II. Available Funding Sources for AT and Steps to Take in Order to
Access Financial Assistance
A. Medicaid
Medicaid is a federal and state program that assists people who have limited
financial resources obtain health care. Georgia participates in this program
and provides financial assistance to its beneficiaries for a variety of covered
benefits. The Department of Community Health ("Department") administers
the Georgia
Medicaid program.
To obtain payment for equipment through Medicaid, an enrolled provider must
submit paperwork to the Department or to a designated entity. A request for
this type of funding can be submitted either prior to delivery of the equipment
or after the beneficiary has received the item. A request that is submitted
prior to delivery is
known as a request for "prior approval." In Georgia, in most instances,
the vendor must submit a request for prior approval. In either case, certain
information must be provided to the agency.
This process is familiar to equipment providers who participate in the Medicaid
program (enrolled providers). For people who live in community settings, contacting
an enrolled provider is appropriate. For Medicaid beneficiaries who live in
nursing homes or other institutional settings, requests for funding are more
complex. A beneficiary can contact the Georgia Advocacy Office for information
regarding that process. (See end of this section for contact information)
1. Eligibility
To obtain assistance from Georgia Medicaid, a person must be eligible for Medicaid.
A request for funding must reflect the person’s Medicaid ID
Number.
Requests are submitted on form DMA-610 to Electronic Data Systems. Although
a Medicaid beneficiary receives a monthly card that reflects his/her eligibility
status, a request for funding need only identify the number.
Eligibility for Medicaid is based on a person’s income and resources.
In Georgia, if a person receives Supplemental Security Income (SSI), he/she
automatically is eligible for Medicaid. A person who receives SSI and turns
18 would be eligible despite his/her parents’ income. On the other hand,
a person whose income and resources are too high may still be eligible for Medicaid
if he/she incurs enough medical expenses.
2. Coverage
To obtain funding for AT through Medicaid, a person must show that it falls
within one of Medicaid’s covered services. The Georgia Medicaid agency
offers coverage for AT through one of the two following programs: 1. Durable
Medical Equipment and 2. Orthotics and Prosthetics. Although Medicaid has lists
of equipment for each of these programs, the lists are not exhaustive.
An item must meet the following Georgia criteria in order to qualify for funding
as Durable Medical Equipment (example: wheelchair):
o The equipment must be appropriate for home use;
o The equipment must be able to withstand repeated use;
o The equipment must be medically necessary; and
o The equipment must have a warranty.
If a person seeks funding for equipment that is not on the Department’s
list, his/her request should reflect how it meets the aforementioned criteria.
To qualify for funding as a Prosthetic (example: artificial limb) or Orthotic
(example: Ankle Foot Orthosis), an item must meet the following Georgia definitions
respectively:
Prosthetic: An external device (other than dental or corrective lenses) which
replaces all or part of an external body part (including artificial eyes) or
replaces all or part of the functions of missing body part or
congenital abnormality. The prosthetic device may be custom fabricated and fitted,
prefabricated and custom fitted or off-the-shelf prefabricated and fitted
Orthotic: A rigid and/or semi-rigid device or brace which is for the purpose
of supporting a weak or deformed body member, or restricting or eliminating
motion in a diseased or injured part of the body. The orthotic device may be
custom fabricated and fitted, prefabricated custom fitted or off-the-shelf prefabricated
and fitted.
As with Durable Medical Equipment, lists of items that qualify as Prosthetics
or Orthotics are not exhaustive, but the request for funding ought to reflect
how the equipment meets the particular definition. These lists are
in the provider manuals and can be found on the agency’s website: www.communityhealth.state.ga.us.
3. Medically Necessary
When trying to obtain funding for AT, the request to the Department must show
how the equipment is "medically necessary." It is important to include
in the request for funding documentation that shows how the item is medically
necessary. A physician’s statement is needed and must be dated and submitted
with a handwritten signature. An evaluation from a therapist (e.g., occupational,
speech-language, or physical) may also be helpful. Forms attached to this article
have been created by the Department to assist in documenting "medical necessity."
The particular forms are not required but can show a beneficiary’s doctor
how to support the funding request. The Department has its own definition for
"medical necessity" for adults.
Medically necessary, medical necessity or medically necessary and appropriate
means medical services or equipment based upon generally accepted medical practices
in light of conditions at the time of treatment which is:
o Appropriate and consistent with the diagnosis of the treating physician and
the omission of which could adversely affect the eligible recipient’s
medical condition;
o Compatible with the standards of acceptable medical practice in the United
States;
o Provided in a safe, appropriate and cost-effective setting given the nature
of the diagnosis and the severity of the symptoms;
o Not provided solely for the convenience of the recipient or the convenience
of the health care provider or hospital;
o Not primarily custodial care unless custodial care is a covered service or
benefit under the recipient’s evidence of coverage; and
o There must be no other effective and more conservative or substantially less
costly treatment, service and setting available.
This Georgia definition recognizes that an item can be "treatment"
although it does not cure a condition. AT may act as palliative and/or restorative
treatment. AT can often treat the effects of a condition and/or restore function
that is missing as a result of a condition. For example, a wheelchair may lessen
the effects of cerebral palsy and restore mobility (function) to an individual,
but it will not cure a person’s cerebral palsy.
For children who are under 21 years old, however, the agency must utilize a broader federal definition. For these requests, the equipment must "correct or ameliorate" conditions identified through medical screenings of the child. The extent of this protection can be quite large and ought to be considered often when seeking funding for AT for children.
In showing that an item is "medically necessary," a beneficiary must
be able to document that it is the least costly item that will be effective.
An item that is more expensive than an alternative can be funded, but it must
also be
more effective than the less costly alternative.
4. Decisions and Fair Hearings
Given the cost of some types of equipment, it is not unusual that the Department
or its designee fails to approve a request for funding. Should the Department
deny the request or fail to act in response to a request, a Medicaid
recipient can seek a fair hearing.
A Medicaid beneficiary must be vigilant when pursuing a request. The Medicaid
agency has a responsibility to act in a timely manner. The agency has written
policy that says it will make a decision within 30 days from
receiving a complete funding request for an augmentative communication device.
It is reasonable to expect that a decision for other types of equipment will
also be made within 30 days. However, it often takes much longer for the agency
to respond. If the agency has not responded after 30 days, requesting a fair
hearing may be appropriate.
If the Department denies a request for funding, it must provide written notice
as to the reason for the denial and the process to use when requesting a a hearing.
A beneficiary has 30 days in which to submit a request for a
hearing. He/She has the opportunity for a hearing before an Administrative Law
Judge. Although the hearing process is informal, the beneficiary must be given
the opportunity to subpoena and present witnesses, present evidence, and view
the agency’s file.
Should a Medicaid beneficiary receive a negative decision, administrative and
judicial review are possible.
5. Contacts
The following contacts will assist a Medicaid beneficiary in obtaining funding
for AT through the Georgia Medicaid program.
a. Requests for prior approval should be sent to one of the following:
Durable Medical Equipment Prior Approval
Electronic Data Systems
Post Office Box 105025
Tucker, GA 30085
(404) 298-1228
(800) 766-4456
Orthotics and Prosthetics Prior Approval
Electronic Data Systems
Post Office Box 105025
Tucker, GA 30085
(404) 298-1228
(800) 766-4456
Augmentative Communication Device Prior Approval
Vangie McKenzie
Georgia Medical Care Foundation
57 Executive Park South NE, Suite 200
Atlanta, GA 30329
(404) 982-0411
(These devices are considered "durable medical equipment," but requests
for "prior approval" are submitted to a different location.)
b. The Department of Community Health Supervisor for the Durable Medical Equipment
and Orthotics and Prosthetics Programs is:
Patricia Ross
Department of Community Health
2 Peachtree Street, 37th Floor
Atlanta, GA 30303
(404) 656-4035
c. Requests for appeals regarding denials of "prior approvals" should
be submitted to:
Nancy Allstrom
Director, Office of Legal Services
Department of Community Health
2 Peachtree Street, 40th Floor
Atlanta, GA 30303
(fax) (404) 657-9711
d. Requests for appeals regarding Medicaid eligibility should be submitted to:
Legal Services Office
Department of Human Resources
2 Peachtree Street, NW, 29th Floor, 29-231
Atlanta, GA 30303
(404) 657-4421
(404) 657-1123 (fax)
e. Questions about the hearing process can be directed to:
The Office of State Administrative Hearings
235 Peachtree Street, Suite 700
Atlanta, GA 30303
(404) 657-2800
f. Requests for legal assistance can be directed to one of the following:
The Georgia Advocacy Office
100 Crescent Centre Parkway, Suite 520
Tucker, GA 30084
(404) 885-1234
(800) 537-2329
The Georgia Legal Services Program
1100 Spring Street, Suite 200
Atlanta, GA 30309
(404) 894-7707
The Atlanta Legal Aid Society
151 Spring Street, NW
Atlanta, GA 30303
(404) 524-5811