For years, a flaw in the Idaho Department of Health and Welfare’s electronic Medicaid claims processing system allowed pull-up protective underwear, worn by those who are incontinent, to be covered by Medicaid for individuals who are 21 and older.
The problem is, they’re not covered for most adults, and haven’t been for 10 years.
But until last month, the claims were being paid. Now clients 21 and older who rely on the pull-ups will have to pay for them out-of-pocket or only have access to the Medicaid-covered adult diapers, also referred to as “briefs.”
“This takes away some of their dignity,” said certified family home care provider Pam Estes, who cares for three disabled adult males. “It decreases their independence. With their developmental disabilities, they wouldn’t understand how to put a taped brief on anyway.”
Claims for the pull-up underwear for those 21 and older had not been rejected because of a flaw in the coding of those claims. Following the discovery and correction of the error, IDHW’s Medicaid Division included a reminder of the policy in the January 2018 MedicAide newsletter, which goes out to Idaho Medicaid providers.
“Unfortunately, with the complexities of how it was coded, it was being paid, and that has been corrected,” IDHW public information officer Chris Smith said Friday. “We completely understand the frustration that beneficiaries have over this. It’s a very personal issue, so it’s unfortunate it happened like this. At the same time, we’re trying to do our very best and manage the taxpayers’ money the most efficient way.”
Claims for the 21-and-older pull-ups sent to Medicaid by Soper’s Mobility Aids in Hayden, were all paid until three were rejected last month. The business owners sent a letter to their Medicaid participants last week, informing them of what was thought to be policy change.
“It’s been very negative. They’re very upset,” said Genny Soper, who owns the medical supply store with husband Steve. “One client has dementia, and her husband said she just doesn’t understand a diaper. She can’t put them on.”
Genny said this is a huge dignity issue, especially for clients who are mobile or still in the workforce.
“With the diapers, it’s an embarrassment, or they don’t have the capability to put them on,” she said. “They’re out in public. How are you going to be able to do something with that?”
The pull-up protective underwear are a convenient and discreet way for clients to manage incontinence. The diapers are much larger, can only be used once and are cumbersome.
“If you’re capable of using the bathroom occasionally, you pull (the pull-up) down and back up,” she said. “With the diaper, you have to completely undress.”
Estes said the diapers impede the bathroom independence of disabled individuals who are able to use restrooms on their own with pull-ups. The time and effort to take off the diaper when they need to use the toilet could cause them to not make it in time.
“That makes them feel bad because they failed at what they tried to do,” she said. “They look at those and they can tell they’re a diaper. That’s what babies wear. At least with pull-ups, you can put them on like underwear.”
This coding flaw also brings to light the issue of cost. For many disabled individuals on a limited monthly income, the additional cost of the pull-ups will tax their already tight budgets by an average $40 to $60 per month.
Estes said this would take most of the monthly funds of a disabled person, “plus not allow him to purchase anything else.”
Smith said at this time, IDHW does not plan to require those who have been receiving the pull-ups to pay for the error.
“To my knowledge, there is no plan to go back and ask for the money,” he said. “This was a mistake by Medicaid and how we were processing claims.”
He said although pull-ups have never been considered a medical necessity, waivers and programs are in place to help people who are developmentally disabled afford alternatives to the adult diapers.
“All they have to do is contact Medicaid and have that conversation,” he said.
“If we’re providing a benefit that we are not legally allow to provide, we have to correct that and we have to stop doing that,” Smith continued. “That doesn’t mean looking forward we can’t be compassionate and considerate in looking at possible alternatives.”
Now that the topic is in the spotlight, Smith said this is something that officials will be looking at more closely.
“I think this is one that everybody would agree is a very personal issue and one that, if we can work with legislators to consider options or alternatives, we certainly would,” he said. “These are vulnerable populations who are in really sensitive circumstances. The last thing we want to do is make it more upsetting for them.”