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The following article revisits the topic of public and private healthcare insurance coverage for equipment that facilitates independent eating for individuals who are unable to self-feed. It was originally published in October 2009. Because the information in the article is still extremely important to individuals who need assistive technology to facilitate independent eating, it is being republished with some additional information included. Although we will specifically address independent eating, much of the information in this article applies to any equipment that aids independence for any activities of daily living (ADLs).
One of the most basic requirements for obtaining insurance coverage for any equipment is that it is medically necessary for the individual requesting it. In this Newsletter we will address some of the ways medical necessity can be established. Private insurance companies definitions of medical necessity vary from policy to policy. For private insurance coverage it is necessary to check each policy to establish the medical necessity requirements of the specific policy. Some private insurance policies consider dining equipment as a medical necessity, while others don’t.
Even though Medicare and Medicaid both provide healthcare coverage they are governed by different regulations. Currently Medicare regulations exclude funding dining aids. However, Medicaid will fund dining equipment if medical necessity is established. Because neither Medicare or Medicaid provide a precise definition of medical necessity, it must be deduced from Medicaid regulations and associated court rulings that dictate what Medicaid should cover as being medically necessary.
Medicaid - Federal law indicates that 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 and self-care”. (The Social Security Act, US Code: Title 42, 1396, states: “rehabilitation and other services to help such families and individuals attain or retain capability for independence or self-care should be provided by Medicaid”.) Therefore, attaining independence or self-care is identified as medically necessary within the scope of the federal law. In the case of dining equipment, if an individual will attain independence at meal and snack times through the use of dining equipment, and being able to feed them self will allow them to contribute substantially to their self-care, the equipment is a medical necessity.
Additionally, the Early and Periodic Screen, Diagnosis, and Treatment (EPSDT) program (which is part of Medicaid, and provides services to children from birth through age 21) guidelines require that a state must provide to Medicaid beneficiaries under age 21, any service among those listed in the Medicaid Act, including optional services, whether or not the service is included in the state’s Medicaid Plan. Under EPSDT (42 U.S.C 1396d(a)(4)(B, 1396d(r)(5)), state Medicaid programs must cover “necessary health care, diagnostic services, treatment and other measures to correct or ameliorate defects and physical and mental illnesses and conditions”. Services must be covered if they correct, compensate for, or improve a condition, or prevent a condition from worsening even if the condition cannot be prevented or cured. This portion of the law establishes that healthcare to ameliorate defects is considered a medical necessity.
However, Medicaid administrators do not always agree with the intent of the laws stated above. As a result there have been various court rulings when states have denied claims. The necessity of durable medical equipment (DME) coverage by Medicaid has been refined through legal judgments since Medicaid was first enacted. Some examples of court rulings relevant to the medical necessity of DME are:
Texas Medicaid agreed in the Alberto N. Settlement Agreement (6:99-cv-00459-LED-HWM, 2005) that DME is medically necessary when it is required to correct or ameliorate disabilities or physical and mental illness or conditions.” To “ameliorate” a condition or illness does not mean that the condition or illness has to “improve”. DME is medically necessary when it ameliorates the effects of a condition or disease. In other words, beneficiaries should receive whatever services, including DME that are necessary to maintain his or her health in the best possible condition. To download the entire settlement agreement (Adobe "pdf" file) that is written in legal terminology, click here. Subsequently, Disability Rights Texas published a document that explains the terms of the settlement and that clearly explains how the settlement impacts the receipt of equipment and services by children ages 0 to 21 years of age who are beneficiaries of Texas Medicaid.
In Meyers v Reagan the Eighth Circuit Court (776 F.2d 241, 243, Eighth Circuit, 1985) reasoned that obtaining or retaining the capability for independence is the primary goal of Medicaid. This decision was made in the era that electronic communication devices were a new technology and many within the insurance and judicial system were unfamiliar with the technology. It should be noted that in 2014 communication devices are a common piece of equipment that is regularly provided to individuals who have difficulty with speech, as long as medical need is established. An article published in the OpenJurist provides insight into the Meyers v Regan judgment that relates to the acquisition of an augmentative communication device.
Starkweather v Wing (662 N.Y.S.2d 658,659 [N.Y.A.D. 4 Dept. 1997) supported the claim for a wheelchair for a child, to “increase the independence and functional ability of the petitioner, and to prevent the development of learned helplessness”. The following is a link to the Starkweather v Wing decision that upheld the need for more than just a basic wheelchair to allow a child to gain function and independence in an activity of daily living (i.e., mobility).
In Fred C. vs. Texas Health and Human Services Commission, et al., the court determined: “the item is medically necessary because it is needed by a recipient who has a serious impairment to: enhance well being, prevent further impairment, increase self-care, or reduce care provided by others (self-care is defined as the ability of the recipient to take care of personal needs, e.g. eating, dressing, walking, talking, or using the device unassisted. Less care or reduced care by others is defined as the ability of the recipient to use a minimum of assistance to take care of personal needs).” Click here for detailed information about this case and its ruling that addresses medical necessity as it relates to self-care.
As can be derived from the court rulings, for appropriate individuals, the medical necessity case can be made for dining equipment by establishing that the equipment allows the individual to attain or retain capability for independence or self-care. It does not require that the individual become 100% independent in performing self-care activities, only that they can substantially contribute. At mealtimes, dining equipment can facilitate an individual feeding themselves every bite of food for a meal. Their caregiver only need prepare, cut up and serve the food. After the food is served, the individual is independent for the rest of the meal. The fact that it may make life more convenient for the caregiver is irrelevant if the primary reason for the equipment is for increasing the independence of the user.
Conclusions. A wide variety of durable medical equipment (DME) is established as being a medical necessity. Many items are assigned a Healthcare Common Procedures Code System (HCPCS) code and the medical necessity of these items is usually well accepted. For other equipment, especially new equipment, the medical necessity must be established for each client and an insurance coverage determination (i.e., prior approval or predetermination) should be sought before equipment is provided.
In many cases initial requests for coverage are denied. However, that should not be considered final. The reason for the denial should be examined and if the reason is unwarranted (review the laws, etc., cited above) an appeal should be submitted. When agreement cannot be reached between Medicaid and a client, a Fair Hearing should be requested to allow an officer, rather than Medicaid, to evaluate the merits of the claim. A claim should not be abandoned without a struggle! This statement applies even more strongly in states that have not previously seen new varieties of assistive technology/medical equipment.
Medicaid has provided funding for Mealtime Partner Dining Systems in many states. Medicaid only funds DME that is a medical necessity. Therefore, a Mealtime Partners Dining System must be considered a medical necessity for individuals who cannot self-feed and are capable of utilizing the equipment to facilitate their mealtime independence. We strongly believe that Medicaid funding for the Mealtime Partner Dining System will eventually become as common place as Medicaid funding for mobility devices and communications devices.
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For most individuals, dehydration is 100% preventable. However, many people with disabilities suffer from some level of dehydration almost constantly. Mealtime Partners various drinking systems allow many individuals who are unable to use their hands to take a drink, to drink independently. For example, the Hydration Backpack with Drinking Tube Positioning provides hands free drinking throughout the day for those who sit in a wheelchair and are unable to lift or hold a cup or glass. The drinking system is quick and easy to set up, the liquid container fits on the back of a wheelchair and the drinking tube can be positioned to meet the unique positioning needs of each individual.
The Front Mounted Drinking System can position a variety of cups and drink containers very close to the users mouth for hands free drinking and allows a variety of other drinks to be made available throughout the day. For example, coffee in the morning, ice tea with lunch, a can of soda in the afternoon and a glass of milk before bed. The user drinks from their own container using a disposable straw. Because the straws and most of the containers can be disposed of or washed in a dishwasher, it is the easiest drinking system to clean.
|The Hydration Backpack with Drink-Tube Positioning||The Front Mounted Drinking System|
|Making liquid constantly available allows the user to drink whenever they want. This lowers the risk of dehydration and improves the quality of life for those who have one of these systems. For more information about all Mealtime Partners drinking systems and information about choosing the most appropriate drink system, click here. Click the following links for pricing and/or for ordering the Hydration Backpack with Drinking Tube Positioning or the Front Mounted Drinking System.|
Each year Mealtime Partners tries to remind readers of its Newsletter about the need for adequate hydration during the summer when temperatures are high. Infants, the elderly, and those with disabilities, are all particularly vulnerable to dehydration due to increases in temperature during the summer. Additionally, it should be noted that during warm weather, people spend more time outside and thus can become thirsty or dehydrated more easily. It is always better to drink too much water and make frequent visits to the bathroom, than to ignore thirst and experience any level of dehydration. The following article combines information that has previously been published but is very important to remember and thus worth revisiting.
Approximately 70% of our body weight is water that is in our cells, blood and the space between cells. Water is constantly lost from our body and must be replaced by drinking. We drink, we use the restroom, we perspire, etc. It is a constant cycle. However, the majority of people in the United States do not drink enough fluids.
Thirst is how our body indicates that the fluid in the body is out of balance (too low). Humans and animals have the innate ability to know when they should drink, however, many people regularly disregard the messages about drinking that their body sends them.
Medical treatment for rehydration is estimated to have exceeded $5 billion in the U.S. in 2004. If these costs are projected to a 2014 population base, it is an enormous medical expense that could be significantly reduced with preventative treatment.
Because medical costs are skyrocketing there is a movement towards providing preventative medical treatment to reduce overall medical cost in the United States. Many health conditions, if treated appropriately on a regular basis, can be managed without hospitalization or the need for emergency treatment, but if neglected can become life threatening. Some examples of these are diabetes, high blood pressure, and some heart conditions. However, something as simple as adequate hydration is often overlooked as a significant health issue that is essential for ongoing good health.
If dehydration is not treated it can have a very serious medical impact. The first signs of dehydration are a headache, dark yellow urine, reduced or lack of sweat, nausea and/or vomiting. Should dehydration worsen, symptoms will escalate to altered mental status, fatigue, sleepiness and depression. If left untreated dehydration can be life threatening.
Dehydration is an ongoing problem for many people, especially those with disabilities. It is responsible for health problems such as urinary tract infections, kidney problems, skin tissue deterioration, and headaches. All of these conditions require medical treatment that, in some cases, can be protracted, require hospitalization, and thus be very expensive.
In most cases, dehydration is preventable! However, it takes a vigilant caregiver to offer a drink on a regular schedule to keep someone adequately hydrated. This is a difficult task when someone is undertaking many care-giving responsibilities. Often, what happens is the person is offered a large drink, infrequently. This introduces an element of risk to the health of the person. When drinking a large quantity of liquid at a time, the person drinking may take a sizeable volume of liquid into their mouth at one time, and swallow repeatedly to clear all of the liquid from their mouth. With each swallow, within the sequence of swallows, the risk of choking or aspiration increases. Therefore, because of the added risk, this is a poor method of avoiding dehydration.
For most people, a drinking system can be made available to them even if they are unable to hold or lift a cup. Regardless of this easy solution to avoiding dehydration, Medicare, Medicaid, and private health care insurance providers consider drinking systems as “aids for daily living” and do not cover their cost. However, they do cover the cost of an emergency room visit and/or hospital stay that was brought about by dehydration. According to the Agency for Healthcare Research and Quality (AHRQ), about one in ten of the nearly 40 million hospitalizations in 2008 were potentially avoidable. Dehydration was among the conditions for which hospitalization was avoidable with the appropriate outpatient care.
Additionally, according to the National Pressure Ulcer Long-Term Care Study (NPULS), dehydration was associated with a 42% increase in risk of developing pressure ulcers in nursing home residents. The estimated annual cost for treating pressure, or decubidus, ulcers in the United States is $1.3 billion.
Mealtime Partners provides hands-free drinking systems that can be mounted on a wheelchair, bed or table, and make water available to users throughout the day and night. For more information about these drinking systems click here.
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Did You Know? Did
you know that energy drinks are not required to disclose how much
caffeine is in each drink? Energy drinks like Red Bull and Monster
are sold as beverages, but 5-Hour Energy and Monster Energy are sold
as dietary supplements. It helps to have a comparison when
discussing the amount of caffeine in these products. As examples, a
16 ounce cup of McDonald’s coffee has 145 milligrams of caffeine, a
16 ounce cup of Starbucks regular brewed coffee (not espresso-based)
average 330 milligrams of caffeine but can range from 259 to 564
milligrams. Monster Energy Drinks contains 160 to 175 milligrams of
caffeine in a drink that is 5 to 16 ounces in size. A typical 12
ounce can of soda contains about a third of that amount of caffeine.
5-Hour Energy does not disclose how much caffeine is in each shot of
its product; however, Consumer Reports determined that each 2 ounce
bottle contained 215 milligrams of caffeine. (That would be the
equivalent of 1,720 milligrams in a 16-ounce serving, which is over
5 times the amount of caffeine in a cup of Starbucks coffee!)
Because 5-Hour Energy has captured 90% of the energy drink market it has received the greatest scrutiny by the FDA, the press, and medical researchers. The New York Times reports that the company has been cited by the FDA in reference to 13 deaths of people who had drunk the product prior to death. The manufacturer of the supplement recommends that a maximum of two bottles of 5-Hour Energy should be drunk each day. But many young adults are consuming more than this amount per day. Caution is recommended when using any of these products as well as excessive consumption of coffee or other products that contain large quantities of caffeine .
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