Durable Medical Equipment (DME) is something you can use in your home to help make life with your medical condition easier. Wheelchairs and hospital beds are examples of DME.
I have Medicaid and I need DME. How do I get it?
1. Your provider will refer you to an evaluator for an assessment.
- Most evaluators are physical or occupational therapists. The evaluator will set up an assessment with you. You might have to wait for the assessment if the evaluator is very busy. You might also have to wait if the DME vendor needs to help you try the equipment. The DME vendoris the company that provides the equipment.
- If the DME that you need is simple, you might not need an assessment. If your provider says you do not need an assessment, skip to step 2.
- The evaluator will decide what kind of DME you need and send an assessment form to your provider.
2. Your provider will write a prescription.
- Your provider will sign the assessment form and send a prescription for the DME to the vendor.
3. The DME vendor will ask Medicaid for prior authorization.
If you do NOT need prior authorization, skip to step 5.
- If you need prior authorization for the DME, the vendor will send information about you and the DME you need to Medicaid. Prior authorization means that Medicaid has to say it is okay before you can get the equipment.
- A clinical reviewer will review your information. The reviewer will decide if you have a medical need for the equipment.
- The clinical reviewer might need more information to decide if you have a medical need for the equipment. If the reviewer needs more information, Medicaid will ask the DME vendor to send it. The vendor must send the information within 12 days. Once Medicaid has all the information, the reviewer must make a decision within 3 business days.
4. Medicaid will send you a Notice of Decision
- Medicaid will tell you the decision by sending you a letter called a Notice of Decision. Medicaid will also send the letter to your provider and the DME vendor. In Vermont, the Department of Vermont Health Access (DVHA) runs Medicaid, so the letters will be from DVHA.
5. The DME vendor will get the DME for you.
- If Medicaid approves, the DME vendor will give you the DME or order it for you.
If Medicaid does NOT approve, you can appeal the decision. To appeal, call Medicaid Member Services at 1-800-250-8427.
Medicaid has worked hard to shorten the amount of time it takes to approve a request for DME in Vermont. For complex wheelchairs, it takes about 9 days. That is shorter than the amount of time Medicaid rules require. It is also shorter than the national average. For simple equipment, the amount of time is shorter.
If you have Medicaid and Medicare or another insurance plan, this process may take longer.