Re: How to get Medicaid to pay for a stroller

[Guest guest]

Tell us which state you are in so we can help formulate a letter.

Also: Knights of Columbus, Civitan, Rotary, Pilots, and a few other civic

organization , as well as Easter Seals and UCP will sometimes pay for one

when Medicaid is unresponsive.

I am now learning (only took me 20 years to learn) that a call to an up for

relection state or federal representative may help you get some motion!

Thirdly: Medicaid frequently REFUSES ddurable medical equipment - just

because. So filing an appeal is almost standard.

MAke sure that the doctor refers to the restraints as being a SAFETY issue

because he could flop out of the stroller - which is why he needs a stroller

to begin with.

On Fri, Jul 18, 2008 at 11:29 PM, Ann Finegan

wrote:

> I am mostly a lurker too but have found lots of useful information from

> you all. Thanks for being there. My son Jimmy who is 12 and weighs about 90

> lbs. does the stop, drop, and flop thing whenever we go shopping. I got the

> Maclaren stroller idea from you all and have been trying to get Medicaid to

> pay for it but they have declined it twice now. The first time was because

> they said it didn't have enough back support so we switched models and this

> time they are saying that since he is ambulatory he shouldn't need a

> stroller. They also said that they didn't like the fact that it restrains

> him from getting out of it (the harness part). We have a prescription or a

> letter form his pediatrician but I guess that isn't making much of an

> impact. Do any of you have any suggestions as to how to go about getting

> Medicaid and/or insurance to pay? Thanks. My back can't take much more of

> picking him up.

>

> Ann

> Mom to , 14 and Jimmy, 12 (DS & Au)

>

>

[Guest guest]

I am in Texas.  Thanks for the suggestions and offering to help compose a

letter.

> I am mostly a lurker too but have found lots of useful information from

> you all. Thanks for being there. My son Jimmy who is 12 and weighs about 90

> lbs. does the stop, drop, and flop thing whenever we go shopping. I got the

> Maclaren stroller idea from you all and have been trying to get Medicaid to

> pay for it but they have declined it twice now. The first time was because

> they said it didn't have enough back support so we switched models and this

> time they are saying that since he is ambulatory he shouldn't need a

> stroller. They also said that they didn't like the fact that it restrains

> him from getting out of it (the harness part). We have a prescription or a

> letter form his pediatrician but I guess that isn't making much of an

> impact. Do any of you have any suggestions as to how to go about getting

> Medicaid and/or insurance to pay? Thanks. My back can't take much more of

> picking him up.

>

> Ann

> Mom to , 14 and Jimmy, 12 (DS & Au)

>

>

[Guest guest]

In a message dated 7/18/2008 11:34:30 P.M. Eastern Daylight Time,

pastmidvale@... writes:

Thirdly: Medicaid frequently REFUSES ddurable medical equipment - just

because. So filing an appeal is almost standard.

Absolutely standard. I will be hitting them up for one too (soon as I

get a minute....;-) as Maddie's outgrown her Maclaren. Took me a year to

get Maddie's nexium approved and almost a year to get her teeth work paid for

($22,000.00) by insurance and MA. They don't even look at you til you

start jumping through hoops.

Donna

**************Get fantasy football with free live scoring. Sign up for

FanHouse Fantasy Football today.

(http://www.fanhouse.com/fantasyaffair?ncid=aolspr00050000000020)

[Guest guest]

Hi Ann!

Have you checked with DADS? As I recall there are contact

numbers/info on the website to ask for help.

http://www.dads.state.tx.us/

Something else for you to know & USE regarding durable equiptment in

Texas:

Alberto N. v. Hawkins

HHSC has settled a lawsuit that affects Texas Health Steps,

Comprehensive Care Program-eligible children under 21 years of age.

The terms of the settlement apply to Medicaid-funded nursing

services, personal care services and durable medical.

The following link should take you directly to the court documents:

http://www.hhsc.state.tx.us/medicaid/SettlementAgreement_072105.pdf

" Case 6:99-cv-00459-LED-HWM Document 176 Filed 05/19/05 (31pages)

You will want to read and QUOTE page 15, 8.1 " Changes to policies,

guidelines and manuals "

This section specifically states the newer, more flexible & federally

compliant guidelines for DME's that were to be changed in their

manual for those under age 21!!

And if you have a prescription from a doctor stating that this is a

medical necessity, then the medicaid people are out of compliance!!

Key words to remember also from the document: " ..when it is required

to CORRECT or AMELIORATE disabilities or physical, mental illness or

CONDITIONS.

These key words are basically what " proves " the medical necessity

requirements of EPSDT/Title XIX of the Social Security Act (Federal

laws)

If the above link does not take you to the document there should be a

direct link on the DADS website near the bottom of the home page.

I hope this helps you somewhat. If you write, keep a copy. If you

speak to someone, log the date, name, time & what was said. And let

them (politely) know that you are doing so. I do not think you will

have to do alot of work once they are reminded of the lawsuit's

wording:)

Good luck!

Peace.

Kris

>

> I am mostly a lurker too but have found lots of useful information

from you all.  Thanks for being there. My son Jimmy who is 12 and

weighs about 90 lbs. does the stop, drop, and flop thing whenever we

go shopping.  I got the Maclaren stroller idea from you all and have

been trying to get Medicaid to pay for it but they have declined it

twice now.  The first time was because they said it didn't have

enough back support so we switched models and this time they are

saying that since he is ambulatory he shouldn't need a stroller. 

They also said that they didn't like the fact that it restrains him

from getting out of it (the harness part).  We have a prescription or

a letter form his pediatrician but I guess that isn't making much of

an impact.  Do any of you have any suggestions as to how to go about

getting Medicaid and/or insurance to pay?  Thanks.  My back can't

take much more of picking him up.

>  

> Ann

> Mom to , 14 and Jimmy, 12 (DS & Au)

>

>

[Guest guest]

ann: It took us almost 8 months to finally get Tori's stroller-she will be

9 in Feb.). Our docs finally suggested getting the P/T to write a letter of

necessity because they see our kids more than they do. It is a fight because of

their dx and they are ambulatory, but it is a major safety issue...they can also

use the fact that our kids have hypotonia. Hope this helps...

Liz

How to get Medicaid to pay for a stroller

I am mostly a lurker too but have found lots of useful information from you

all. Thanks for being there. My son Jimmy who is 12 and weighs about 90 lbs.

does the stop, drop, and flop thing whenever we go shopping. I got the Maclaren

stroller idea from you all and have been trying to get Medicaid to pay for it

but they have declined it twice now. The first time was because they said it

didn't have enough back support so we switched models and this time they are

saying that since he is ambulatory he shouldn't need a stroller. They also said

that they didn't like the fact that it restrains him from getting out of it (the

harness part). We have a prescription or a letter form his pediatrician but I

guess that isn't making much of an impact. Do any of you have any suggestions

as to how to go about getting Medicaid and/or insurance to pay? Thanks. My

back can't take much more of picking him up.

Ann

Mom to , 14 and Jimmy, 12 (DS & Au)

[Guest guest]

I gave up trying to get Kayla a Maclaren Major through Medicaid. The

medical supply company here doesn't even carry adaptive strollers any

more because NY Medicaid won't pay for them any more (they used to).

I ended up getting grant through our local ARC through our Service

Coordinator and got one last Christmas! It was the BEST present. We've

used it a lot since then! I highly recommend trying to get one through

whatever means necessary.

Ecki

Mom to Kayla (DS/ASD, 4/5/04) and Laurie (PDD-NOS, 7/12/01)

http://oppositekids.blogspot.com/

[Guest guest]

Request a Fair Hearing to appeal the denial with medicaid. My son

walks but I would not be able to go anywhere without a wheelchair. He

will walks so far and then stop,drop & flop. Walking is a state of

mind or in other words can be a mental disability. Make sure the

Dr.'s letter supports the request by explaining that he can walk but

if he chooses not to walk he will not walk. Definately get a letter

from a PT to back up this request.This also shows someone has been

working on helping the child to walk but the child will not always

comply. I hope this helps. Cyndi B

>

> Tell us which state you are in so we can help formulate a letter.

>

> Also: Knights of Columbus, Civitan, Rotary, Pilots, and a few

other civic

> organization , as well as Easter Seals and UCP will sometimes pay

for one

> when Medicaid is unresponsive.

>

> I am now learning (only took me 20 years to learn) that a call to

an up for

> relection state or federal representative may help you get some

motion!

>

> Thirdly: Medicaid frequently REFUSES ddurable medical equipment -

just

> because. So filing an appeal is almost standard.

>

> MAke sure that the doctor refers to the restraints as being a

SAFETY issue

> because he could flop out of the stroller - which is why he needs a

stroller

> to begin with.

>

> On Fri, Jul 18, 2008 at 11:29 PM, Ann Finegan

> wrote:

>

> > I am mostly a lurker too but have found lots of useful

information from

> > you all. Thanks for being there. My son Jimmy who is 12 and

weighs about 90

> > lbs. does the stop, drop, and flop thing whenever we go

shopping. I got the

> > Maclaren stroller idea from you all and have been trying to get

Medicaid to

> > pay for it but they have declined it twice now. The first time

was because

> > they said it didn't have enough back support so we switched

models and this

> > time they are saying that since he is ambulatory he shouldn't

need a

> > stroller. They also said that they didn't like the fact that it

restrains

> > him from getting out of it (the harness part). We have a

prescription or a

> > letter form his pediatrician but I guess that isn't making much

of an

> > impact. Do any of you have any suggestions as to how to go about

getting

> > Medicaid and/or insurance to pay? Thanks. My back can't take

much more of

> > picking him up.

> >

> > Ann

> > Mom to , 14 and Jimmy, 12 (DS & Au)

> >

> >

[Guest guest]

>

> I am in Texas.� Thanks for the suggestions and offering to help

compose a letter.

Ann,

I have had several friends who were able to get a stroller through

Medicaid and their individuals with autism who do not have physical

disabilities qualified for one here in Texas.

Their Pediatricians wrote letters of medical necessity for one for

sensory and safety concerns.

Let's see if anything helps, info from Texas Medicaid.

Going on no email soon as I am about to head out to Indiana this noon

or I would have you contact some of the people who I know and maybe

even from the city you live in. Is your child receiving any other

Medicaid Waiver funds? Like maybe the In-Home Family?

Check out the Txp2p site and they too would not mind assisting.

http://www.dads.state.tx.us/providers/ihfsmr/service_code_definitions.html

013

Mobility Equipment

Requires a recommendation from a physician or physical or occupational

therapist following an evaluation. Used to improve or increase the

person's mobility. May include a wheelchair, stander, walker,

specialized stroller, and transfer boards.

Service Types & Service Codes

Requirements/Definitions

Alternate Resources

Private insurance, Medicaid, Medicare, HCS, CLASS , CSHCN, Deaf-Blind

Waiver, DARS, ECI, CHIP, Texas Health Steps

http://www.tmhp.com/File%20Library/File%20Library/Provider%20Manuals/CSHCN/2008%\

20CSHCN%20Provider%20Manual%20Individual%20Chapters/14_DME.pdf

14.4 Adaptive Strollers

Adaptive strollers may be noncustom DME, or they may be custom DME if

they are in any way customized to the individual client’s needs.

Adaptive strollers are mobility devices that resemble regular

strollers purchased for healthy infants and toddlers. Adaptive

strollers have a limited range of accessories that allow some

positioning for clients with minor postural problems. Adaptive

strollers may be authorized only when medically necessary and when all

of the following conditions are met:

•The stroller has a firm back and seat, or insert.

•A stroller (rather than a wheelchair) is specifically recommended by

the licensed therapist completing the wheelchair evaluation.

The requested stroller meets all recommendations made in the

wheelchair evaluation.

•The client is not expected to develop motor skills necessary for

self-propulsion and is not expected to need a travel chair or

wheelchair within two years of the request date, or the client is

expected to be ambulatory within one year of the request date.

Requests for clients older than two years of age must meet the above

criteria, and there must be medical documentation of the need for a

stroller versus a wheelchair. Medical documentation should indicate

that a stroller allows adequate support for a client’s particular

condition, stature, and need for positioning (completion of the " CSHCN

Services Program Wheelchair Seating Evaluation Form " serves as medical

documentation).

The following criteria must be met for the level of stroller requested:

•Level 1: Basic stroller. The client meets the criteria for a stroller.

•Level 2: Stroller with tray for oxygen and/or ventilator. The client

meets the criteria for a Level 1 stroller and is oxygen- or

ventilator-dependent.

•Level 3: Stroller with positioning inserts. The client meets the

criteria for a Level 1 or Level 2 stroller and requires additional

positioning support.

Providers should use the following procedure codes and modifiers to

submit claims for strollers. Levels 2 and 3 require the addition of a

modifier:

Description

Procedure Code/

Level 3: Stroller with positioning inserts. The client meets the

criteria for a Level 1 or Level 2 stroller and requires additional

positioning support.

Providers should use the following procedure codes and modifiers to

submit claims for strollers. Levels 2 and 3 require the addition of a

modifier:

Description

Procedure Code/Modifier (As Applicable)

Level 1: Basic Stroller

J-E1035

Level 2: Stroller with tray for oxygen and/or ventilator

J-E1035 with TF modifier

Level 3: Stroller with positioning inserts

J-E1035 with TG modifier

Another is this program.

http://projectmend.org/index.php?option=com_content & task=view & id=15 & Itemid=30

Children’s Program

The Children’s Program assists with the purchase of fitted devices for

children who are uninsured or whose parents are unable to afford these

items.

These fitted devices include: helmets, prosthesis for legs or arms,

orthopedic shoes, gait trainers, special needs strollers and

wheelchairs, therapeutic car seats, feeder seats, pediatric toilets

and bathing equipment. Project MEND will help with a maximum of $1000

per child ages 0 to 18.

For more information on qualifications or program information, call

ext. 221.

Hope you are able to get one, make sure you also apply for the

Handicap Placard.

Irma,19,DS/ASD