What is Medi-Cal?
Medi-Cal is a properly planned healthcare program instituted by state and federal authorities so that low-income earners can access quality healthcare service. The department of healthcare services is the lead state agency for Medi-Cal. It can be likened to the version of the federal “MediCaid” program in California. On the federal level, the Department of Health and Human Services is saddled with the responsibility of administering MediCaid.
Individuals that receive SSI are automatically eligible for Medi-Cal. For others, approval from the county social services department determines Medi-Cal eligibility. Med-Cal Managed Care Health Plans (MCP) provides Medi-Cal services. It may also be provided by an independent body on a fee-for-service basis.
What does assistive technology mean?
By Assistive Technology (AT) we refer to any item, substance, material, piece of equipment, or software that can be used to make the living condition of people living with disabilities a lot better. It improves the functional capabilities of people living with disabilities. Durable Medical Equipment (DME), Orthotic and Prosthetic Devices (OAP) which are all available under the Medi-Cal program are all included under this definition.
Durable Medical Equipment (DME): As long as it meets your medical equipment needs and there is a prescription from a physician or doctor, DME will be covered by Medi-Cal. There must be medical necessity and the following standards must be met:
- It must serve a purpose medically
- It must be able to withstand consistent and repeated use
- It must be beneficial to the beneficiary as it concerns illness, congenital anomaly, and functional impairment.
- It should be usable at home or out of home.
Orthotic and Prosthetic Devices: OAP will also be covered by Medi-Cal as long as there is a prescription from a medical specialist and it has been confirmed to be medically necessary.
DME must play a medical role under Medi-Cal. What this means is that the device is needed because of disability. It goes beyond going to the doctor for medical care. If you are unable to walk, talk, or carry out any of your usual daily activity because of disability, it means that the device is medically necessary. Therefore, it will be covered by Medi-Cal based on necessity standard. To prove medical necessity, it must be certain that the proposed DME will reduce the burden created by disability.
What does medical necessity mean according to Medi-Cal?
According to state law, medically necessary devices, services, supplies or items are “reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.”
Some services that are classified as medically necessary include rehabilitation. This is a general standard, there is a medical necessity standard for people below the age of 21, folks in different medical facilities, and people with double eligibility (i.e., they are eligible for Medi-Cal and Medicare). These special standards become useful if the general standard cannot be applied to the item or service. Federal agencies require the special standard under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program.
Is there an exclusive list of covered DME and O&P in California?
No. Although there is a list of O&P and DME that have been pre-approved in California, it is not an exclusive one. Federal law requires you to be given “a meaningful opportunity for seeking modifications of or exceptions to its pre-approved list.”
Is it possible to get DME or O&P without been authorized by Medi-Cal or managed care plan?
You do not need prior authorization for the following devices on the pre-approved list.
1. Prosthetic devices or services not up to $500 in total cost
2. Orthotic devices or its repair not up to $250.
3. DME that does not cost up to $100.
4. DME repair and maintenance with total cost not more than $250 within the calendar month.
What steps do I take secure prior authorization for O&P or DME under the Medi-Cal program?
A Treatment Authorization Request (TAR) must be completed and submitted by your DME or O&P provider. Submission should be done at the Medi-Cal field office. You can also submit it at your managed care plan if you are enrolled in one. You should submit the Treatment Authorization Request along with necessary documentation including medical justification letter from a health care provider.
Does Medi-Cal put a limit on DME and Medical supplies?
A limit is placed on DME authorization by Medi-Cal to the lowest cost-item that will cater for your medical needs. Any item that does not serve medical care purposes will not be covered by Medi-Cal. Such items include food blenders, air filters, air conditioners, and other household items. A household item will not be authorized whether it meets a medical need or not.
Will Medi-Cal ever provide a lightweight, custom or power wheelchair?
You must be able to provide justification for Medi-Cal to purchase a lightweight, custom or power wheelchair. A lightweight or ultra-lightweight chair will be purchased only if you are incapable of propelling a heavier wheelchair by yourself. Medi-Cal does not provide sport wheelchairs. However, a power wheelchair may be approved if it is confirmed and verified that you are incapable of moving a manual wheelchair as a result of reduced upper arm strength.
Does Medi-Cal cover the cost of home alterations?
This is on some occasions. However, this will not be done under the regular Medi-Cal program except home dialysis services has become a necessity. These items may be catered for if you are in the Medi-Cal managed care plan. However, it is not a requirement. If Medi-Cal is received through a Home and Community-Based services (HCBS) waiver, Medi-Cal will cover home alterations.
Will Medi-Cal bear the cost of self-help items needed to carry out daily activities?
Yes. Medi-Cal will cover the cost of self-help aids needed to ensure daily ease and comfort. These aids include items like utensil holders, designed eating utensil, standing tables, raised toilet seats, buttoning aids, and flexible shower hoses. Regardless of cost, prior approval is needed for these items because they are not listed as DME by Medi-Cal.
Will Medi-Cal cover the cost of synthesized speech augmentative communication devices (previously referred to as augmentative/alternative communication (AAC) devices?
Medi-Cal will bear the cost of augmentative and alternative communication devices as long as it is considered a medical necessity. It is only Med-Cal beneficiaries that have been diagnosed with a significant communication disorder that can benefit from this.
How often can I get a replacement for my DME?
There is a limit to the number of times DME can be replaced. Actually, there is a frequency list which is not a hard and fast requirement. For instance, according to 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.”
What steps can I take if Medi-Cal or my managed care plan does not provide my required DME or OAP?
Appeal is allowed. You can request a Medi-Cal fair hearing if dissatisfied with the actions taken. If under a managed care plan, an appeal can be filed with the plan and fair hearing requested. An independent medical review (IMR) can also be requested if under a managed medical plan. The request should be done with the California Department of Managed Health Care (DMHC).