The ACA has been involved in debates and advocacy work around assistive devices primarily through our coalition work.  Recently, we signed onto a letter aimed at the Centers for Medicare & Medicaid Services, the division of the U.S. Department of Health & Human Services that oversees Medicare and Medicaid regulations.  This letter is a continuation on the work to ensure access to funding for assistive devices.

Excerpts from the coalition letter....

There are concerns regarding how the state Medicaid program’s are being guided in terms of  coverage for various items of durable medical equipment.

One of the items in this new guidance states:

    A State could, for example, determine that it is only medically necessary to provide equipment that assists individuals with basic activities of daily living (bathing, toileting, etc), finding in a specific instance that a manual wheelchair is sufficient for an individual rather than an electric wheelchair.

Defining coverage as “only to meet basic activities of daily living “ is excessively restrictive.  This is not a reasonable standard.

The statutory obligation for Medicaid regulations says that “each service must be sufficient in amount, duration and scope to reasonably achieve its purpose.” 

Medical need standards also have been applicable equally to all covered services, not individual benefits categories or individual types of treatment.  This guidance by contrast, is not based on “accepted medical standards” for any medical or health care discipline.  It states a medical need standard that different from that applied by every other system of health benefits.

Medicaid services must be provided in sufficient scope to enable recipients to attain

or retain capability for independence and self care.

The clearly stated and recognized congressional purpose or goal of the services provided under the Medicaid Act is to enable recipients to attain or retain their capability for independence and self-care.

The new CMS guidance does not further those goals.  “Independence and self care” imposes a dual obligation: Medicaid programs may not provide services to support only one and not both functional outcomes. 

A coverage or medical need standard for medical equipment that is limited to “assist[] individuals with basic activities of daily living” will not be consistent with one of the fundamental purposes and goals of the Medicaid Act.

The scope of Medicaid benefits must not preclude recipient access to Medicaid

Work Incentives.

Just as the Medicaid Act will support school attendance by children, it will support employment by recipients old enough and able to work.  It will do so through provisions that enable Medicaid recipients to continue to receive benefits while employed.  Section 1619(b) of the Social Security Act authorizes extended Medicaid coverage for recipients who work. 

Although these provisions are not themselves a source of medical equipment coverage or funding, they state a goal of the Medicaid Act that its substantive medical services benefits categories must facilitate.  For a Medicaid recipient with e.g., a severe mobility impairment, or who has a severe communication impairment, medical equipment in the form of a mobility aid or speech generating device must be functionally sufficient to enable the recipient to benefit from the Medicaid Act’s work incentives.  That one Medicaid benefit not preclude or interfere with access to another benefit is the essence of a “reasonable standard.” In the context of a Medicaid recipient who seeks to utilize Medicaid work incentives provisions, “basic activities of daily living” will be but a small part of daily needs.  For this reason, the scope of substantive Medicaid services that cover and provide medical equipment must be more extensive. 

Conclusion

Access to appropriate medical treatment, and in particular, medical equipment, will be “vital” to treat the severe disabilities experienced by Medicaid recipients throughout the country.  Appropriate medical equipment will enable individuals with even the most severe disabilities to overcome the functional limitations that might otherwise preclude living successfully in community settings, attending school, or working.  Appropriate medical equipment also will protect against development of secondary impairments. 

Notwithstanding the importance of access to appropriate medical equipment items by Medicaid recipients, the Medicaid guidance referenced here is not a reasonable standard and is instead an erroneous interpretation of the Medicaid Act and regulations.  Medicaid programs may not adopt and may not apply a standard of coverage or medical need that limits medical equipment to items that assist with basic activities of daily living.  The Medicaid Act as a whole, all of the Medicaid benefits categories that cover and provide medical equipment, the EPSDT benefit, and Medicaid work incentives provisions all require that the scope of medical equipment provided enable recipients to engage in all typical daily activities, in all environments. 

In sum, whether based on the Medicaid Act, its regulations or on practical considerations, the CMS guidance referenced here should be withdrawn because it is based on an erroneous interpretation of the Medicaid Act.