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Thread: Can someone privately pay for DME when they have both Medicare and Medicaid?

  1. #1
    Senior Member forestranger52's Avatar
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    Can someone privately pay for DME when they have both Medicare and Medicaid?

    I know this sounds stupid but the Support Coordinator of an agency that provides attendant care to a women who one of my aides takes care of, says she can not purchase a low air loss mattress privately. The poor women needs this mattress and her x-husband wants to buy it for her. M&M has denied the request and it has been repealed but it is likely that she will lose. 6 months wasted already. They will not believe me when I tell them she can pay for the mattress.

    Can someone please write that it's OK or not. I will show them this and can only hope they understand.
    Thanks.

  2. #2
    Certainly, if they have the money to purchase it. One concern is that having sufficient funds to purchase a mattress like this (in the range of $3000-6000 each) may trigger an audit of her resources and threaten her eligiblity for Medicaid (audits are often done). If someone else purchases it and gives it to her, the monetary value of the gift may also be considered income. This is something that could be purchased through a PASS plan though, since it is medical equipment needed to accommodate the disability.

    There are a number available used...check out eBay.

    (KLD)

  3. #3
    Senior Member ~Lin's Avatar
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    As already answered, yes. The only issue would be trying to purchase it from a dealer who has a medicaid contract. When you have medicaid, you cannot self pay for items from dealers with a medicaid contract because of rules preventing balance billing. For example, I got my wheelchair paid for by medicaid and was not allowed to upgrade items and pay for them out of pocket. However once I had the chair there's nothing that could prevent me from purchasing upgraded options from sportaid.com or bike-on.com. One upgrade I badly needed was a higher quality cushion. I could not purchase it from the DME who supplied my chair because they have a medicaid contract and know I have medicaid. I did attempt to try out cushions locally by claiming I had NO insurance to prevent being turned down, but no one locally even had high quality cushions in stock. If I had the money and told the DME I was self pay with no medicaid, they wouldn't be able to do anything. I do not know if there could be a retro-active problem though so I'd just advise to avoid dealers with medicaid contracts.

    Medicaid rules are state dependent, as its a state government program and not federal. I'm in Indiana, in my state a gift would not be considered income. For example, at one point my dad was paying my rent because I could not afford it. I was on medicaid. If my dad had sent me cash, and I'd paid the rent, that cash would have to be considered income and documented for the state. However, my dad was sending the checks directly to my landlord and I never saw the money personally and so they told me that was not considered income. But, gifts CAN be considered "assets" which are considered. For example my grandmother paid for my last car. I was supposed to pay her back but fell on hard times shortly after and never did. Even though I'm supposed to pay my grandmother back, the state considers my car one of my assets and guages its worth (lucky its not worth much) with my case. I don't know if a state would consider a piece of medical equipment an asset, I would think not because its not as if someone who owns a powerchair prior to going on medicaid could have the cost of the chair considered in their assets (never heard of it at least), but again ever state has its own rules. If the individual runs into any problems, I would suggest filing an appeal immediately. If nothing else it will cause someone higher up to look into the case and result in a better explanation of whats going on to the individual. I've so many people fall through the cracks, watched friends run into ridiculous problems, dealt with ridiculous problems myself, IMO its always better to appeal just in case they're in the wrong. If you're in the wrong, at least you'll better understand why which can help in further dealings.

    Hope I didn't make this too convoluted by trying to simplify it with examples ;)

  4. #4
    Senior Member forestranger52's Avatar
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    Thanks KLD and Lin. I believe she is allowed to have $8,000 in assets. She lives in an elderly high rise and owns her furniture but has much less than that in the bank. Her husband has always given her some money and she could buy it by herself if needed.

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