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4.5. State Medicaid Coverage

State Medicaid Coverage

  • State Medicaid Overview
  • Required Medicaid Paperwork
  • Want to Know More? Details about Unified Medicaid Policies

A medical insurance claim form sits on a messy desk waiting to be completed.

State Medicaid Overview

Medicaid is a state run program, which is subsidized, or partially paid for, with federal funds. Individual state Medicaid programs must follow a basic foundation of federally mandated DME coverage rules, but beyond this the states have some freedom to develop their own programs, policies and coverage criteria. You can find out information about your state's Medicaid program, including enrollment data and link's to individual state's sites, at the Medicaid website.

Required Medicaid Paperwork

State-by-State Inidividual Paperwork

Each State has varying requirements for specific paperwork required and fluctuating time frames to obtain prior authorization for mobility equipment. To find information about your state's  Medicaid paperwork requirements, you can visit their website (a listing can be found at the Medicaid website) or call them directly.

Want to Know More?

Details about the Unified Medicaid Policies

Though the paperwork varries, the laws surrounding State Medicaid programs are consistent across the country.  

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Medicaid's Statutory Purpose:

Medicaid's purpose is clearly stated and backed up

  • "To furnish rehabilitation and other services to help such families and individuals attain or retain capability for independence or self care." 42 U.S.C. § 1396 (2)
  • The primary goal of Medicaid is to provide medical assistance to persons in need and to furnish them with rehabilitation and other services to help them "attain or retain capability for independence or self-care." Meyers v. Reagan, 776 F.2d 241, 243 (8th Cir. 1985)
  • The Medicaid Act requires that each state medical assistance program be administered in the "best interest of the recipients." 42 U.S.C.§1396a(a)(19).
  • Given the remedial nature of this legislation, both the Act and its implementing regulations must be liberally construed in favor of Medicaid beneficiaries seeking medically necessary health careCristy v. Ibarra, 826 P.2d. 361 (Court of Appeals, Co. 1991).

Equal Protection – Age:

  • Estaban v Cook, 77 F. Supp. 2d 1256 (S.D.Fla. 1999). Florida Medicaid's cost cap of $582 for wheelchairs effectively denied both motorized and customized mobility devices to Medicaid recipients over age 21 and thus failed to comply with HCF's policy on DME coverage as the cap was absolute and there were no procedures for requesting an exception. The exclusion was unreasonable because it was based solely on age (over 21) rather then medical necessity, and did not comport with the purpose of the Medicaid "ct which is to help individuals "attain or retain capacity for independence and self-care."
  • Fred C. v Texas, 988 F. Supp. 1032 (W.D. Tex. 1997), aff'd 167 F.3d 537 (5th Cir. 1998). Denial of coverage for ACDs for beneficiaries over the age of 21 is irrational in light of purpose of the Medicaid Act, which is to help individuals attain the capability for independence and self-sufficiency. State may not deny treatment solely based upon age as there is no rational basis for distinguishing between those over and under 21.
  • Hunter v Chiles, 944 F. Supp. 914 (S.D.Fla.1996). Adults sought ACDs which state conceded it would cover for child if unavailable from other sources. Citing Salgado, court held that "Medicaid funding cannot be denied on the basis of age." Age as sole criterion is wholly unrelated to medical necessity and is unreasonable.

Equal Access to Care:

Found in Title XIX of the Social Security Act, 42 U.S.C. § 1396a:

  • 1396a(a)(2) – requires that the state plan ensure that there is an equalization of services provided and that the lack of adequate funds from local sources will not result in lowering the amount, duration, scope or quality of care and services available under the plan.
  • 1396a(a)(30) – requires that the state medical assistance plan enlist enough resources and providers so that the care and services provided under the plan are at least equal to the care and services available to the general population in the geographic area.

Amount, Duration, and Scope Rule:

  • Each Service Must Be Sufficient in Amount, Duration and Scope to Reasonably Achieve Its Purpose. 42 C.F.R. § 440.230(b)
  • The Medicaid Agency May Not Arbitrarily Deny or Reduce the Amount, Duration, or Scope of a Required Service To an Otherwise Eligible Beneficiary Solely Because of the Diagnosis, Type of Illness, or Condition. 42 C.F.R. § 440.230 (c)

Reasonable Promptness Revision:

The Medicaid Act requires that a state plan for medical assistance:

  • "must . . . provide that all individuals wishing to make application for medical assistance under the plan shall have opportunity to do so, and that such assistance shall be furnished with reasonable promptness to all eligible individuals." 42 U.S.C. § 1396a(a)(8).
  • Federal regulations implementing this provision require that a state Medicaid agency must "furnish Medicaid promptly to recipients without delay caused by the agency's administrative procedures" and "continue to furnish Medicaid regularly to all eligible individuals until they are found to be ineligible." 42 C.F.R. § 435.930


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