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Medi-Cal is a state and federally funded program for certain groups of Californians with limited income and resources. 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, self care and employment.
The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a federal Medicaid requirement. EPSDT provides additional benefits to children and youth under age 21 using a commonsense medical necessity definition rather than the adult definition. EPSDT requires the state to authorize equipment and services that are medically necessary under the EPSDT standard, so long as the equipment or services could be included in the State Plan if the State elected to do so and regardless of whether the equipment or service is, in fact, available to adults 21 and older.
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 and, because of a recent case, stair glides and lifts. Unlike Medicare, Medi-Cal will authorize equipment for use outside of the home in addition to what you need in the home.
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. In addition, 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.
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. Usually a therapist will do the assessment and a report that explains what you need and why a less expensive alternative would not meet your needs. The treating physician will use the report as the basis of his or her prescription.
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
Re: Medi-Cal Scope Hearing
Your name, address and telephone number
Your Social Security Number
If you ask for a fair hearing within 10 days of the date of Medi-Cal’s written notice or before the benefit terminates, which ever is later, current benefits will continue until an Administrative Law Judge issues a hearing decision. However, in most cases you will be challenging a denial of a device or services you need in order to use the device effectively so there will be no continuation of benefits. The time for appealing a denial is 90 days from the date on the notice.
– December 2002, Protection & Advocacy, Inc.
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