and environmental control units (ECU). However, since Medicaid considers requests on a case-by-case basis, do not assume an ADL or ECU will not be covered. An example of where a device might be covered as "medically necessary" is when an ECU is part of a covered item such as an AAC device. DMAP also does not cover home or vehicle modifications.

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DMAP DME Access for Fee-For-Service and Diamond State Partners Members

• The decision as to whether to approve DME for fee-for-service and Diamond State Partners members is made by a DME Review Team. As previously stated, the DME Review Team has expressed its willingness to review any request for DME, supported by an LMN, on a case-by-case basis. DMAP, as well as the MCOs, strongly prefer that the LMN and any supporting documentation be submitted as one package.
• However, the fact that a health care practitioner may order or recommend a type of item does not by itself make it a covered service. DMAP defines "supplies" as "disposable items that are used...to carry out the written plan of care of a licensed medical practitioner." A DME provider is not permitted to dispense more than a one-month quantity of supplies. This policy also provides that "supplies and equipment may not be dispensed and billed to the DMAP when the primary use is intended for a setting other than the client's home." DMAP will not reimburse a DME supplier for a duplicate item to be used in other settings (e.g., nursing homes, inpatient and outpatient hospitals, or physician/practitioner's offices).
• What is important to remember is that if the device can be prescribed, and can restore or improve function that is absent due to a medically diagnosed condition, Delaware Medicaid programs may permit purchase, lease, or rental of the device. However, even if some non-medical equipment may have some distant medically related use, the item will not be covered because its primary and customary use is not medical. It is also important to remember that there must be prior authorization for equipment purchases and some equipment requires a physician's LMN.

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DME Access for First State Health Plan Members

The First State Health Plan requires prior authorization for all AT purchases. In order to receive prior authorization, you must have a physician's prescription, an authorization request form and an LMN. The case manager at the MCO will review the prescription and the LMN prior to giving authorization.

An MCO maintains a list of its own preferred/contracted equipment suppliers. The MCO will only furnish equipment through suppliers with whom they have agreements. However, in cases of "unusual" equipment claims, an MCO may be willing to recruit other suppliers of such equipment if the device is judged to be a covered item. Regulations issued by the Department of Health and Social Services (DHSS), effective January 10, 2002, mandate MCO referral to a non-network provider when the network provider is unable to provide medically necessary services or cannot do so within a reasonable period of time. The regulations also require MCOs to cover nonparticipating providers if there are an insufficient number of network providers within a reasonable geographic distance.

An MCO is required to cover all the equipment and services covered by the DMAP fee-for-service plan, although the MCO is permitted to exceed DMAP's coverage and offer broader coverage.

First State's policy defines DME as "those items and related services which are customarily provided and used for medical purposes, in order to improve, support or maintain the health and functional capabilities of an individual." Examples of DME include, but are not limited to, wheelchairs, prosthetics, AAC devices, ambulatory assistance devices (e.g., canes, walkers, etc.), bath chairs, cushions/mattresses, and nebulizers. First State does not cover home or vehicle modifications and it offers limited coverage of ADL and ECU devices. The procedure for obtaining DME is as follows:

• The primary care or other physician sends a prescription and a detailed LMN (including the diagnosis, prognosis, pertinent history and physical exam) supporting the "medical necessity" finding to the First State Case Management Department. The LMN must include information from the physician or an appropriate sub-specialist with expertise in the proper application and use of the specific DME requested.
• The physician must also submit a prescription for the DME to a participating vendor.
• The vendor submits a DME Authorization Form to the Case Manager. In some cases, items may be approved without further investigation. First State may contact non-participating vendors if the DME is not stocked by participating vendors.
• The Case Manager reviews the documentation in support of the request, including the prescription, evaluation, CMN, and LMN prior to giving authorization.
• In cases in which "medical necessity is questionable or approval is otherwise uncertain," the request is referred to the Medical Director for consideration using DMAP's definition of "medical necessity."
• First State notifies DME vendors within three business days—or within 24 hours in urgent cases—of approval or denial. In cases where successive orders are placed for the same item, First State may authorize "home care-takers" to contact the vendors to "expedite re-supply of discardable items or those which can not be reused."
• Members are informed in writing of a denial and their appeal rights.

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Obtaining Orthotics and Prosthetics

First State has a separate policy for requests for orthotics and prosthetics. The process is as follows:

• The primary care physician (PCP), physiatrist, or other specialist determines if the member requires an orthotic or prosthetic. If so, a prescription is sent to a participating vendor. A full evaluation by a physical therapist or occupational therapist is required for approval of devices applicable to extremities unless the PCP's report has sufficient detail. Certain prosthetics (breast, ocular) require a LMN from the PCP or specialist. First State covers dental orthotics as well as orthotics/prosthetics that allow individuals to function more effectively in vocational settings and in performing activities of daily living.
• The vendor contacts First State Case Management or the Pre-certification Department via fax, using a standard DME authorization form.
• The Case Manager, Pre-certification Nurse, and First State physician make a medical necessity determination and notify the vendor and member of the approval or denial.
• If the participating vendor does not stock the required equipment, the Case Manager or Pre-certification Nurse may negotiate a purchase with a non-participating provider.
• In situations in which DME is rented, those costs are applied to the purchase price. However, First State will not cover rental costs in excess of the purchase price. The vendor has the responsibility for all maintenance and replacement parts on rented items.

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Funding of Specific AT Categories

Aids for Daily Living (ADL)

This category includes devices and adaptations to increase participation or independence in activities such as eating, dressing, grooming, and toileting, as well as routine tasks such as getting out of bed, cooking, and doing laundry. Medicaid generally does not fund ADL. However, because Medicaid considers requests on a case-by-case basis, it may be possible to get funding if one can satisfy the detailed "medical necessity" test and overcome Medicaid's position that an ADL does not meet the definition of DME ("generally not useful to a person in the absence of an illness, injury or disability").

Switches and Environmental Control Units (ECU)

These are controls or systems that enable people without mobility or sufficient dexterity or cognition to control household devices and appliances (radio, television, lights) or to make other changes in their immediate environment. As with ADL, Medicaid generally does not fund ECUs. However, ECU devices may be covered if they are built into covered devices such as AAC systems.

Assistive Listening Devices

This category includes equipment that amplifies auditory signals (e.g., hearing aids, personal listening devices) and devices that alert a person to sounds in the environment (e.g., flashing light for doorbell, vibrating pager that alerts a caregiver to a baby's cry). Once again, though Medicaid covers hearing evaluations, it does not generally cover devices in this category.

Aids for Low Vision

These include devices that increase contrast or enlarge images, or substitute tactile or auditory signals for visual ones. Examples are writing templates, talking watches and calculators, Braille, large print, magnifiers, the use of tape recorded materials, and auditory signage. Medicaid does not cover items in this category.

Augmentative and Alternative Communication (AAC)

This category includes equipment and services that enhance face-to-face communication: devices or systems that supplement or replace natural speech, ranging from language boards to speech amplifiers to computer-based systems with voice output; telecommunications (text telephones, speaker phones, voice activation and automatic dialing that enhances telephone access by people with physical limitations); and writing aids (devices or systems that support written communication, ranging from adaptations to writing utensils to alternate ways of generating written communication such as voice dictation). Medicaid provides very good funding for AAC devices. Please review the process set forth by Medicaid as well as a copy of Delaware Medicaid's AAC policy.

Delaware Medicaid's AAC Policy  |  PDF  |  Large Print  |  Text

Computer Access

This category includes items that enhance access to computers in variety of ways to both facilitate input (adapted keyboards, keyguards, voice dictation, word prediction) and enhance output (screen readers, enlarged font, tactile displays). Medicaid will only fund computers when an important use of the computer is as the beneficiary's communication device.

Seating, Positioning, and Mobility

This category includes devices that support or improve mobility and the equipment used to customize mobility alternatives for use by a particular individual. Medicaid does fund these services and has set up a detailed process. Seating and positioning devices and systems improve body stability, trunk/head support and upright posture, and reduce pressure on skin surfaces (cushions, lumbar supports) for those using wheelchairs and other seating systems. Power mobility options include three or four wheeled vehicles or chairs, usually powered by battery, for independent personal mobility. Movement may involve movement in space, such as stand and/or tilt features, as well as movement over distances. Manual mobility involves wheeled chairs or beds for personal mobility. Finally, this category includes mobility aids such as walkers and canes.

Home Modifications and Vehicle Modifications

This category includes modifications to residences and vehicles that help a person to live as independently and productively as possible. Medicaid does not cover funding for these modifications.

Orthotics and Prosthetics

Orthotic items are used for correction or prevention of physical deformities throughout the body. Prosthetic items replace all or part of the function of a body part. Medicaid covers orthotics and prosthetics. However, when there is a request to cover a prosthetic device, the DME Review Team will look at whether there is duplication. For example, Medicaid is not likely to pay for a prosthetic limb for an amputee who uses a wheelchair unless the beneficiary can show an attempt to eliminate reliance on the wheelchair through the use of a prosthetic leg.

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