Over 79 million people are currently enrolled in Medicaid and Children's Health Insurance Programs (CHIP) throughout the US, but finding out what's covered and what's not isn't always easy. Eligibility requirements for products under Medicaid coverage vary by state, making it even more challenging for those amid a move or while on vacation. Pennsylvania's Medicaid program, also called Medical Assistance (MA), is jointly funded by the state and federal governments. Here, we'll go over what that means for individuals experiencing incontinence and how to get your incontinence supplies covered by Pennsylvania Medicaid.
What is Urinary Incontinence?
Urinary incontinence (UI) is a common medical condition that causes a person to lose control over their bladder, leading to accidental urine leakage. It can range from mild, occasional leaks to complete loss of bladder control. This condition affects people of all ages but is more prevalent among older adults, individuals with neurological disorders, and those with weakened pelvic muscles. UI can be caused by various factors, including pregnancy and childbirth, prostate issues, spinal cord injuries, chronic conditions like diabetes, or even certain medications.
There are several types of urinary incontinence, which include:
- Stress Incontinence: This occurs when pressure on the bladder, such as from coughing, sneezing, laughing, or exercising, leads to leakage.
- Urge Incontinence: Characterized by a sudden, intense need to urinate, often resulting in leaks before reaching the bathroom. This is sometimes referred to as an overactive bladder.
- Overflow Incontinence: When the bladder doesn’t empty completely, causing frequent dribbling or leakage.
- Functional Incontinence: When physical or cognitive impairments make it difficult to reach a bathroom in time, even if bladder function is otherwise normal.
Medical supplies can help manage symptoms and maintain hygiene, comfort, and dignity for those who experience ongoing incontinence. If you have incontinence and need incontinence products as part of your treatment or management plan, they're typically covered by insurance. However, every insurance provider and state-run program is different, so it's important to check with your plan and talk to your doctor.
Does Pennsylvania Medicaid Cover Incontinence Supplies?
Yes, eligible individuals enrolled in the state program can receive insurance-covered incontinence supplies through Pennsylvania Medicaid. The types of products and quantity you will be provided without cost depends on a few factors, namely your doctor's diagnosis and prescription. You must also be actively enrolled in PA’s Medicaid program, meaning you must already meet the eligibility requirements. In Pennsylvania, to apply for Medicaid, you need information or documentation that verifies your identity, income, legal status within the country (i.e., citizen or legal resident), Social Security Number, and information about other household members.
According to the state's rules, general eligibility is separated into two categories: eligibility based on modified adjusted gross Income (MAGI) and eligibility not based on MAGI.
Eligibility based on Modified Adjusted Gross Income (MAGI):
- Children aged 18 and under
- Pregnant women
- Parents and caretakers of children under 21
- Adults ages 19-64 with incomes at or below 133 percent of the Federal Income Poverty Guidelines (FPIG)
- Family planning services
Eligibility not based on MAGI
- Individuals 65+
- Individuals who are blind and/or disabled
- Medical Assistance for Workers with Disabilities (MAWD)
- Individuals receiving long-term care (LTC)
- Individuals receiving home and community-based services (HCBS)
You can find more details on this here.
Requirements for Medicaid-Covered Incontinence Products in Pennsylvania
Like many other states, Pennsylvania will only cover incontinence products if they're deemed medically necessary to treat a specific condition. This means you'll need to schedule an appointment with your doctor to undergo an examination and get documentation of your medical condition. Only then can you receive incontinence supplies through Pennsylvania Medicaid. The paperwork you'll need to verify this and prove eligibility typically involves a prescription and a note from your doctor. The most important requirements to be considered eligible for incontinence-related Medicaid benefits include the following:
- Be enrolled in Pennsylvania Medicaid or a Medicaid-managed care plan.
- Have a diagnosed medical condition that causes incontinence. A licensed healthcare provider must confirm that incontinence supplies are necessary for managing the condition.
- Obtain a prescription or Certificate of Medical Necessity (CMN). This document must outline the specific types and quantities of supplies needed.
- Demonstrate a medical need for ongoing incontinence management. Your doctor must indicate that incontinence is a chronic condition requiring consistent supply usage.
- Be at least three years old. Pennsylvania Medicaid typically provides coverage for children three or older with a qualifying medical condition.
However, Pennsylvania Medicaid may hold your order while they confirm that you have incontinence or another condition requiring the products. This is typically just a slight delay in administration, as supplies need to be pre-approved by Medicaid before they're eligible for coverage. Once you're pre-approved, the order can be completed. Working with a reputable medical supply company like Byram Healthcare to order insurance-covered incontinence products can simplify this process. If you have any questions before starting, don't hesitate to talk to your doctor or contact a representative from Pennsylvania Medicaid.
What Happens if You're Denied Coverage?
If you're denied coverage despite being an active Pennsylvania Medicaid recipient, you may need to review your documents and ensure that everything is accurate and current. You can appeal the decision, but you'll need to gather more medical documentation to help support your claim.
If the number of supplies authorized doesn't meet your needs, discuss with your healthcare provider whether additional documentation can justify increased supply quantities. It's also important that you order from a Medicaid-approved medical supply company to ensure that your insurance can be processed accordingly.
Which Urinary Incontinence Supplies Are Covered by Pennsylvania Medicaid?
Pennsylvania Medicaid covers a variety of incontinence products based on medical necessity. The exact products and allowable quantities depend on individual needs, as outlined by a healthcare provider. According to the Department of Human Services in Pennsylvania, a maximum of 300 monthly products may be prescribed. This can be a combination of one or more incontinence products, including some of the following:
- Adult Diapers or Briefs — High-absorbency products with adjustable tabs for individuals with moderate to severe incontinence.
- Protective Underwear (Pull-ups) — Designed for moderate incontinence, these offer discretion and ease of use.
- Bladder Control Pads and Liners — Thin, absorbent pads that provide protection against light to moderate leakage.
- Underpads (Chux) — Disposable pads that protect bedding and furniture from leaks.
- Booster Pads — Added absorbency pads that work in conjunction with primary incontinence products.
- Gloves and Wipes — Sometimes covered when necessary for hygiene and caregiving.
How to Order Incontinence Products Through Pennsylvania Medicaid
If your incontinence products fall under the category of medically necessary items, getting incontinence supplies from Pennsylvania Medicaid can be fairly simple. You will need to work with your doctor and have some patience (due to the pre-approval process in PA), but all of this is pretty straightforward.
1. Schedule a Doctor’s Appointment
Meet with your primary care physician or specialist to discuss your incontinence symptoms. Your doctor will assess your condition and determine if incontinence supplies are medically necessary.
2. Obtain a Prescription or Certificate of Medical Necessity
Your doctor must provide a written prescription or CMN detailing the specific incontinence products required, along with the frequency of use.
3. Choose a Medicaid-Approved Supplier
You must use a durable medical equipment (DME) provider that accepts Pennsylvania Medicaid. Many Medicaid-managed care plans have preferred suppliers, so be sure to check with your plan. Byram Healthcare is a Medicaid-approved medical supplier that carries a range of high-quality incontinence products for individuals of all ages.
4. Submit Documentation
Your Medicaid-approved supplier will need your prescription and any additional documentation to verify your eligibility. They will handle the insurance billing process for you.
5. Receive Your Supplies
Once approved, your incontinence supplies will be shipped directly to your home. Depending on your plan, you may need to renew documentation periodically to maintain coverage.
Partner With Byram Healthcare Today
Byram Healthcare is here to help you throughout every step of the ordering process. As one of the leading medical supply companies in the country, we work with Medicare, Medicaid, and most private insurance providers to help you navigate the intricate process of obtaining high-quality incontinence products. As an in-network provider with over 260 million covered individuals, our customers can enjoy lower co-pays and deductibles. Learn more about our mission and get started today to enjoy discreet delivery directly to your doorstep.
