Medical Supplies Benefits
This fact sheet is intended to help Navigators answer specific questions that people with disabilities might ask about medical supplies benefits when they are considering buying health insurance through the Marketplace
Q1. What are medical supplies benefits?
A. Health plans available through the Marketplace must offer rehabilitation and habilitation services and devices as essential health benefits. While individual and small group plans sold in and out of the Marketplace are required to cover the broad category of “devices,” the federal government has not defined what specific devices, sometimes referred to as Durable Medical Equipment (DME), plans must provide. The federal government has also not indicated if and how “medical supplies” fit within the rehabilitation and habilitation services and devices category. However, HealthCare.gov defines the term DME as “Equipment and supplies that are ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.”
Since the benefits offered by plans sold through the Marketplace are modeled after a typical plan available in each state, the model plan acts as a guide to the DME that Marketplace plans likely will cover. Moreover, medical supplies that are used with covered DME tend to be covered when the supply is necessary for the effective use of the DME device. For example, a DME benefit can commonly include oxygen tubing or masks used with an oxygen concentrator, tubing for a respiratory device such as a continuous positive airway pressure (C-PAP) machine, or testing strips for glucose monitors. On the other hand, many plans exclude coverage for various types of disposable supplies that are not used in concert with a DME device, such as bandages, incontinence supplies, gauze, dressings, cotton balls, and alcohol wipes. It is important to be aware, therefore, that not all supplies will be covered by plans available through the Marketplace.
Q2. I have a spinal cord injury and require disposable catheters. Will Marketplace plans cover these supplies?
A. That will depend on the insurance plan on which your state modeled its Marketplace coverage. It will also depend on whether or not your doctor prescribes your catheters, how frequently you use them, and whether you will need to use them for an extended period of time. Your doctor will also probably provide you with a prescription for catheters, so plans you are considering should cover them. However, to be sure, you should contact customer services for the plans you are considering and ask if these supplies are covered. (See “Contacting Your Health Plan’s Customer Service Phone Number”) If you enroll in a plan and later learn that catheters are not covered, the plan has to tell you why they have denied your claim. You also have the right to dispute the decision. If you lose, you can appeal the plan’s decision and have it reviewed by a third party. (See “How do I appeal a health plan decision?”)
Q3. My spouse has a colostomy and uses various ostomy supplies including pouches and irrigation sleeves. Will the plans sold through the Marketplace cover these items?
A. Typically, medical supplies ordered by a physician to treat an illness or disease in a home setting and that are needed for the effective use of some type of DME will likely be covered. Since ostomy supplies are necessary to manage a surgically-created stoma, then Marketplace plans will most likely cover related supplies. However, you should contact customer services for the plans you are considering and ask if these supplies are covered. (See “Contacting Your Health Plan’s Customer Service Phone Number”) If you enroll in a plan and later learn that ostomy supplies are not covered, you can appeal that decision through the plan. If that appeal is unsuccessful, you have the right to take your appeal to an independent third party for review.
Q4. I am eligible for the Medicaid expansion in my state. I need a variety of medical supplies. Will I be able to get them under my Medicaid coverage?
A. Medicaid coverage varies from state to state. Your state’s Medicaid plan describes the healthcare services that are available. State Plans typically include a category for home health services and medical supplies are generally included as a provided benefit, with limitations. While it is likely you will be able to get some of the medical supplies you need, you might not be able to get everything. Check with your state’s Medicaid office to find out if the supplies you need are covered under the benefit package being offered to the newly eligible Medicaid expansion population. If your state is not offering the same benefit package to the Medicaid expansion population as the benefit package that is available to traditional Medicaid enrollees, then your health conditions may qualify you as someone who can choose either the Medicaid expansion’s “alternative benefit package,” or the traditional Medicaid benefit package. (See Fact Sheet on Medically Frail Status)