Private Insurance
Private health insurance is the “payer of first resort” for DME, if you have it. Advice and resources are provided here for understanding your coverage, obtaining “prior approval,” and appealing denials.
Private health insurance coverage for durable medical equipment varies greatly between plans. If you have private (commercial) insurance—usually through an employer—it’s very important to become familiar with your specific policy. Private insurance is often complex, so understanding your coverage is essential.
Some individuals may have coverage under both Medicare and MassHealth (Medicaid) in addition to private insurance. In these cases, your private insurance is considered the “payer of first resort,” meaning it must first deny coverage for your durable medical equipment (DME) before MassHealth or another public source will review your claim.
The Delaware Assistive Technology Initiative (DATI) offers a clear and helpful explanation about public and private health insurance and how to obtain assistive technology. You can read the DATI article, “Public and Private Insurance”. Their article helped inform this information.
Who is Eligible?
To receive durable medical equipment (DME) benefits from your private insurance, you must be enrolled in a plan that specifically covers DME. Your plan’s policy documents explain exactly what is covered, the conditions for coverage, and whether certain items may require pre-approval.
How are DME Services Provided?
Review your insurance policy booklet (separate from the contract itself) for instructions on obtaining durable medical equipment. Usually, your insurer’s procedures involve obtaining “prior approval” or “pre-authorization.” Prior approval means the insurer must agree that the equipment is medically necessary before you receive it. Your policy booklet will outline this process. Contact your insurance plan’s member services representative with any questions.
Here’s an outline of the general process:
First, obtain a prescription from your doctor for the equipment you need. Your doctor or specialist will provide this prescription. Depending on your plan and the specific device requested, your insurance may also require a letter of medical necessity from your healthcare provider, detailing exactly why the equipment is required as part of your medical treatment.
Next, locate a medical equipment supplier approved by your insurer. Your doctor’s office or therapist can usually suggest suppliers. The supplier will work closely with your doctor or specialist to gather any required documentation, including medical justification, letters of support, or other materials necessary to secure approval from your insurer. It’s advisable to keep copies of all documents provided during this process.
Your supplier then submits the request for prior approval directly to your insurance company. The insurer will then review the request, which typically involves their medical staff evaluating whether the requested equipment is medically necessary and reasonable in cost. They may request additional documentation. Once the review is complete, you and the supplier will receive a decision, typically in writing. If approved, the supplier will arrange for the delivery and setup of the equipment.
Keep in mind that certain costs, such as copayments, coinsurance, or deductibles, may apply. These will vary based on your plan’s specifics, so it is important to know in advance exactly what your share of the cost might be.
What if I Need to Appeal a Denial for DME?
Denials are common, so don’t get discouraged if you receive one initially. Appeals are frequently successful if additional documentation clearly supports medical necessity. If your insurer denies coverage for a DME item, it’s important to file an appeal as soon as possible. Federal law provides up to 180 days from the date of service to initiate an appeal.
Your denial letter—often called an Explanation of Benefits (EOB)—must explain your appeal rights and the steps you must follow. Read this letter carefully. Keep copies of all correspondence, any forms you complete, and take notes from any phone conversations, including the date, who you spoke with, and details of the conversation.
Your first step in appealing is typically an internal review through your insurer’s own grievance process. Each insurance plan, including private HMOs, has a formal internal appeal procedure regulated by the Office of Patient Protection (OPP) in Massachusetts (105.CMR.128).
If you believe the internal appeal was unfairly denied, you may request an external review. External review is an independent process conducted by the Office of Patient Protection, part of the Massachusetts Department of Public Health. Decisions made through the external review process are final.
The Kaiser Family Foundation provides a useful guide explaining how to conduct internal and external appeals for your private (commercial) or Commonwealth Care insurance denial. Their guide clearly explains the insurance appeals process and relevant state and federal regulations. You can find more information on the Kaiser Family Foundation website.
Frequently asked questions about the external review process are also available at this Office of Patient Protection web page (click on “External Review Process” in the Quick Links and then choose the “External Review Overview”).
Contact:
Commonwealth Choice is a Massachusetts program that helps people find and sign up for private health insurance plans through the Health Connector Authority. The Health Connector has endorsed particular plans for providing good value to consumers.
(877) 623-6765
(800) 623-7773 TTY.
Mass HealthConnector website
Health Care For All (HCFA) is a non-governmental organization that answers questions about healthcare in Massachusetts.
HCFA’s Health Helpline: (800) 272-4232
www.hcfama.org