Facilitating Access to Medicaid Durable Medical Equipment for Dually Eligible Beneficiaries in the Fee-for-Service System: Three State Approaches

Integrated Care Resource Center Technical Assistance Tool Brief
Publisher: Washington, DC: Integrated Care Resource Center
Jun 13, 2018
Paul Montebello

Key Findings:

  • Dually eligible Medicare and Medicaid often face difficulties accessing durable medical equipment (DME).
  • State Medicaid programs can facilitate access to these items by:
  • Implementing a process to provisionally authorize payment for them; and
  • Posting lists of DME items for which Medicare Part B generally does not pay.
  • This can make it more likely that suppliers will provide DME services to these beneficiaries.
Beneficiaries who are dually eligible for Medicare and Medicaid often experience difficulties accessing DME, such as wheelchairs, in a timely manner. Whether Medicare or Medicaid covers a specific item may be unclear. Medicaid usually is the “payer of last resort,” which means that DME suppliers generally must obtain a Medicare denial before Medicaid will pay. For higher-cost items, waiting for a Medicare denial can create an access problem, especially for lower-income beneficiaries. To address this issue, some states, such as Illinois, California, and Connecticut, have developed procedures for provisional prior authorization from Medicaid for such items. States may supplement these procedures by posting lists of DME items that Medicare consistently denies as non-covered, and allow DME suppliers to bill Medicaid directly for these items without first billing Medicare. This can make it more likely that suppliers will provide DME to dually eligible beneficiaries in a timely way, with less confusion and uncertainty about who will pay and when.