Medi-Cal, California’s Medicaid program, provides coverage for incontinence supplies as a medical benefit for its beneficiaries. Coverage is not automatic; the patient’s need must be clearly documented and determined to be medically necessary. The program aims to cover these products to manage incontinence caused by a chronic medical condition, helping beneficiaries maintain health and perform daily activities. This support is part of the comprehensive health services Medi-Cal offers.
Establishing Medical Necessity for Coverage
Coverage for incontinence supplies is strictly tied to a diagnosis of a chronic pathologic condition causing the beneficiary’s incontinence. A licensed healthcare provider must document the underlying, long-term medical reason for the need, as simply experiencing incontinence is not sufficient. This documentation establishes medical necessity, which is the primary prerequisite for all supply coverage.
The initial process requires a prescription or order from a qualified provider, such as a physician, physician assistant, nurse practitioner, or clinical nurse specialist. This order must clearly state the recipient’s name, the specific cause of the incontinence, and an estimated amount of supplies required per day. The prescription must be signed and dated, typically remaining valid for twelve months from the date of the claim submission.
For children aged five and older, supplies are covered through standard benefits. For those younger than five, coverage is provided through the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Supplemental Services benefit. In these cases, the incontinence must be due to a chronic physical or mental condition, such as cerebral palsy or developmental delay, at an age when continence would normally be expected.
Specific Incontinence Supplies Covered
Medi-Cal covers a range of disposable and reusable products designed to manage both urinary and bowel incontinence. These products are categorized as medical supplies and are reimbursed by the program when prescribed for a qualifying condition. The covered items include various styles of absorbent garments, which are the most common supplies provided to beneficiaries.
The program covers full garments intended for moderate to heavy incontinence. These include disposable adult briefs, often referred to as adult diapers, which are single-use garments with fasteners. Another covered style is disposable adult protective underwear, or pull-ons, designed to be worn like regular underwear.
Coverage also includes smaller absorbent products worn inside regular underwear, such as liners, shields, pads, and guards, which are suitable for managing light to moderate leakage. Additionally, Medi-Cal covers disposable underpads (chux pads) to protect surfaces. Incontinence creams and washes for skin care and hygiene are also covered benefits.
Quantity Limits and Authorization Procedures
Coverage for incontinence supplies is subject to specific quantity and cost limitations per patient each month. Without formal authorization, the cost for covered supplies, excluding creams and washes, is generally limited to a maximum amount per calendar month. This cost cap includes sales tax and any markup applied by the supplier.
Medi-Cal implements quantity limits based on the product type, such as a specific maximum number of items allowed within a 27-day or 30-day period. These limits are determined by the Department of Health Care Services (DHCS) and published in official billing code lists. A beneficiary is approved for a certain number of items based on the provider’s estimate of daily need.
If a beneficiary requires supplies exceeding the standard quantity or cost limits, a formal Prior Authorization (PA) or Treatment Authorization Request (TAR) is required. This process involves the provider submitting a request, often including the specific Incontinence Supplies Medical Necessity Certification form (DHCS 6187), to justify the increased need. The Durable Medical Equipment (DME) provider manages these complex orders and secures the necessary authorization for ongoing shipments.