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Fund Your AT > Medically Necessary > Private Insurance

Funding for Medically Necessary AT

Private Insurance

Private health insurance is the "payer of first resort" for DME, if you have it. Advice and resources are provided here for understanding your coverage, obtaining "prior approval," and appealing denials.

Private health insurance coverage for durable medical equipment varies from plan to plan. If you have private (commercial) coverage (usually provided through an employer), it is important to get to know your policy. Private insurance is often overlooked when people are pursuing funding their AT needs.

Some consumers have MassHealth and/or Medicare in addition to a private insurance policy. In this case it is still important to get to know your private insurance benefits and policies. Both MassHealth and Medicare consider private insurance the "payer of first resort". This means that you have to be denied coverage for your DME needs from your private carrier before any public provider will consider your claim.

The Delaware Assistive Technology Initiative has produced a brief and useful explanation of public and private health insurance and the process for obtaining AT. Get the DATI article, "Public and Private Insurance". Their article helped inform this section.

What DME Services are Provided by Private Insurance?

To learn if DME is a covered benefit from your private insurer, you will need to get a copy of your plan's specific benefits contract. A member services representative can help you obtain and understand it. As you review the contract, be aware of other terms used to refer to DME; these can include home medical equipment, rehabilitation technology, orthopedic appliances, medical supplies, vision/hearing services and equipment, and prosthetic devices. Keep in mind, too, that a needed device can sometimes be provided as part of covered therapy services even if it is not listed as a covered DME service. (For example, an augmentative and alternative communication [AAC] device may be provided as part of speech and language therapy services.)

Your contract will also tell you what your portion of the DME's cost is likely to be. "Coinsurance", "co-pays", and "deductibles" are all terms that indicate a portion of expenses you will need to pay yourself.

How are DME Services Provided?

Review your plan's policy booklet (separate from your contract) for its procedures for obtaining durable medical equipment. The process may include obtaining "prior approval" or "pre authorization" (i.e. the plan's permission) before you can fill a prescription for DME. Your insurance provider may also work with particular "preferred" medical equipment suppliers.

Often the process for obtaining DME starts with your doctor (primary care provider) writing a prescription for the device and referring you to a medical equipment supplier. The medical equipment supplier then helps you obtain prior approval from your insurer, working with your doctors and specialists to gather letters supporting the "medical necessity" of the device, as needed. (It's a good idea for you to keep copies of all paperwork and letters of support). Depending on the equipment, the medical equipment supplier may also evaluate you for exactly what device you need, and work with your doctor's office to obtain an appropriate prescription.

Plans that are "fee-for-service" instead of managed care sometimes do not require prior approval and suppliers may bill your insurance after supplying your equipment. Be careful to learn in advance of any deductibles, co-insurance, or co-pays that you will have to pay. Some plans require their enrollees cover a percentage of the cost of the device, in addition to meeting a substantial deductible for the year.

Again, it's important to learn the particulars of your plan's contract and policies. A member services representative can help you.

What If I Need to Appeal a Denial for DME?

Denials are common so it may be best to consider them just another step in the process of obtaining DME. Often providers just need more information and supporting documentation to approve a claim.

If your insurance provider denies your request, you should file an appeal as soon as you can. (Federal law, however, gives you up to 180 days to appeal a decision from the service date.) Your denial letter (sometimes an "explanation of benefits") must detail your appeal rights and procedures. Review and follow these carefully. It's a good idea to keep all correspondence, forms you fill out, and even a written record (log) of who you speak with and the actions you take.

If you are covered by a managed care plan ("health maintenance organization" [HMO]), you first need to follow the HMOs "internal review" procedures (the health plan's own appeals process). Each private HMO has a formal internal grievance process. This review process is internal to the plan, but governed by the state's Office of Patient Protection regulations (105.CMR.128).

If you feel you are denied unfairly by the internal review, you can next ask for an "external review". This is an independent appeals process through the Office of Patient Protection (part of the Massachusetts Department of Public Health). Decisions from the Office of Patient Protection are final.

The Kaiser Family Foundation provides a useful guide for how to pursue internal reviews as well as external reviews of your private health insurance claim denial. The guide also helps explain health insurance coverage and relevant state and federal laws: see
Kaiser Family Foundation web page.

Frequently asked questions about the external review process are also available at this Office of Patient Protection web page (click on "External Review Process" in the Quick Links and then choose the "External Review Overview").


Commonwealth Choice is a Massachusetts program that helps people find and sign up for private health insurance plans through the Health Connector Authority. The Health Connector has endorsed particular plans for providing good value to consumers.

(877) 623-6765
(800) 623-7773 TTY.
Mass HealthConnector website

Health Care For All (HCFA) is a non-governmental organization that answers questions about healthcare in Massachusetts.
HCFA's Health Helpline: (800) 272-4232