Will Medical Assistance Pay for Assistive Technology?

AT devices or services are medically necessary if doctors or therapists would order the equipment or services for a person with similar needs. The Medical Assistance rules say the doctor or therapist has to answer 3 questions:

• Is the equipment or service seen as the standard of care for your diagnosis or condition?
• Would the equipment or service allow you to function in the community the way doctors and therapists usually expect a person with that diagnosis or condition to be able to function?
• Would the equipment or service prevent or lessen the occurrence of an illness, infection, disability, or other health condition?

The Medical Assistance program helps pay for medical supplies and equipment, eyeglasses, hearing aids, prosthetics and orthotics, and augmentative and alternative communication systems. Medical equipment includes both durable and non-durable medical equipment and supplies.

Durable medical equipment is a device that:

1. can be used repeatedly
    
2. is generally not useful if you don’t have an illness, injury, or disability and
    
3. corrects or accommodates a physiological disorder or physical condition, or is used primarily for a medical purpose
    

Examples of durable medical equipment are:

1. Mobility devices. This includes: 

• Canes
• Walkers
• Wheelchairs
  Wheelchairs may be for use in your home or in a nursing home. In some cases, Medical Assistance will pay for a power wheelchair AND a manual wheelchair when they are needed for different purposes. Custom designed wheelchairs are covered when medically necessary.
   

2. Dressing and bathing aids. This includes:

• shower chairs
• bath lifts
• personal care aids
• environmental control units 
   

3. Standing equipment, equipment needed to help you stand upright. This includes:  

• stationary and mobile standing frames
• standing wheelchairs
   

4. Adaptive car seats for children with disabilities, including behavioral disorders.
    
5. Communication devices. This includes:

• accessories (like a mount or carrying case)
• computer tablets, like an iPad, if it is used as a communication device
   

Non-durable medical equipment means a supply or piece of equipment that is used to treat a health condition. Non-durable equipment can’t be reused. This is things like: enteral supplies, thickening agents, gloves, and incontinence products.

Prosthetic and orthotic devices replace missing body parts or body parts that do not function properly, or prevent, correct, or support a deformed or weak body part.

AT services: Medical Assistance also pays for services related to picking out, getting, or using an AT device. Services may include an evaluation or therapy to learn how to use a device. For example: speech therapy to learn how to use a communication device or occupational therapy to learn how to drive a wheelchair.

In most cases, Medical Assistance has to okay payment for AT devices and services before you get them. This is a process called prior authorization.

You need:

• a letter of medical necessity written by your medical provider (a doctor, therapist, or home health care nurse)

• a prescription

• any other necessary documentation like forms required by Medical Assistance or other medical records that show why you need the device

• a medical equipment vendor (the place where you will purchase the AT)

In most cases, the first step is to ask for an evaluation by a medical provider. A medical provider can be a doctor, physical therapist, occupational therapist, speech-language pathologist, home health care nurse, or other medical professional. The medical provider should write a letter of medical necessity that clearly shows that the equipment you are asking for will help you.

For example, a letter of medical necessity for a wheelchair should show why you need it, how it will help you and that you are able to operate it.

Sometimes you need letters from different therapists to give information on different areas. For example, a speech-language therapist may say you need a specific communication device based on your speech language needs. You may also need a letter from an occupational or physical therapist explaining how you will operate the device.

The letter of medical necessity should cover the 6 things listed below in the section “How does Medical Assistance decide what is approved?”

Yes. If your doctor did not write the letter of medical necessity, you will need a doctor’s order that specifies all of the equipment and shows why the equipment is medically necessary.

You will need to choose a vendor who can supply the equipment or services. The vendor is the place you will purchase the AT. The vendor must be enrolled with Medical Assistance and authorized to provide the equipment you need. Your doctor or therapist may have names and addresses of vendors.

DHS has a list of vendors at http://mhcpproviderdirectory.dhs.state.mn.us.

Your vendor submits the prior authorization request, the letter of medical necessity, the prescription and other necessary paperwork to the Department of Human Services (DHS). 

DHS administers the Medical Assistance program. DHS contracts with a company to review requests for prior authorization. A nurse or other health care professional reviews the request and sends you and the vendor a notice telling you if the request is approved, denied, or if more information is needed.

In Minnesota, Medical Assistance looks at 6 things when deciding if a prior authorization request should be approved or not. The equipment and services must be:

1. medically necessary
2. meeting your medical needs
3. something you need now
4. supplied by an authorized vendor
5. the least expensive option
6. a good use of program funds

All 6 things must be met in order for the AT to be approved. The letter of medical necessity should address all 6 of these.

DHS has a Provider Manual that is used as a guideline. It can be found at DHS website at https://mn.gov/dhs. At the top of the page, click on A-Z Topics, then Manuals, and scroll down to the Minnesota Health Care Programs (MHCP) Provider Manual.

The manual is for guidelines, it is not law. If you have issues with differences that come up between the two make sure you talk to a lawyer.

DHS must give you written notice of its decision.

The notice must include:

• if the request is approved or denied

• the reason for approval or denial

• the specific regulations that were used to make the decision

• an explanation of your right to appeal, how to appeal, and that you have a right to be represented by legal counsel or some other spokesperson and

• an explanation of the circumstances under which Medical Assistance will be continued if a hearing is requested
   

If the notice states that the request is “pended” or the agency has taken “no action,” this usually means that DHS wants additional information. If the notice does not tell you what information is missing, contact your vendor. Your vendor may be able to get a list of what is needed. You may need to ask your doctor or therapist to give more medical information.

If you think DHS is unreasonably delaying your request by repeatedly asking for more information, talk to an advocate and ask for an appeal.

Sometimes a request for equipment is approved but the amount okayed is so low that a vendor can’t provide it. This “approval” is really a denial and you can appeal.

If this happens, get help from an advocate.

Some things don’t need prior authorization, like replacement batteries and tires for wheelchairs more than a year old. Your vendor should know if you need prior authorization or not.

Yes. Vendors have to make a good faith effort to get payment or authorization from third-party payers, such as Medicare or a private health plan, before requesting prior authorization from Medical Assistance.

The vendor can show a good faith effort by getting authorization or a determination of payment from the other health plan or by confirming that the item is not covered by the other health plan.

If DHS denies the service or equipment you need or doesn’t allow enough money to pay for it, you can appeal. DHS must get the appeal within 30 days of the date you got the denial notice.

You may have up to 90 days to appeal if you can show good cause for not filing an appeal within 30 days. You may have good cause if you were seriously ill or hospitalized or there was a death in your family.

To appeal you need to write a letter. The letter should be very simple. It only needs to say that you disagree with the decision, you are appealing, and you request an in-person hearing. Include a copy of the denial with your letter. Send the letter to:

MN Department of Human Services
Appeals Office
P.O. Box 64941
St. Paul, MN 55164-0941

Be sure to keep a copy of both your letter and the notice of denial. For more information about the appeal process, see our fact sheet Assistive Technology Appeals: Medical Assistance.

Yes. Some people on Medical Assistance get their benefits through a private health plan that contracts with DHS to provide Medical Assistance benefits. This is called “managed care.” People on managed care programs have the right to get the same level of benefits as people who are on fee-for-service Medical Assistance through DHS. But, the managed care plan may have a different prior authorization process than the process described in this fact sheet. Your vendor can explain the authorization process for your health plan.

If you are on a managed care program, you must file an internal appeal with the health plan before you can appeal to DHS. You have 60 days to file the internal appeal. If you don’t agree with the health plan’s decision, you can file an appeal with DHS. You must file your appeal within 120 days.

You may be able to get funding from another program.

• Schools provide AT to help students learn.

• Vocational Rehabilitation Services provides AT to help people get or keep a job.

• Home and community-based waivers provide AT to help a person be more independent in their community.

• Waiver programs pay for home modifications, like ramps, stair lifts, and grab bars.

• Waiver programs also cover vehicle modifications, such as ramps, lifts, and raised roofs.
   

Call the Minnesota Disability Law Center for advice about which program may be able to help you.

The Minnesota Disability Law Center provides free legal help to people with disabilities in Minnesota. Contact us at: 
 
Metro: (612) 334-5970
TDD: (612) 332-4668
Toll Free: 1-800-292-4150 
 
Minnesota Disability Law Center
111 North 5th St., Suite 100
Minneapolis, MN 55403 
 
www.mndlc.org