Obtaining Assistive Technology through Medi-Cal
Obtaining Assistive Technology through Medi-Cal
What is Medi-Cal?
Medi-Cal is a state and federal program that ensures health care coverage to many low-income people. The lead state agency for Medi- Cal in California is the Department of Health Care Services.
Medi-Cal is California’s version of the federal “Medicaid” program. The federal agency that administers Medicaid is the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS).
Medi-Cal eligibility is automatic for individuals who receive SSI. For all others, Medi-Cal eligibility is determined by the county social services department. Medi-Cal services are provided by Medi-Cal Managed Care Health Plans (MCP), or by independent providers on a fee-for-service basis.
What is assistive technology?
Assistive technology (AT) is generally defined as any item, piece of equipment, software or product system that is used to increase, maintain, or improve the functional capabilities of individuals with disabilities. This definition includes Durable Medical Equipment (DME) and Orthotic and Prosthetic Devices (OAP) available under the Medi-Cal program.
Durable Medical Equipment (DME) under the Medi-Cal program includes equipment such as basic and custom wheelchairs, canes, crutches, walkers, grab bars, hospital beds, water or gel pressure mattresses, oxygen therapy equipment, augmentative communication devices and other devices. Medi-Cal also provides DME needed to assist a parent, stepparent, foster parent or legal guardian with a disability to care for a child.
Orthotic and Prosthetic Devices (OAP) under the Medi-Cal program includes appliances to restore function or replace body parts.
What DME and OAP does Medi-Cal cover?
Durable Medical Equipment: Medi-Cal covers DME if it meets your medical equipment needs and is prescribed by a licensed medical practitioner. It must be medically necessary and meet the following standards:
- serve a medical purpose;
- withstand repeated use;
- be useful to you because of illness, injury, functional impairment or congenital anomaly;
- not be useful to someone in the absence of illness, injury, functional impairment or congenital anomaly; and
- be appropriate for use either in or out of your home.
Orthotic and Prosthetic Devices: Medi-Cal covers OAP if it’s medically necessary and is prescribed by a licensed physician, podiatrist or dentist. Lower limb prostheses must be prescribed by a licensed physician.
Under Medi-Cal, DME must serve a medical purpose. Medical purpose means you need the device because of your disability, and you would not need it if you did not have a disability. This includes much more than getting to the doctor to get medical care. If you need a device to help you to walk, speak, or perform other activities of daily living, you have a medical need for the device and it is therefore covered under Medi-Cal based on the Medi-Cal medical necessity standard. The key to demonstrating medical necessity for DME is to show that the proposed device is the most reasonable treatment for your disability.
What does Medi-Cal consider to be medically necessary?
State law defines medically necessary as those services, medicines, supplies and devices that are “reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.” Medically necessary services include rehabilitation and other services needed to attain or retain the capability for normal activity, independence or self-care.
In addition to this general standard, Medi-Cal has special medical necessity standards for people under age 21, people in different types of medical facilities, and people who are dual eligible for Medicare and Medi-Cal. These special standards can be used if the item or service does not meet the general medical necessity standard. For example, individuals under age 21, are entitled to necessary health care “… to correct or ameliorate defects and physical and mental illnesses and conditions…” This special standard is a federal requirement under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program.
If you have problems getting coverage for DME or OAP because Medi- Cal says it is not medically necessary, please call Disability Rights California.
Does California have an exclusive list of covered DME and O&P?
No. California has lists of pre-approved DME and O&P but the lists are not exclusive. Under federal law you must be given “a meaningful opportunity for seeking modifications of or exceptions to its pre-approved list.” The federal standard is discussed in a State Medicaid Director letter dated September 4, 1998, which can be found on the federal Center for Medicare and Medicaid Services (CMS) website.
Can I get DME or O&P without prior authorization from Medi-Cal or my managed care plan?
For the following devices on the pre-approved list, prior authorization is not necessary:
- Prosthetic devices or services that cost less than $500.
- Orthotic devices or their repair if the cost is less than $250.
- DME if it costs less than $100; and
- Repair and maintenance of DME if the cost does not exceed $250 within the calendar month.
How can I get prior authorization for DME or O&P under the Medi-Cal program?
Your DME or OAP provider must complete a Treatment Authorization Request (TAR) and submit it to the Medi-Cal field office or your managed care plan if you are enrolled in one. The TAR should be submitted along with documentation of your need for the service including a medical justification (medical necessity) letter from a health care provider. See our publication on Medi-Cal TARs for more information.
What are some of the limitations Medi-Cal puts on DME and medical supplies?
Medi-Cal limits authorization for DME to the lowest-cost item that will adequately serve your medical needs.
Medi-Cal does not cover household items, items not used primarily for medical care, and articles of clothing – even if they meet a legitimate medical need. If a household item will serve your medical needs, Medi-Cal will not authorize a medical device. Medi-Cal does not cover air conditioners, air filters, food blenders, orthopedic mattresses or automobile modifications.
Will Medi-Cal pay for synthesized speech augmentative communication devices (formerly known as augmentative/alternative communication (AAC) devices)?
Yes. Medi-Cal will provide augmentative and alternative communication (AAC) devices and services when determined to be medically necessary. See the Speech Generating Devices section of the Medi-Cal Durable Medical Equipment and Medical Supplies manual. This benefit is available to Medi-Cal beneficiaries who have been diagnosed with a significant communication disorder.
How often can I get my DME replaced?
Medi-Cal has a frequency list that places limits on the replacement of DME but the Frequency List is not a hard and fast requirement. For example, under state law Medi-Cal “shall allow the replacement of durable medical equipment and medical supplies when necessary because of loss or destruction due to circumstances beyond the beneficiary’s control.”
Federal law allows Medi-Cal to have frequency lists as a matter of administrative convenience but it must allow exceptions to “ensure that the amount, duration, and scope of coverage are reasonably sufficient to achieve the purpose of the service.” The best source of authority for this is a federal State Medicaid Director letter dated September 4, 1998.
How do I get DME if I have both Medicare and Medi- Cal?
A court order in the case of Charpentier v. Kizer, established procedures for getting Medi-Cal authorization before Medicare is billed. That way when the DME provider bills Medicare for the item the provider can be assured of full payment at the Medi-Cal rate, which is usually higher than the Medicare rate. Under the Charpentier procedures:
1. The DME provider first submits a TAR to Medi-Cal.
2. Once Medi-Cal approves the TAR, the DME provider can provide the equipment and bill Medicare for the cost.
3. If Medicare decides that the item is medically necessary, Medicare will pay 80% of what it considers to be the reasonable rate for the item. Medi-Cal will then pay the difference between the Medi-Cal rate and what Medicare pays. If Medicare does not approve the item, Medi-Cal will pay the entire cost at the Medi-Cal rate.
What do I do if Medi-Cal or my managed care plan does not provide me with the DME or OAP that I need?
You can appeal. If you are dissatisfied with the action Medi-Cal took, you can request a Medi-Cal fair hearing. If you are in a Medi-Cal managed care plan, you can file an appeal with the plan and request a fair hearing if you are dissatisfied with the decision. You can request a fair hearing without filing an appeal. If you are in a managed care plan, you can also request an independent medical review (IMR) with the California Department of Managed Health Care (DMHC). If you want to request an IMR you must generally first file an appeal with the managed care plan. Many of the materials discussed in the following section have helpful information about fair hearings. For more information about fair hearings generally, visit the website of the Department of Social Services’ State Hearings Division.
The following are some other internet resources:
Applying for Medi-Cal. If you have SSI, you get Medi-Cal automatically. If you do not have Medi-Cal, you can apply at the county social services department or online. You can find information about Medi-Cal applications on the DHCS website.
Medi-Cal eligibility. A good place to get information about Medi-Cal eligibility and services is the NHeLP manual, Overview of the Medi-Cal Program (2008), available on the Health Consumer Alliance website.The Health Consumer Alliance has other useful publications on Medi-Cal eligibility and services on the same website.
Medi-Cal provider manuals. Medi-Cal provider manuals can be found on the Medi-Cal provider website. The Durable Medical Equipment and Medical Supplies (DME) manual can be found under “Allied Health.”