2002 Conference Proceedings

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HOW TO ACCESS EQUIPMENT THROUGH THE MEDI-CAL SYSTEM

Michael Kluk, Senior Attorney
Protection & Advocacy, Inc.
100 Howe Ave., #235N
Sacramento, CA 95825
(916) 488-9950
mikek@pai-ca.org

Eligibility and Benefits

Medi-Cal is a state and federally funded program. It is California's Medicaid program. It pays for medically necessary treatment services, medicines, durable medical equipment, and medical supplies. It covers people with disabilities who meet its income and resource rules.

State law defines "medically necessary" as those services, medicines, supplies and devices necessary to protect life, to prevent a significant illness or disability, or to alleviate severe pain. Medically necessary services include rehabilitation and other services needed to attain or retain the capability for normal activity, independence or self care.

The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a federal Medicaid requirement. It is the Medicaid/Medi-Cal program for people up to age 21. States must follow EPSDT requirements in order to receive federal Medicaid money. EPSDT does not limit Medi-Cal services like the adult program. That means EPSDT recipients may, based on medical necessity, receive more benefits than adults.

Medi-Cal puts assistive technology in a number of categories. For example it may be called medical supplies, durable medical equipment, or a prosthetic device.

California regulations define durable medical equipment (DME) as equipment prescribed by a licensed practitioner to meet medical equipment needs of the patient. This is a very broad definition. It includes equipment such as canes, crutches, walkers, oxygen therapy equipment, basic and custom wheelchairs, and other devices.

Prosthetic and orthotic appliances are those appliances prescribed by a physician, dentist or podiatrist to restore function or replace body parts.

Medi-Cal will only pay for the least expensive item that meets your medical needs.

Medi-Cal does not cover household items, items not used primarily for medical care, and articles of clothing - even if they meet a legitimate medical need. If a household item will serve your medical needs, Medi-Cal will not authorize a medical device.

Medi-Cal will pay for self-help aids essential to the performance of common activities of daily living. Such aids include specially designed eating utensils, utensil holders, buttoning aids, raised toilet seats, flexible shower hoses, standing tables, and many other items. Since Medi-Cal does not list these devices as DME, they all require prior approval, regardless of cost.

Medi-Cal recipients can now get augmentative and alternative communication (AAC) devices and services. Under Medi-Cal's new policy, an AAC device is a therapy option that a speech therapist selects as part of a patient's treatment. Coverage extends to all three phases of access to AAC - (1) initial assessment, (2) device acquisition, and (3) services such as setup and training after delivery.

Your rights under Medi-Cal managed care are the same as under regular Medi-Cal, except for limits on your choice of providers.

Authorization Process

For almost all technology, your doctor or medical provider must submit a Treatment Authorization Request (TAR) form that describes why you need the requested services, medicine or device. The provider must submit complete medical justification with the TAR form, because that is the only thing the Medi-Cal analyst reviews.

Appeals

You have the right to challenge any decision Medi-Cal or a Medi-Cal managed care provider makes that you believe to be wrong. You challenge the decisions of Medi-Cal or a Medi-Cal managed care provider by asking for a "fair hearing." You do not have to have a written notice of action to request a fair hearing, but you should ask for one because it will tell you why Medi-Cal has denied your request.

To file for a fair hearing fill out and mail the reverse side of the Medi-Cal notice-of-action form. Or, you can send a letter to:

Chief Administrative Law Judge
State Hearings Division
Department of Social Services
744 P Street
Sacramento, CA 95814

If you ask for a fair hearing within 10 days of the date of Medi-Cal's written notice, current benefits will continue until an Administrative Law Judge issues a hearing decision. If you receive a notice terminating kidney dialysis, chemotherapy or radiation treatments, transportation, in-home medical care services or a stay in a skilled nursing or intermediate care facility, benefits will continue until the hearing decision if you file for a fair hearing within 10 days of the notice date or before the benefits end.


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