Process to get diapers covered my Medicare/Medicaid in US

[BlakeJordan]

Hi all,

 

I fairly recently lost what continence I had due to systemic nerve damage that is still spreading slowly and steadily.

 

I also have cerebral palsy, postural orthostatic tachycardia syndrome/autonomic dysfunction, amongst many other conditions, which makes the need for high absorbent and highly re-adjustable a must. I currently have 2 diapers and 1 booster that works well for me. The megamax and xp 5000., along with the the Northshore boosters in various sizes.

 

I know this falls under durable medical equipment. As far as I can tell neither Northshore nor medicalxp are contracted with Medicare a,b,d or Medicaid.

 

I have an already established history of incontinence with several referrals to urologists including typical testing and failed medication trials. This is a couple years old and since then my incontinence has only gotten worse and thus my increased need for protection has only been exasperated. There are however many recent and numerous documented accounts of this within medical and hospital records over the past several years.

 

 

So my question is, how does one go about getting a preferred incontinence product covered by Medicare/Medicaid in the United States?

 

Who writes the prescription and who can fill the prescription? What happens when the e product written for doesn’t have a contracted supplier and no alternatives are feast?

 

To elaborate....

 

What happens in the case that the preferred/functional products are sold from vendors/manufactures that are not contracted with Medicare or Medicaid. Due to my physiology combined with my physical limitations there are specific products that provide the necessary reliability required, along with the required flexibility and durability to wear during the day and night.

 

I believe all of this falls under durable medical equipment, but I’m not sure how such a situation is handled when the supplier is not directly contracted nor resells see vendors that are contracted with Medicare/Medicaid. Honestly I have avoided confronting this shit head on in hopes that things will go back to normal. As of now I really don’t have a choice in the matter of whether I can wear or not wear and experience tells me that anything less then the top-tier premium products will lead to disastrous flooding concerns me, and is reason enough that I have avoided confronting the issue head on. Alas with multiple other medical conditions deteriorating it’s become necessary to pursue the logistics of getting at least some of my incontinence products covered by Medicare and or Medicaid. I know that parents here products are all but useless for me both inform function and design.

 

In my mind I feel like this should be covered by Medicare part D and require a prior authorization, but I’m not sure how to go about doing this or which specialist I should have write the script and provide the sporting documentation considering that I not only need protection but what most insurance providers would consider excessive premium protection simply due to the fact of dexterity issues due to cerebral palsy as well as autonomic dysfunction which has a strong side effect of my body not retaining fluids thus leading to an increased need for I absorption protection.

 

 

I suppose my confusion is most prevalent and how to deal with manufacturers/providers that are not contracted with insurance. Most Medicare/Medicaid coverage is dependent on contracts, even if they happen to be out of network and require a pre-certification/pre-authorization. If they are not participating in any insurance coverage whatsoever, how does one go about obtaining such products through insurance reimbursement?

 

Thanks!

[~Brian~]

@BlakeJordan

On 9/24/2020 at 8:05 PM, BlakeJordan said:

Hi all,

 

I fairly recently lost what continence I had due to systemic nerve damage that is still spreading slowly and steadily.

 

I also have cerebral palsy, postural orthostatic tachycardia syndrome/autonomic dysfunction, amongst many other conditions, which makes the need for high absorbent and highly re-adjustable a must. I currently have 2 diapers and 1 booster that works well for me. The megamax and xp 5000., along with the the Northshore boosters in various sizes.

 

I know this falls under durable medical equipment. As far as I can tell neither Northshore nor medicalxp are contracted with Medicare a,b,d or Medicaid.

 

I have an already established history of incontinence with several referrals to urologists including typical testing and failed medication trials. This is a couple years old and since then my incontinence has only gotten worse and thus my increased need for protection has only been exasperated. There are however many recent and numerous documented accounts of this within medical and hospital records over the past several years.

 

 

So my question is, how does one go about getting a preferred incontinence product covered by Medicare/Medicaid in the United States?

 

Who writes the prescription and who can fill the prescription? What happens when the e product written for doesn’t have a contracted supplier and no alternatives are feast?

Let me see if I can be of assistance here:  The Doctor is usually the one who has to write the script for the incontinence supplies, and he usually does that based on what you tell him or her that you are dealing with, your Cerebral Palsy, your diagnosis's, your changes in your diagnosis's and what the doctor is aware of in your medical history.  When you tell your doctor what is going on, he or she can make a finding of medical necessity, and he may do that based solely on what he knows of your conditions, or can do that based on your medical history.  He would then write the script that you request, and provide the medical documentation to prove medical necessity, which is submitted   All of my diagnosis's are listed, so all he did was add the Incontinence, Diverticulitis and IBS, along with my CP, and my mobility issues being  on the record, insures that I will NOT have any problems with that part again, and I won't have someone try to challenge the need for diapers

What the doctor did for me, was to get the information about what happened to me when they had me use the Cloth backed diapers, and then, based on that, wrote the prescription for "Plastic Backed Briefs" and SPECIFIED the brand name of the diapers and or boosters or whatever you need.   My understanding of how scripts are dealt with is that if a DOCTOR WRITES the script to be specific (ie:  "Northshore Megamax Plastic Backed briefs, and Northshore Booster Pads Large") They CANNOT change what the doctor writes, and CANNOT change what is provided to you UNLESS the words "substitution allowed" are written in it, or he specifically says "Brand Necessary."  It then would go to the Medicaid Clinical Unit (In Vermont) for Approval, and the supplier would be "authorized" to provide products.  As long as the doctor can support the evidence for what you are asking, its just a matter of getting the medicaid agency in your state to cover what you are asking for, and the doctors usually can word it so you can get what you need.

Based on information provided here, I would think that you would have NO PROBLEM being able to prove medical necessity for the diapers and or and other products that you need to get to make your situation better for yourself to deal with.  I am NOT a medical professional, but am a consumer, who has gone through the system, and has asked for the products I need, was given the excuse that they could not provide me anything else, besides the cloth diapers, which I learned was NOT true, because they can go to the second level, and ask for the plastic backed, apparently AFTER I tried the Cloth backed diapers, and they failed me.  I am under the impression that I will NOT be denied for the plastic backed ones again, so I don't have to worry about that again.  The problem is that MANY online sites DON'T DEAL with State Medicaid Agencies, because the reimbursement rates are abysmal, and (for example: Prevail air's are reimbursed at $13 per script, and I was paying $3 per script of 300, and $3 for the prevail Underpads).  Good Products usually run (Megamaxs in this case are $34/bag) so they will undercut the going rate, and this is why they are able to sell you cheap products that do NOT work well:  something that costs $34/bag is reimbursing at a ridiculous rate, maybe like $15-20/bag, so the supplier can't even break even, so that is why stuff is low quality and cheap.  I would have the doctor PUSH for what you and him/her agree to, and try to see if there are suppliers that are willing to provide you the diapers and supplies you need - This may require Medicaid and a supplier or a Doctor to help you find a supplier for the products you need, and you may have to prove that the cloth ones don't work for you, which I think is ridiculous, but you may have to do that.

For your Reference, here is how I had to go through the system for my Megamax Diapers:

I have learned a lot from going through the process.  Most of the problem is that many online suppliers DO NOT TAKE medicaid or medicare, because of the fact that the reimbursement rates are really low, or ridiculously UNDERreimbursed.  I live in Vermont, and I can get diapers and other incon supplies covered, but as is the current situation, they give you the CHEAPEST (cloth backed) diapers available, and they get away with that because they say that using the cloth backed diapers do not cause skin breakdowns, infections or other issues.  The REALITY is, that ANYONE who is in a nursing facility or hospital they say is changed every 2 hours, so plastic backed diapers are not ideal, but if you really look at this, this is an EXCUSE so that the supplier can proffer to you the CHEAPEST products available, and that won't work with some individuals: Me INCLUDED.

The procedure that you have to follow is based on rules for your State Medicaid or Medicare system.  Medicare does NOT cover Incon supplies - Medicaid does.  What I had to do was to go to my doctor in August of 2019, and inquire about how to get diapers.  I was having problems with Incontinence, Diverticulitis and IBS, and was having accidents, so I asked the doctor to see if he would be willing to write me a script for diapers, because I was having issues, and I was NOT willing to wait anymore: I wanted to be able to live my life to the fullest extent possible, and I was NOT willing to wait for the system to decide that I couldn't get what I needed.

So, the Doctor asked me some questions, and accepted that because of MY CP, he was willing to write that script.  I got 300 cloth backed prevail airs. and after 2 months, I basically was just peeing right through the diapers, and they were causing skin breakdowns, and chafing, and they were NOT working for me.  I wanted Plastic Backed diapers, but I was getting some sort of run around saying that there was NO WAY I was gonna be able to get them at all, and like I said, they were giving me excuses. 

I then talked to Vermont Medicaid:  I told them that these cloth backed (and ANY AND ALL Cloth backed products) are NOT working for me, and I was also giving them hell because they go cheap, and I tried these diapers for 2 months, and told them that I might as well just pee all over the floor, because I was simply flooding them - I was then given a lecture of the reasons that they use the cheap stuff, and told to "double and triple them up" but this is not ideal.

So, I was then told that they CAN get me the Plastic Backed briefs, and all I would have to do is to ask for a Prior Authorization:  The Doctor writes the script with a diagnosis of "Incontinence Due to Immobility" / "IBS" and "Diverticulitis." I believe that if you have your doctor write diagnosis that indicate incontinence and other issues related to it, and you also have the doctor write the script SPECIFYING the fact that you want "Plastic backed Briefs", you should be all set. 

The Office of Vermont Health Access Clinical Unit Nurse told me that she wanted me to "Do my Homework", and give her a list of 5 brands of plastic backed briefs, and I was told that whatever I gave her in the 5, that I was to tell her my top 3.  The Megamax was Number one: They told me that it would be pretty easy to approve, because the cloth backed were not working, causing skin problems, and was not keeping me dry.  The Nurse told me that whatever we (Doctor and I) agreed to, she would approve the request as fast as it hit her desk.  It is my understanding, that because I have my diagnosis' listed, that they will NOT change the type of diaper, or the BRAND of diaper, and I was told that I should NOT have to worry that they would not cover it:  I am getting older, and I want the freedom to live my LIFE, and NOT worry about incontinence, and my mobility is one reason why I want to have the diapers, and because of the other issues, the IBS and the Diverticulitis.

The Prior Authorization I received permits me 540 Plastic Backed Briefs over the life of the Prior Authorization.  This equates to 90 Plastic Backed Diapers per month.  Each one of these lasts 6 months, and is renewed  every 6 months.  My Doctor's Office's Community Health Team (CHT) is contacted, and my doctor's Nurse files the paperwork and resubmits it.  Last Time, and because of COVID-19, there was not only a LAPSE in the ability to reorder supplies, but a FUNDING screw up, which needed to be addressed before I could reorder them.  I had a problem with the situation like this, because the Authorization says "BILL MEDICAID DIRECTLY, Special Rate Approved" and apparently, there  was a problem that had to be worked out, which eventually was.  Once they did that, they told me I was all set, and from now forward, I have been asked to call in the Reauthorizations at LEAST 2 months ahead or so, because then, I won't have a lapse while the reauthorization is being redone each time.

Next time, however, I will ask for, and have asked for Northshore Boosters, because that will keep me dry, and because I take Dyazide, I would need additional protections.  They have agreed to add this requested product - so I should be OK now

That's Basically how it works on my end!  If I can be of any further assistance to you, or if you wish to send me a PM, please feel free to do so

God Bless!

Brian

Edited September 26, 2020 by ~Brian~
added additional information