Mobility issues present unique challenges when it comes to caring for your personal hygiene and your safety in the bathroom. Regardless of your age, illness or injury can add to your risk of a fall, but seniors can be especially vulnerable. According to the National Institute on Aging, 80% of falls experienced by seniors over the age of 65 occur in the bathroom. Special equipment can be used to help you manage your needs and minimize your risk of injury in the bathroom.
Medicare-Medicaid Dual Eligibility
Beneficiaries who qualify for both Medicare and Medicaid-related services are known as dual-eligibles. Dual eligibility can be full or partial depending on a number of factors. Because Medicaid is a needs-based program, there are limits on how much earned and unearned income an individual can have in order to qualify. Some states also impose asset limits on dual-eligibles.
Full dual eligibility grants recipients access to all Medicaid-related benefits. Partial dual eligibility can also include these benefits if certain financial or level of care requirements are met, but coverage may be limited to payments for premiums, copayments, coinsurance or deductible amounts.
When partial dual eligibility is approved, a recipient will be enrolled into one of the following Medicare Savings Programs:
- Qualified Medicare Beneficiary (QMB). This program can help pay for all out-of-pocket expenses associated with Original Medicare Part A and Part B.
- Specified Low-Income Medicare Beneficiary (SLMB). This program can help pay for Part B premiums.
- Qualifying Individual (QI). Like the SLMB category, this program can help pay for Part B premiums, but for individuals who do not qualify for SLMB benefits and still fall under certain financial limits.
- Qualifying Disabled and Working Individuals (QDWI). For recipients with certain qualifying disabilities, this program pays the Part A premium if premium-free Part A coverage is lost due to resuming work.
Coverage Differences Between States
While the federal government creates a basic structure that determines mandatory coverage terms for Medicaid, states have a lot of flexibility when it comes to setting eligibility criteria and deciding on optional benefits. Because of this, a recipient in one state may not qualify for coverage in another. Additionally, a dual-eligible recipient may only have coverage for certain needs depending on which category of Medicare-Medicaid programs they qualify under.
Medicaid-related programs may provide coverage for certain types of bathroom equipment if a healthcare professional prescribes its use for a recipient with mobility issues, but the recipient may be limited on which brand or what type of bathroom equipment they can order. A recipient may receive their benefits through a Medicaid-contracted private insurer, which means there may be additional rules regarding brand, price and type of equipment covered.
Recipients who are receiving services through Medicaid’s long-term care provisions may not be able to order equipment for themselves, however, their long-term care provider may include this equipment as part of the care they receive during their stay. Charges like these are likely to be a part of the overall costs associated with long-term care coverage.
In cases of exceptional need or increased risk of injury, it may be possible to appeal a denial of coverage for bathroom equipment. The process for requesting equipment or appealing a decision can be different not only in each state but also for each Medicaid-contracted insurer.