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Children with disabilities or special health care needs might need medical equipment or supplies. If you find that your child needs this help, you might be wondering what the choices are and how to find the money to pay for these things. Insurance – both Medicaid and other health insurance – often covers some or all of the costs for these medically necessary items.
To help you navigate the insurance system, including Medicaid, we’ve put together a few key tips.
Durable Medical Equipment (often shortened to DME) is medical equipment usually meant to be used for a longer period of time, not just once or twice. Most DME is expected to last for 3 to 5 years. It includes:
- Manual and power wheelchairs.
- Hospital beds.
- Oxygen equipment.
- Hearing aids.
- An augmentative communication device (something that helps a child who is unable to speak or cannot speak clearly).
Many children who use DME also need medical supplies that are used for a very short time (maybe only once) and then thrown out. Many of these supplies are needed on a daily or weekly basis. Examples of medical supplies might include:
- Specialized formulas or food.
- Feeding tubes or syringes.
- Diapers and diaper wipes (for a child who is 5 years or older).
- Ask your child’s doctor for a prescription that clearly describes what equipment or supplies your child needs. A therapist or specialist can also help figure this out, including measurements for a wheelchair or which type of communications device would be helpful. Once you or the therapist gives the doctor the therapist’s report, the doctor would use it to write the prescription.
- Businesses that sell medical supplies and equipment are called DME providers. They will also handle your insurance claims. If you have an insurance or Medicaid case manager, ask for their help to find an in-network DME provider. Connecting with other parents or getting recommendations from your doctor or therapist are also great ways to find a DME provider.
- Talk with the DME provider about your child’s needs. They will need to know about your insurance plan, how the equipment will be used, and any specific requirements for your child. They can then help you find the right items for your child. And they will tell you what needs to be approved by the insurance company before you order it. (This is called prior authorization.)
- The DME provider will then get the prior authorization and file any paperwork with the insurance company. Once they have received approval, the supplies will be ordered and delivered to your home or therapist’s office.
Your child’s DME provider is an important part of making sure your child has the right piece of equipment and the right supplies. They will talk with your insurance company on your child’s behalf, and hopefully be your child’s advocate in getting the right equipment.
Here are a few things you should expect a DME provider to do:
- Check in with you at least once a month.
- Clearly explain the differences in types of equipment and supplies, including special features or problems of an item you’re considering.
- Deliver and set up equipment in your home – and teach you how to use and care for it.
- Check on and repair any rented equipment.
- Ask you to sign a form showing that you received the equipment and were trained on how to use it.
Before you sign off on any delivery of equipment or supplies, make sure that:
- It fits your child.
- It fits in your home, can make it into your van or car, and can otherwise be used as you expect it to.
- You have received all the items listed.
- You have been trained on how to use everything.
- You know how it works and how to take care of it.
If you aren’t happy with your DME provider, you can switch at any time. You are always free to use any DME provider within your health insurance network. Please know that it might take extra time to make a switch. Always check to be sure the new provider will have all of the equipment your child needs.
- Medicaid plans and other health insurance cover some or most of the cost of DME and supplies if they have been prescribed by a doctor and deemed medically necessary.
- Many insurance plans have co-payments or other limits on how many supplies they will pay for or how often they can replace DME.
- If your child is 20 years old or younger and on Medicaid, they have the right to receive all the supplies and equipment prescribed by a doctor and considered medically necessary. Medicaid might waive its limits on supplies and equipment replacement for children and teens.
- Ask your child’s therapist to be with you for fittings or delivery of the new piece of equipment. You might be able to have this delivery done at the therapist’s office if you don’t have therapy at home.
- If your health insurance doesn’t want to pay for the exact equipment or supplies your child needs, don’t give up. Work with your doctor and DME provider to clearly explain to the insurance company why your child needs that specific prescription instead of another one.
- If the equipment arrives and it doesn’t fit your child correctly, don’t sign off on delivery of the equipment. If supplies arrive and they are not correct, don’t sign off on delivery.
- There is no need to stockpile medical supplies beyond what your child needs. If you ask the DME provider to reduce the amounts, your child won’t lose their access to supplies. You can always increase the amounts later if needed.
- Choose a DME supplier that is on your family’s side as an advocate for your child. They are an essential part of your child’s care team.
Assistive Technology
There are many technology products (called assistive technology) designed to help children with disabilities or other special health care needs that would not be considered DME.
Learn more about assistive technologies.
