Navigating Insurance Coverage for Pediatric Incontinence Supplies

“Wait — you mean our pull-ups could be covered by Medicaid?”

Every day, it’s a statement we hear from families just like yours. Most people just aren’t aware that their child’s incontinence supplies can be covered by Medicaid. Or if they are aware, they’re not sure where to start, or how to navigate the process.

No matter which category you fall into, you’re in the right place. In this blog, we’re going to walk you through the insurance coverage process, some of the bumps you might run into, and what we do at TMS to help families get over those bumps and get approved faster.

Ready? Let’s get started.

Incontinence Supplies and Medicaid: A Walkthrough of the Ideal Process

Let’s start with how things should work. The process usually starts in your doctor’s office.

Potential Roadblocks in Getting Diapers Covered Through Insurance

Now that we know how things should go, let’s look at where things could go wrong and how TMS ensures they don’t.

Roadblock No. 1: Prescription Issues

One of the first hurdles you might face is with the prescription itself. Medicaid requires specific details on the prescription, including the doctor’s signature and precise information about the supplies (sizes, amounts, etc.).

If any of the required information is missing, you’ll face delays.

To avoid this, we double-check the forms to make sure everything is there before we submit them. We verify the doctor’s signature, the specific supplies needed, and any other essential information.

If any details are missing, we’ll contact your doctor’s office to correct the issue. That helps us stop delays before they happen so your child never has to wait for the diapers they need.

 Roadblock No. 2: Insurance Verification

Every state has its own Medicaid requirements for covering supplies like diapers and wipes.

Arkansas Medicaid and Texas Medicaid, our main coverage areas, have different documentation and coverage requirements. (Note: Some states may cover only a portion of the necessary supplies. Arkansas Medicaid, for example, will cover only three to four changes a day — compared to eight in Texas.)

It can be hard to know exactly what you need to provide, especially if you’ve recently moved to a new state or have never navigated the Medicaid process before. Luckily, when you work with TMS, we gather the necessary documentation and ensure it’s all filled out correctly, so you don’t have to.

Here’s a look at what each state requires:

Documentation Requirements for Medicaid

Requirements for Both Arkansas and Texas:

• Prescription Details: The prescription must include the doctor’s signature, specific supply details (type and quantity), and a diagnosis that qualifies the child for coverage.
• Primary Care Physician (PCP) Information: The PCP listed on the prescription must match the PCP on file with Medicaid. If a different doctor signs, a letter explaining the situation (for example, the PCP is on leave) may be required.
  
  

How Arkansas and Texas Differ:

Arkansas Medicaid: Well Child Exam: The date of the last well exam must be included on the prescription. Coverage Limits: Arkansas Medicaid typically covers fewer supplies (three to four changes per day) and may require more out-of-pocket expenses.

Texas Medicaid: Title 19 Form: Texas requires a specific form with billing codes, units, and pricing information. Medical Necessity: Detailed documentation proving the supplies are medically necessary, including growth charts and medical records, is required. Doctor's Authorization: The order must include a signature from an authorized healthcare professional and specify the frequency of use. Authorization Submission: An authorization must be submitted and approved before supplies can be dispensed. Texas Medicaid generally offers broader coverage, such as up to eight changes per day.

 Roadblock No. 3: Provider Changes

If your child’s PCP changes, it can complicate the process. Medicaid is strict about who can sign off on these prescriptions. Only the PCP they have on record for your child can do it. So, if you change PCPs, make sure to let us know immediately. We’ll update this information with your Medicaid provider to avoid delivery delays.

 Roadblock No. 4: Reordering Supplies

Medicaid won’t cover a product you don’t have a current prescription for. So, if yours expires, you’ll need to visit the doctor to renew it. This usually happens every six months. But don’t worry. We’ll reach out to remind you that your prescription is expiring so you can make the necessary doctor’s appointments. That way, you won’t have to worry about paying out of pocket for diapers while you wait to see the doctor.

 Roadblock No. 5: Delivery Concerns

We get it. No one wants their neighbors to know that their older child wears diapers. So, you don’t need a giant box labeled “Diapers” in bold lettering sitting on your front porch until you get home. At TMS, we believe in discreet deliveries. So, we do whatever is necessary to keep what’s inside the box a mystery to anyone but you. We might put them inside another unmarked box, tape over the label on the current box, or repackage the entire order to disguise its contents. And when we add our own shipping labels on top, they’ll contain only necessary information, like your name and address, so even the post office employees won’t know what’s inside.

Getting Incontinence Supplies Covered by Medicaid: Our Insider Advice

This definitely isn’t our first rodeo. We’ve helped thousands of parents like you get supplies covered under Medicaid. And along the way, we’ve picked up a few helpful tips.

Here are some that might help:

Keep Records

This process will throw a lot of information at you (like prescription renewal dates, size specifications, and information about your child’s condition, just to name a few). Write it all down. Keep a notebook or calendar with doctor’s appointments, prescriptions, expiration dates, notes from appointments, and everything else you need to keep track of. That way, you won’t have to hunt down the information you need. And don’t worry: We’ll keep track of all that information as well, and we’ll call you to remind you when something is expiring or we need more information to get your order shipped.

Are You a Healthcare Team Partner? Here’s How You Can Help

• Ensure accurate prescriptions: Double check that all required details are included to prevent any delays in the supply process. This includes verifying that the correct doctor is listed as the PCP and that all necessary documentation is attached.
• Advocate for your patients: Without a doctor’s approval, a patient won’t get the supplies they need. So even if you think a patient needs counseling or other interventions alongside incontinence supplies, recognize that diapers and wipes are still important. After all, incontinence won’t magically stop on the first day of therapy or medication.

Save Our Contact Information

An important note about those calls from us: You won’t want to miss them. It could delay your next shipment. So, save our number in your phone so you don’t dismiss an important call from us as spam.

Set Reminders

You’ve got a lot on your plate. So, it can be hard to keep track of a doctor’s appointment or when a prescription is expiring. But missing these dates can mean long delays in getting your supplies. So put reminders in your phone so you never miss an important date.

Understand Coverage Limitations

If you live in Arkansas, Medicaid probably won’t cover all the diapers your child needs. So, plan for other ways to pick up the slack, whether it’s supplemental coverage or clipping coupons to save money on the occasional extra pack you have to buy out of pocket.

Consider Switching Providers if You Have to

Most doctors understand the need for pediatric incontinence supplies and will work with us to help you get them covered. But a few don’t. Some, for instance, might only prescribe treatment to address the root cause of incontinence, but won’t prescribe supplies. In cases like this, we’ll talk to the doctor to try to change their opinion. But as a last resort, it might be worth exploring other primary care doctors for your child. If you do switch, remember to let us know immediately so we can update Medicaid.

“Our child’s diapers can be covered by Medicaid?” Yes. And it’s easier than you think.

Getting the pediatric incontinence supplies you need doesn’t have to be a pain. But navigating Medicaid coverage by yourself can be a frustrating process — especially if you run into roadblocks.

Luckily, the right partner can help you avoid (or quickly get past) any roadblocks, so all you’ll have to do is answer a few phone calls and see the doctor twice a year.

The rest of the time, you just get your products shipped right to your door. Because trust us: You have enough on your plate as it is. The least we can do is make this process easier for you.