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Insurance & Funding

Medicaid, managed care and waivers: how equipment is actually funded

Medicaid is not one program. It is a joint federal and state program run separately in every state, which means the durable medical equipment benefit, the fee schedule, the prior-authorization rules and the appeal path are all set at state level and none of them are the same twice. A page that told you what Medicaid covers for a hospital bed or a pressure-reducing mattress, nationally, would be making it up.

What is the same everywhere is the shape of the process: a documented clinical need, a written order from a treating practitioner, a request to the program or to the managed-care plan that administers it, a decision, and an enrolled provider who is authorized to supply the item. Most of what goes wrong happens in the gaps between those steps, and most of it is avoidable if you know where the gaps are.

We do not bill Medicaid. We are an authorized Joerns dealer supplying Dolphin® FIS® fluid immersion simulation systems privately, to rent or to buy. Dolphin® FIS® and Fluid Immersion Simulation® are registered trademarks of Joerns Healthcare LLC. This page exists because the people who land on it are usually trying to work out whether to wait for a decision or to arrange something now, and that is a real question we can help with even though we are not part of the payment path.

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A plain wall calendar with one date circled in pen, hanging beside a cordless phone on a kitchen wall.
Timelines that differ by state
Who sets the rules
Your state, not the federal government alone
Usually administered by
A managed-care plan with its own prior-authorization rules
Second funding route
Home and community-based services (HCBS) waivers
Our role in billing
None. We do not bill Medicaid or submit claims

Working out what your state and plan will actually do

  1. 1

    Find out who administers the benefit

    Look at the card. If it names a health plan rather than the state agency, the person is in Medicaid managed care and that plan decides, using its own published medical policy. If it is straight fee-for-service Medicaid, the state agency and its DME fee schedule decide. These are different processes with different phone numbers, and calling the wrong one costs days.

  2. 2

    Ask for the written policy, not an opinion

    Ask the plan or the state program for its coverage policy for pressure-reducing support surfaces, and for the prior-authorization form that goes with it. Get the document. A policy read in ten minutes tells you more than a week of calls, and it tells you what the reviewer will actually be looking at.

  3. 3

    Check whether the item is even on the fee schedule

    State DME fee schedules list the HCPCS codes the program pays for and at what rate. If a code is not on the schedule, no amount of documentation makes it payable. This is where fluid immersion simulation ends the conversation early: there is no HCPCS code for it at all, so there is no line for it on anybody's fee schedule.

  4. 4

    Get the order and the clinical documentation aligned

    A written order from the treating practitioner, plus the wound assessment, the staging, what has already been tried, and for how long. Medicaid programs commonly model their support-surface criteria on the Medicare group structure, so the documentation that satisfies a Group 2 review is usually a good starting point even where the wording differs.

  5. 5

    Ask about the waiver in parallel, not afterwards

    If the person is on, or eligible for, a home and community-based services waiver, that is a separate funding route with its own rules and often its own equipment list. Ask the case manager about it at the same time as the DME request, not after the DME request fails. Waivers commonly have waiting lists, and the queue does not start until someone asks.

  6. 6

    Decide what happens in the meantime

    Authorization timelines and discharge dates rarely line up. If the person is coming home before a decision, decide consciously whether to bridge it privately, borrow, or delay the discharge — rather than discovering on the day that nobody decided. A private rental is one answer among several and is not automatically the right one.

Why nobody can tell you "what Medicaid covers"

Every state runs its own Medicaid program within federal rules, and the durable medical equipment benefit is one of the places where states differ most. The list of covered items, the codes on the fee schedule, whether a given item needs prior authorization, how long a decision takes, what an appeal looks like and which providers are enrolled are all state-level answers. Two families in neighboring states, with identical wounds and identical orders, can get different outcomes and both be correct under their own rules.

On top of that, most states now deliver Medicaid through managed-care organizations. The plan takes on the benefit and applies its own medical policy and its own authorization process within the state's framework. So the real question is not "does Medicaid cover this" but "does this plan, in this state, cover this code, for this documented situation".

We are national. We ship to all fifty states, and we are not going to pretend to know your state's fee schedule. What we can do is tell you which questions produce real answers and which documents to ask for by name, so that the first call you make is the one that matters.

Managed care, and how prior authorization actually goes

When a managed-care plan administers the benefit, the decision on a pressure-reducing surface is usually a prior-authorization review against the plan's own written medical policy. A clinician submits the request with supporting documentation, a reviewer applies the policy criteria, and the request is approved, denied or returned for more information. The third outcome is the most common and the least talked about.

The criteria in those policies are commonly modelled on the Medicare support-surface group structure — Group 1 non-powered, Group 2 powered, Group 3 air-fluidized — which is why the Medicare page on this site is useful reading even for someone who is not on Medicare. The wound stage, the location on the trunk or pelvis, what surface was already in use, the turning schedule, the nutrition and the moisture management all tend to reappear, in the plan's own wording.

Some plans publish policies addressing specific technologies by name. If you want to know whether yours has said anything about fluid immersion simulation, ask the plan directly for any policy it holds on the item and ask for it in writing. We are not going to summarise a policy we have not read, and we would rather tell you that than guess at what your plan says.

  • Ask which clinical criteria set the plan applies, and get the document.
  • Ask whether prior authorization is required for the specific code being requested.
  • Ask what the standard decision timeframe is, and whether an expedited review exists for a pending discharge.
  • Ask which DME providers are contracted with the plan for that code in your area.
  • Ask what the appeal path and deadline are, before you need them.

Home and community-based services waivers

Alongside the standard state plan benefit, most states operate home and community-based services waivers. These exist to support people living at home who would otherwise need institutional care, and they frequently fund things the standard DME benefit does not: specialized equipment, home modifications, personal care hours, respite. Which waivers exist, who qualifies, and what each one will fund are state decisions and vary widely.

Two things are worth knowing before you start. Waivers commonly have waiting lists, sometimes long ones, and the waiting list position usually dates from the application rather than from the need — so applying early matters even if the answer today would be no. And waiver funding often runs through a case manager or support coordinator rather than through a DME supplier, which means the person you need to convince is different from the person you would call about a Medicare claim.

If the person already has a case manager, that is the call to make. Ask whether specialized equipment is within the waiver's service definitions, what the request process is, and what documentation the reviewer will want. Ask it in parallel with any DME request rather than as a fallback, because the two timelines are long and running them in sequence can add months.

When someone has both Medicare and Medicaid

Plenty of the people we hear from are dually eligible. Where that is the case, Medicare is generally the primary payer for durable medical equipment and Medicaid sits behind it, which means the Medicare criteria and the Medicare documentation drive the process even though Medicaid may be the program the family thinks of first. The order in which payers are billed is not something a family should be improvising, and getting it wrong produces denials that look clinical but are administrative.

Practically, this usually means the Medicare group criteria are the criteria that matter for a support surface, and the Medicaid piece comes into play for cost-sharing and for items or quantities Medicare does not cover. If there is a case manager, ask them to state in one sentence which payer is being billed first for this item. If nobody can answer that, the claim is not ready to go in.

Where a private route fits, and where it does not

We supply Dolphin FIS systems privately, by rental or outright purchase. That route has no authorization step, which is sometimes exactly what a family needs when a discharge date is fixed and a decision is not. It also has no payer behind it, which means the cost is the household's, and for a five-figure therapy surface that is not a small thing to decide in a hurry.

So we will say the unhelpful thing first: if the person's clinical need is met by a Group 2 surface that their program or plan will authorize, pursue that. It is a covered category, there are contracted suppliers, and the outcome for the skin is a matter for the wound-care team rather than for us. A private purchase that duplicates a benefit somebody was entitled to is a bad outcome, and we would rather lose the sale than be the reason it happened.

Where a private rental genuinely earns its place is narrower: the care team has specifically asked for fluid immersion simulation and no payer route exists for it; or the discharge is happening before any decision will arrive and the household has decided to bridge it deliberately. In both cases the sensible thing is a rental rather than a purchase, so the commitment is monthly and stops when the situation changes.

What we can give you that is actually useful

Confirmed manufacturer specifications for whatever configuration you take, so the clinical record and any later claim can describe the surface accurately rather than approximately. An itemised invoice showing the item, the date, the amount and a description written for substantiation. And the measurements — width, length, depth and rated capacity — that a case manager or a plan reviewer will ask for and that nobody else in the chain will have.

What we cannot give you is a coverage answer, a prediction, a letter of medical necessity, or an assurance that anything will be authorized. Those belong to your state program, your plan, your case manager and your clinician, in that order.

Before you call your plan or case manager

  • The Medicaid ID and, if there is one, the managed-care plan name from the card
  • Whether the person is also enrolled in Medicare, and which plan
  • The treating practitioner's name, office and direct fax or portal details
  • The wound stage, location and measurements as currently documented
  • What surface is in use now, and how long it has been in use
  • The documented turning schedule, wound care, nutrition and moisture management
  • Whether there is a case manager or support coordinator, and their contact details
  • Whether the person is on, or waiting for, an HCBS waiver
  • The planned discharge date, if there is one
  • A written note of who you spoke to, when, and what they said

Questions people ask us

Does Medicaid cover a hospital bed?
Often, but it depends entirely on your state and, where the benefit is delivered through managed care, on your plan. The item has to be on the state's durable medical equipment fee schedule, a treating practitioner has to document the need, and prior authorization is commonly required. Ask your state program or plan for its written coverage policy and prior-authorization form rather than relying on a general answer.
Does Medicaid cover a Dolphin FIS mattress?
No. There is no HCPCS code for fluid immersion simulation, so there is no code for a state fee schedule or a managed-care plan to pay against. We do not bill Medicaid and do not submit claims. Dolphin FIS systems from this business are rented or bought privately.
Why is the answer different in another state?
Because Medicaid is administered state by state within federal rules. The covered item list, the fee schedule, the prior-authorization requirements, the decision timeframes and the appeal path are all set at state level, and most states then delegate administration to managed-care plans that apply their own medical policies. Identical clinical situations genuinely produce different answers in different states.
What is an HCBS waiver and could it pay for equipment?
A home and community-based services waiver funds support for people living at home who would otherwise need institutional care, and many waivers cover specialized equipment and home modifications that the standard state plan benefit does not. Which waivers exist and what each covers is a state decision. Ask the case manager or support coordinator, apply early because waiting lists are common, and pursue it in parallel with any DME request rather than after one fails.
The person has Medicare and Medicaid. Who pays first?
For durable medical equipment, Medicare is generally the primary payer and Medicaid sits behind it, which means the Medicare support-surface criteria and documentation usually drive the process. Ask the case manager or supplier to confirm in one sentence which payer is being billed first for the specific item. If nobody can answer that, the claim is not ready to submit.
How long does a prior-authorization decision take?
It varies by state and by plan, and the standard timeframe is published in the plan's own materials. Ask for it, and ask specifically whether an expedited review exists for a pending hospital discharge — many plans have one and it is not always offered unless requested.
Can you help with the paperwork?
Only with our part of it. We can provide confirmed manufacturer specifications and an itemised invoice describing exactly what was supplied and when. We do not write letters of medical necessity, submit prior-authorization requests, or bill any payer. Those belong to the treating clinician and to a provider enrolled with your program or plan.
Should we rent privately while we wait for a decision?
Sometimes, and it should be a deliberate decision rather than a default. If the need is met by a covered Group 2 surface that your plan will authorize, pursue that instead. If the discharge is happening before any decision will arrive and the household has chosen to bridge the gap, a monthly rental keeps the commitment short and endable. Buying outright while a coverage decision is pending is the option we would argue against.

Working against a discharge date?

Tell us the configuration the care team has asked for and when it has to be in the room. We will tell you what is available to rent or to buy — and if a covered surface through an enrolled provider is the better route for you, we will say so.

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