Innovations: DME Funding Problem — How to Get What You Need

Contact The Editor

Mark E. SmithOver the years, I’ve written about countless innovative products in this column, mostly in the mobility realm. However, right around the time I started this column in 2007, mobility funding began getting slashed. Year after year, funding has decreased or codes have changed, making it more difficult to get the mobility products we need. In fact, at this writing, we’re on pins and needles at year’s end waiting to see if Congress rescinds Medicare’s scheduled Jan. 1, 2016, funding cuts that may affect 171 complex rehab manual and power chair components.

However, as with funding cuts in recent years — and yes, we arguably live in a tougher time than ever when it comes to access to mobility funding — all is not without hope. In fact, by understanding basic funding policy, debunking funding mythology and using self-advocacy, you’ll be amazed at how many presumed funding denials become possible funding approvals.

Debunking the ‘Medicare-Rules-All’ Myth
Ask most people who are familiar with mobility funding, and they’ll tell you how omnipotent and restrictive Medicare is: Medicare sets mobility funding policy; they only fund mobility for in the home; and they don’t fund features like power elevating seats. We’ve all heard and been told this, right?

Here’s the problem with that line of thinking. For most complex rehab users, it doesn’t apply. With few exceptions, most complex rehab beneficiaries don’t have Medicare as their primary insurer. Most have a state’s Medicaid, private insurance, workers compensation, or Veterans Affairs benefits. Therefore, while Medicare is the most vocal and recognized policy that affects mobility funding, it’s not applicable toward many complex rehab users under age 65.

Fortunately for these complex rehab users, individual state Medicaid programs, private insurers, workers compensation, and the VA are typically far more considerate of aspects like use outside of the home, quality-of-life features, etc., than Medicare. So the first move toward maximizing mobility funding is to realize it is far more expansive than Medicare policy for most complex rehab users. That is, let your actual insurance lead you, not Medicare policy.

The Real World of Funding
Your insurance very well may cover far more than you assume. State Medicaid programs, for example, often consider one’s activities of daily living in their entirety, so they not only look at in-home use, but they also often consider your community needs, from school to career to everything in between. The result is that for, say, over-sized knobby tires, if you live in snow country, your state Medicaid may cover them because they look at your overall activities of daily living more than Medicare ever would. The same “big picture” funding approach extends to most private insurers, workers compensation and VA benefits. These funding sources are far more open to considering expanded mobility funding than many realize.

Elevating Funding Success
Power seat elevation is a fantastic recent example of how dispelling funding myths and applying funding protocols is enhancing lives. For decades, everyone said that power seat elevation wasn’t funded, period, because that’s Medicare’s policy. Everyone accepted it, and users went without the life-enhancing technology.

Photo courtesy of Permobil

Photo courtesy of Permobil

However, some of us began looking into each state’s Medicaid policy on power seat elevation. To our amazement, 46 states have processes that allow beneficiaries to have power seat elevation considered for funding. As word spread, providers and beneficiaries began explaining in their funding submissions that power seat elevation is a vital tool of activities of daily living. The result in a current market sampling is now a 65 percent successful approval rate for power seat elevation nationwide. The impact is proving profound, allowing users to function in the home and community more independently.

How It’s Done
Funding isn’t simply ask and ye shall receive. Rather, funding is a methodical process, but it’s a logical one. Using power seat elevation as a further example, state Medicaid programs and other insurers want to know the whys of your needing the feature. Rather than you and your provider just submitting for coverage of power seat elevation, an explanation of how it increases your activities of daily living should be included:

• Allows safer, independent transfers due to adjustable seat height
• Allows independent shopping by reaching top shelves
• Allows independent access to closets and cabinets in the home
• Allows greater access to work environments vital to your job duties

In short, itemize how and why the technology will benefit you in meaningful ways that are concise and obvious to your activities of daily living. This approach works with items ranging from a power assist system on an ultralight manual chair to an outdoor power chair package, and many technologies in between.

Stacking Funding Sources
As accommodating as state Medicaid, private insurers, workers compensation, and VA benefits are, they’re not always foolproof. Sometimes you will need a back-up plan, technically called a “secondary.” For example, say you’re on your spouse’s insurance, and that plan covers the basics, but denies power seat elevation. You shouldn’t stop there. You may qualify for, or already have, Medicaid as a secondary insurance provider that would cover the denied technology. Also, if you’re seeking employment, in school, or already employed, state occupational and vocational rehabilitation programs are tremendous funding sources. (When I was in college, my insurer covered my power chair, and vocational rehabilitation covered the lighting package because I had night courses). When needed, a secondary and even a third funding source may cover a denial of equipment.

What if I do Have Medicare?
For those with traditional Medicare (Part A — hospital coverage), adding Medicare Part B (regular doctor’s visits, supplies, etc.) will not cover most items deemed non-medically necessary or for use outside of the home. However, these limitations may not extend to Medicare Part C (more costly), which allows opt-in coverage with private insurers (Medicare Advantage plans). These plans must meet the minimum of Part B, but often also offer durable medical equipment funding beyond basics. Not unlike other insurers, many Medicare Advantage plans have processes to consider mobility technologies for expanded aspects of activities of daily living. Therefore, even if you have “Medicare,” a Part C Advantage plan may liberate you from funding roadblocks by offering more encompassing mobility funding. Advantage plan open enrollment is Oct. 15 through Dec. 7 each year, and researching as much as you can about prospective insurers’ DME coverage is vital since there are so many different Advantage plans available.

No Rarely Means No
When it comes to funding mobility technology, no rarely means no. Going back to where we started on this topic, we need to remove preconceived notions of what’s covered and what’s not. Instead, as savvy consumer-beneficiaries, let us elect the technology truly needed, state a valid case, and work with all funding source possibilities. By doing this, denials become approvals and we can become part of the latest 65 percent success rate that is still climbing!

By | 2017-01-13T20:41:37+00:00 January 1st, 2016|