Durable Medical Equipment: Medi-cal, Medicare, And Dual Eligible Individuals

Durable Medical Equipment: Medi-cal, Medicare, And Dual Eligible Individuals
Both Medicaid (or “Medi-Cal”) and Medicare cover medical equipment and supplies, also known as durable medical equipment (DME). However, Medi-Cal and Medicare have different rules regarding coverage, payment, and appeal rights.
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I. Introduction
Both Medicaid (or “Medi-Cal”) and Medicare cover medical equipment and supplies, also known as durable medical equipment (DME). However, Medi-Cal and Medicare have different rules regarding coverage, payment, and appeal rights. This publication is intended to help you understand how to get the DME you need when you have Medi-Cal, Medicare, or both.
a. What is Durable Medical Equipment (DME)?
Medi-Cal and Medicare cover different types of DME.1 Durable medical equipment includes medical equipment and supplies like walkers, wheelchairs, canes, scooters, oxygen equipment, speech generating devices, therapeutic mattresses and bed equipment, patient lifts, blood sugar test strips, and more.
Medi-Cal and Medicare also have different definitions for DME:
Medi-Cal2 | Medicare3 |
---|---|
DME is equipment that is:
|
DME is equipment that is:
|
b. What is Medi-Cal?
Medicaid, known as “Medi-Cal” in California, is a state and federally funded program. It pays for medically necessary treatment and services, medicines, DME, and medical supplies. Medi-Cal is automatic for people who receive Supplemental Security Income (SSI). For all others, Medi-Cal eligibility is determined by the county social services department. You can visit the California Department of Health Care Services (DHCS) website for more information about Medi-Cal and how to apply at: https://www.dhcs.ca.gov/services/medi-cal/Pages/ApplyforMedi-Cal.aspx.
Most Medi-Cal members are in managed care plans, but some people have fee-for-service Medi-Cal through the Department of Health Care Services.
c. What is Medicare?
Medicare is health insurance for people over the age of 65 and certain people with disabilities under 65. There are 2 types of Medicare:
- Original Medicare (fee for service), and
- Medicare Advantage (managed care) or Part C.
- This includes integrated Medicare Medi-Cal Plans (MMPs) and Dual Special Needs Plans (D-SNPS). Integrated plans accept payment from Medicare and Medi-Cal for your healthcare.
Note: Individuals enrolled in the Program for All-Inclusive Care for the Elderly (PACE) also receive integrated Medicare Medi-Cal benefits through PACE.4
You can find out if there is an integrated Medicare Medi-Cal plan, or HMO D-SNP, in your area online at: https://www.dhcs.ca.gov/provgovpart/Pages/Medicare-Medi-Cal-Plan-List.aspx. For help enrolling in a Medi-Medi plan, you can contact Medicare at: 1-800-MEDICARE. For more information about Integrated Care for Dual Eligible Benefits you can visit California Department of Health Care Services (DHCS) online at: https://www.dhcs.ca.gov/services/Pages/Integrated-Care-for-Dual-Eligible-Beneficiaries.aspx.
Medicare includes:
- Part A (inpatient/hospital coverage): hospital stays, care in skilled nursing facilities, hospice care, and limited home health care.
- Part B (outpatient/medical coverage): care such as doctor visits, medical supplies, durable medical equipment, and preventive services.
- Part C (also known as Medicare Advantage Plans): includes what is covered in parts A and B. Many of these plans also include prescription drug coverage and other benefits not provided by part A and B such as vision, hearing aids, and dental care.
- Part D covers prescription drugs. If you receive original Medicare (parts A and B) then you will need to choose and enroll in a stand-alone Medicare private drug plan.
d. DME for Dual Eligibles
If you have both Medi-Cal and Medicare, you are considered a “dual eligible” member or “Medi-Medi.” Under California’s CalAIM initiative, the state is trying to make it easier for dual eligibles to access DME.5 The process for obtaining your durable medical equipment will be different depending on whether you are enrolled in an integrated Medicare Medi-Cal plan (MMPs, Medi-Medi Plans, or D-SNPs) or if you receive your Medicare separate from Medi-Cal. If you are in an MMP, Medi-Medi plan, or D-SNP, your plan should coordinate the request for DME through both your Medi-Cal and Medicare.6
i. Dual Eligible Special Needs Plans (D-SNPs)
Dual Eligible Special Needs Plans, or “D-SNPs,” are a type of Medicare Advantage plan that provides specialized, integrated care for dual eligibles. There are different kinds of D-SNPs in California, and they vary by county. If you are unsure whether you’re currently enrolled in a D-SNP, or eligible for one, you should call your Medi-Cal plan or the Medicare and Medi-Cal Ombudsperson Program (MMOP) at: 1-855-501-3077.
D-SNPs are required by federal law to coordinate Medi-Cal benefits and services along with your Medicare plan, including managed care or fee for service benefits.7 D-SNPs are also required to assist with grievances and appeals, screen for housing, food, transportation needs, and other forms of assistance.
ii. Charpentier Requirements
Medicare is the primary payer for dual eligible individuals, and generally always pays before Medi-Cal.8 However, there are special rules for dual eligibles seeking DME because of a court case called Charpentier v. Belshe.9 If you have Medi-Cal and Medicare and need DME, your Medi-Cal plan must process an authorization request in the same manner as a Medi-Cal only patient, regardless of whether Medicare (or any other health coverage) has authorized the equipment or been billed. In other words, your Medi-Cal plan should not require you to first seek coverage through Medicare or delay authorizing DME until Medicare authorizes or denies the equipment.10
II. How to get DME: Prior Authorization and Medical Necessity
a. Medi-Cal Prior Authorization
To get DME in Medi-Cal, your primary care physician must refer you for an evaluation from a DME provider. Once you have an evaluation, the DME provider must submit a request to your health plan. If you are not in a managed care plan, the DME provider must submit a Treatment Authorization Request, or “TAR,” to the Department of Health Care Services.
Medi-Cal Managed Care health plan’s “prior authorization” procedures may vary. You can ask for a copy of your MCP’s “prior authorization” procedures directly from your health plan. To get “prior authorization” approval, your provider completes a Treatment Authorization Request (TAR) and submits it to your MCP (or directly to Medi-Cal if you are not enrolled in an MCP) along with medical documentation including a letter from health care providers explaining why the DME is “medically necessary” for you to have.
b. Medi-Cal “Medical Necessity”
Medi-Cal will pay for DME only if it is “medically necessary.” “Medically necessary” DME must be, “reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.”11 This includes coverage for conditions that “cause suffering, endanger life, result in illness or infirmity, interfere with capacity for normal activity including employment, or for conditions which may develop into some significant handicap.”12
Authorization for DME is also limited to the lowest cost item that meets your needs.13
In addition to this general standard, Medi-Cal has special medical necessity standards for people under age 21. Under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program, individuals under age 21 are entitled to necessary health care if it corrects or ameliorates defects and physical and mental illnesses and conditions discovered through screening.14 For more information about EPSDT, visit: https://www.medicaid.gov/medicaid/benefits/early-and-periodic-screening-diagnostic-and-treatment/index.html.15
c. Medicare Prior Authorization
To get DME in Medicare, the first step is to speak with your doctor to request a prescription for the durable medical equipment you need. If you are enrolled in a Medicare Advantage plan, your doctor or your plan will provide you with a referral to a supplier you can use to get your prescription for DME filled.
If you are enrolled in Original Medicare, you will need to use Medicare approved suppliers. You can find a Medicare approved supplier online, at: https://www.medicare.gov/medical-equipment-suppliers/?redirect=true.
d. Medicare Medical Necessity
Medicare will only pay for durable medical equipment that is “medically necessary.”16 Medicare defines “medically necessary” as reasonable and necessary health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.17 This means that normally, Medicare will pay for durable medical equipment that is:
- Prescribed by your doctor,
- Can be used in your home,
- Durable (can withstand repeated use),
- Used for a medical reason, and
- Expected to last 3 years.18
e. Dual Eligible Prior Authorization (Charpentier)
If you are dual eligible, the process for obtaining DME is like the process described above for Medi-Cal. A DME supplier submits a TAR to DHCS or prior authorization request to the MCP. DHCS or the MCP reviews the TAR for medical necessity and confirms Medi-Cal eligibility and returns an Adjudication Response (AR) to the DME supplier. DHCS or the MCP should process the request for prior authorization regardless of whether Medicare has authorized the equipment or been billed. If the TAR or prior authorization is approved, the DME supplier orders and delivers the equipment. The DME supplier first bills Medicare, then Medi-Cal for any costs Medicare did not cover.19
III. Denials and Appeals
a. Medi-Cal Appeals and Grievances
For information on Medi-Cal Appeals and Grievances, please see DRC’s Publication: “Medi-Cal Managed Care: Appeals and Grievances,” at: https://www.disabilityrightsca.org/publications/medi-cal-managed-care-appeals-and-grievances.
b. Medicare Appeals and Grievances
The Medicare appeal process is different depending on whether you are in original Medicare or a Medicare Advantage plan.
If you have original Medicare, your appeal goes to the Medicare Administrative Contractor. For more information, visit: https://www.cms.gov/medicare/appeals-grievances/fee-for-service/first-level-appeal-redetermination-medicare-contractor or call 1-800-MEDICARE.
If you have a Medicare Advantage plan, your appeal will start as an “Organizational Determination.” For more information, visit: https://www.cms.gov/medicare/appeals-grievances/managed-care/organization-determinations or call 1-800-MEDICARE.
For more information about Medicare complaints and appeals you can visit Medicare’s website at: https://www.medicare.gov/claims-appeals/file-a-complaint-grievance/complaints-about-durable-medical-equipment-dme.
You can also contact Health Insurance Counseling and Advocacy (HICAP) at: https://cahealthadvocates.org/hicap/ or 1-800-434-0222.
c. D-SNP Appeals and Grievances
If you are enrolled in a Dual Eligible Special Needs Plan, or “D-SNP,” that is an “Applicable Integrated Plan” or “AIP,” you are entitled to a unified appeal process at the plan level. This means that your D-SNP plan should review your request using both Medi-Cal and Medicare criteria and send you a single notice explaining the reasons for any denial. The D-SNP oversees the initial decision and first level of appeal; any higher-level appeals are not integrated, and you should follow the steps listed above.
If you’re unsure whether your D-SNP plan is AIP, you can refer to this list20 and/or call the Medicare and Medi-Cal Ombudsperson Program (MMOP) at: 1-855-501-3077.
IV. DME Repairs and Replacements
If DME needs repair or replacement, you should reach out to the supplier that provided the equipment. If the supplier does not respond or delays the process, you have certain rights.
If the DME was supplied by Medi-Cal, you can contact your MCP and file a grievance. You can also contact the Medi-Cal Managed Care Ombudsman by calling 1-888-452-8609 or the Department of Managed Health Care Help Center at 1-888-466-2219.
If your DME was supplied by Medicare, you can contact 1-800-MEDICARE. For Original Medicare, if the supplier is a competitive bidding contractor, you can file your complaint with the Competitive Acquisition Ombudsman (CAO).21 If you have a Medicare Advantage plan, contact the plan, and ask to file a grievance.
V. Resources
If you have questions or concerns about your legal rights:
- Call DRC’s intake line at: 1-800-776-5746
If you have questions or concerns about being a dual eligible individual:
- Call the Medicare and Medi-Cal Ombudsperson Program (MMOP) at: 1-855-501-3077
If you have questions or concerns about your Medi-Cal managed care plan:
- Call the Medi-Cal Managed Care Ombudsperson Program at: 1-888-452-8609
If you have questions or concerns about your Medicare benefits:
- Call the Health Insurance Counseling and Advocacy Program (HICAP) at: 1-800-434-0222
- 1. For a full list of Medicare covered items, visit: https://www.medicare.gov/coverage/durable-medical-equipment-dme-coverage. For a full list of Medi-Cal covered items, visit: https://mcweb.apps.prd.cammis.medi-cal.ca.gov/publications/manual?community=durable-medical-equipment-and-medical-supplies.
- 2. 22 C.C.R § 51160.
- 3. 42 C.F.R § 410.38.
- 4. For more information about PACE, please visit: https://calpace.org/what-is-pace/where-is-pace/; also see DRC’s publication: https://www.disabilityrightsca.org/publications/medi-cal-programs-to-help-you-stay-in-your-own-home-or-leave-a-nursing-home.
- 5. https://www.dhcs.ca.gov/provgovpart/Pages/Cal-MediConnect-to-D-SNP-Transition.aspx.
- 6. 42 C.F.R § 422.562(a)(5).
- 7. Id.
- 8. 42 U.S.C.A § 1396a(a)(25).
- 9. Charpentier v. Belshe, 1994 WL 792591 (Dist. Ct., E.D. Cal., 1994).
- 10. Department of Health Care Services Medi-Cal Provider Manual, Durable Medical Equipment and Medical Supplies Manual, Durable Medical Equipment (DME): An Overview (dura), at page 16. https://mcweb.apps.prd.cammis.medi-cal.ca.gov/publications/manual?community=durable-medical-equipment-and-medical-supplies.
- 11. Welf. & Inst. Code, § 14059.5.
- 12. Welf. & Inst. Code, § 14059.
- 13. 22 C.C.R. § 51321(g).
- 14. Title XIX of the Social Security Act, § 1905(r)(5); Welf. & Inst. Code, § 14059.5(b)(1).
- 15. See also, Department of Health Care Services Medi-Cal Provider Manual, EPSDT, https://mcweb.apps.prd.cammis.medi-cal.ca.gov/assets/032769EA-D044-4B1D-A973-C617165FE3BE/epsdt.pdf?access_token=6UyVkRRfByXTZEWIh8j8QaYylPyP5ULO.
- 16. Title XVIII of the Social Security Act, § 1862(a)(1)(A).
- 17. 42 C.F.R. § 410.38.
- 18. https://www.medicare.gov/coverage/durable-medical-equipment-dme-coverage.
- 19. Department of Health Care Services Medi-Cal Provider Manual, Durable Medical Equipment and Medical Supplies Manual, Durable Medical Equipment (DME): An Overview (dura), at pages 16-17, https://mcweb.apps.prd.cammis.medi-cal.ca.gov/publications/manual?community=durable-medical-equipment-and-medical-supplies.
- 20. https://www.dhcs.ca.gov/provgovpart/Pages/Medicare-Medi-Cal-Plan-List.aspx.
- 21. To file a complaint with CAO, ask the 1-800-MEDICARE representative to submit your complaint or inquiry to the CAO. https://www.cms.gov/medicare/payment/fee-schedules/dmepos-competitive-bidding/aquisition-ombudsman-cao.