View Full Version : Supplies medicaid doesn't pay for?
12-16-2005, 06:32 PM
We'll be capping out of our insurance very soon. Now I've got to thinking about how "spoiled" I am with private insurance...we can get almost anything we need from our DME.
So I can stock up now, what are the items that Medicaid does NOT cover?
12-16-2005, 07:03 PM
It differs from state to state. We could appeal the hydrasorb and maybe even get them to cover them, but Joseph should only need them for about a month....it will take much longer than that to appeal it.
Another strange thing our state does not cover...spacers for kids that need the breathing treatments. That is $50.00 here and then you have to have one at school and home....sometimes one for the car. WHY? Who knows.
Hugs to you,
12-16-2005, 09:15 PM
Medicaid covers everything I need for my boys, plus some stuff our private insurance does not cover (like diapers). It's like a gold card, at least in MA. Thank goodness for Medicaid coverage! We pay nothing out of pocket.
12-16-2005, 09:42 PM
Roberta is right. Â*It varies greatly. Â*I know some states are restricting DME supplies, therapy, and covered medication. Â*Colorado seems to be one of the better states as they have yet to deny any of their services/supplies (well they did once, but we appealed and won easily). Â*Anyone on from NJ that knows specifically??
With Comcast we have PPO plans (with caps) and HMO plans (no caps). Once we cap on the PPO, we can switch to the HMO for coverage. Is this an option for you? Our HMO options aren't as good as the PPO's, but it is something...
12-16-2005, 10:20 PM
It seems to vary state to state and patient to patient. Medicaid wouldn't pay for Nate's pmv for two years. Now they will (maybe an age thing??). Also there were several things we were fighting and other patients in Kansas were getting them. I'd check with your DME to find out exactly what medicaid pays and how many/month.
12-16-2005, 11:30 PM
Oh I didn't even think about the PMVs.
Hopefully someone from NJ will see this. (I know Carrie and Susan only use private insurance right now).
12-17-2005, 12:13 AM
Hannah is on NJ Medicaid (straight medicaid NOT a medicaid HMO) Some helpful hints, I hope:
1. Try to stay away from the HMO's in my opinion, if they will let you, because what happens is the coordination of care is a nightmare. Trying to pick which HMO all of your boys' specialists are in,(impossible!!! so you may have to switch MD's) seeing if your nursing companies take that HMO, then worrying about your DME company and which one they take. And just when you think you may have found "the one", some doctor drops out(which they can do at any time).
2. As far as what they don't cover-Nothing that I can think of, honestly. I am not sure if they will give you as much or as many of each item as private insurance. We have been very fortunate, and I don't think they have ever denied anything for Hannah. We even have backups of everything. Some examples: PMV- yes, one every three months, so like four each year. Trachs- 2 or 3 per month. HME- 60 per month. Suction Cath with sleeve, 50/month. Resp H2O & Saline for suctioning( 24 bottles of each). Trach ties- Dales 30/month. Gloves 3 boxes. Suction canisters and tubings 2 per month. 2X2's split, 4X4's split 2 boxes of each monthly. Saline bullets 100/month. Sterile Qtips 100/month. Neb kits, 2/month. Trach masks 4/month. Corrugated tubing 1 box every 3 months. O2 liquid tank, filled twice per month. G tube and extension sets 1 every three months or sooner if they fall out. Formula 6 cases per month. Feeding bags for pump 50/month. Diapers 180/ month. All syringes as needed. Nursing 16 hours/day X 7 days/week (the nursing companies cannot even cover what we are entitled to).Pharmacy- I have never paid one penny for any medication, including some OTC, like tylenol, motrin (just get a RX from your MD)
They have even provided a Hard Pediatric Bed which acts like a crib as she is growing. The Dr. at Nj medicaid is awesome. His name is Dr. Degennaro. He is so reasonable and very nice to talk to. If you need something and cannot get it, talk to him directly. Also always have your RX's from your MD for anything new or anything you need increased. He came out to my house to assess the bed situation and the need for it. He certainly agreed that it was very necessary and got it pushed through.
Also keep after your DME and nursing companies, they know that they need prior authorizations from Medicaid, every three months. They should put those through so they don't hold you up on supplies etc. Any other ?'s please do not hesitate to ask....been there, done that. Lots of luck
12-17-2005, 06:11 AM
I don't have anything to add from a NJ perspective, but did want to reiterate the point about prior authorizations. If these aren't done in a timely manner, it's a nightmare. I'm not sure what all would fall under this in NJ, but in OH Hannah's reflux med needs a prior auth. Unfortunately, it's another thing to keep track of, but ensuring they are in place takes a few minutes, yes, but hours of headaches if the pre-auth needs to be phoned/faxed in. It ALWAYS gets lost.
If you get a case mgr, s/he might be able to provide some insight.
12-17-2005, 01:26 PM
Thanks everyone! Thanks Sharon! You gave me everything I need to know http://www.tracheostomy.com/iB_html/non-cgi/emoticons/biggrin.gif Good to know about the Tylenol and Motrin!
We just started getting Medicaid diapers. They told us the max is 240/month. If you're not getting this then ask for it! Oh good, I will start getting back-up PMVs, gloves and H20. We use a lot of gloves here. 15 different care givers can't share 3 boxes a month!
My DH is going to throw me out if I order one more box of sx caths though! Our basement is filled to the top w/'em.
And I will make sure we're pre-authorized.
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