ModifiedADAPolicy N/A

Coverage and authorization of adult incontinence briefs for MO HealthNet beneficiaries over age 21

Governs MO HealthNet (Missouri Medicaid) coverage and authorization of adult incontinence briefs for beneficiaries over age 21, addressing medical necessity determinations and exceptions/authorization processes.

Policy Summary

PayerADA

PolicyCoverage and authorization of adult incontinence briefs for MO HealthNet beneficiaries over age 21

Policy CodePolicy N/A

Change TypePermanent injunction and clarification requiring coverage to non-institutionalized adults when provided to institutionalized adults

Effective DateN/A

Next Review DateN/A

Key ActionUse the MO HealthNet Exceptions Unit to request authorization when a prescriber documents that incontinence briefs are medically necessary.

SourceLink

POLICY UPDATE CHANGES

Court declares state policy deeming adult incontinence briefs 'personal hygiene items' for participants over age twenty violates the Medicaid Act and federal disability integration mandates.

Defendants must provide Medicaid coverage of incontinence briefs to non-institutionalized adults if such coverage is provided to institutionalized adults pursuant to Olmstead.

22–49named plaintiffs ages

4–20previously covered ages

399Prevention Waiver slots

1-800-392-8030MOHN Exceptions Unit

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June 24, 2011date of order

Coverage Criteria for Adult Incontinence Briefs

Court-mandated coverage criteria

Covered when ALL of the following are met (as interpreted by the Court):

Medicaid/DME determination: State materials identify incontinence briefs as DME or as supplies/equipment, and Missouri must cover prescribed medically necessary DME under state statute and federal Medicaid reasonable-standards requirements.

See MO provider bulletins and DME manual stating coverage language and Mo. Rev. Stat. § 208.152.1(19).

Medical necessity: A prescriber documents that adult incontinence briefs are medically necessary to prevent skin deterioration, infections, or to sustain community living for the Medicaid participant.

Physician determinations from treating institutions cited by plaintiffs.

Home health services requirement: Adult incontinence briefs qualify as home health supplies/equipment and are covered if medically necessary under mandatory Medicaid home health services provisions.

See 42 U.S.C. §§ 1396a(a)(10)(A),(D); 42 C.F.R. §§ 440.70(b)(3), 440.210, 441.15.

Integration/Olmstead requirement: If the state covers incontinence briefs for institutionalized adults (via per diem), it must also provide coverage to non-institutionalized adults to avoid forced institutionalization in violation of ADA/Rehabilitation Act integration mandates.

Olmstead factors satisfied by plaintiffs; failure to provide community-based coverage forces potential institutionalization.

Mandatory coverage for non-institutionalized adults

Covered when ALL of the following are met

Court-ordered coverage: Medicaid coverage of medically necessary incontinence briefs must be provided to non-institutionalized adults when such coverage is provided to institutionalized adults; coverage cannot be withheld by classifying briefs as personal hygiene items for adults over age 20.

Based on Olmstead and the Court's permanent injunction; state must establish a fair process for obtaining medically necessary briefs.

Prior to the Court's intervention, Missouri's MO HealthNet policy treated adult incontinence briefs for beneficiaries older than twenty as non-covered "personal hygiene" items rather than medically necessary durable medical equipment. State provider materials and bulletins limited coverage to participants ages 4–20, and the agency refused claims or prior‑authorization requests for adults over twenty despite physician documentation of continuing medical need. (See MO provider notices and DME manual language incorporated by reference.)

The Court entered a declaratory judgment and permanent injunction on June 24, 2011, finding the state's policy unlawful. The order declares that the state's practice of deeming adult incontinence briefs for participants over age twenty as "personal hygiene items" violated the Medicaid Act's reasonable‑standards and home‑health services requirements, as well as the ADA and Section 504 integration mandate, and permanently enjoins the state from applying those policies while directing the state to establish a fair process for obtaining medically necessary briefs.

The Court criticized the agency's blanket classification because Missouri's own regulations and provider materials treat adult diapers as DME and the statute requires coverage of prescribed medically necessary DME. Rejecting a categorical label that excludes all adults over twenty, the Court held that individualized medical necessity determinations — supported by treating clinicians' documentation — are required rather than an across‑the‑board "personal hygiene" exclusion.

The Court expressly rejected the state's reliance on waiver programs as an adequate substitute for direct Medicaid coverage. It found the waivers were limited in eligibility and enrollment, that most plaintiffs were not reliably served by waivers, and that denying community‑based coverage unless a beneficiary is enrolled in a waiver would effectively force institutionalization — a result contrary to the ADA/Olmstead principles and therefore not permissible.

Provider Actions, Authorization & Documentation

Prior Authorization

Prior Authorization / Exceptions Process

Providers must use the MO HealthNet Exceptions Process to request authorization when a prescriber determines adult incontinence briefs are medically necessary. During the preliminary injunction period, such requests will be granted upon a determination of medical necessity. For assistance, contact the MO HealthNet Exceptions Unit at 1-800-392-8030, option 2.

Contact: MO HealthNet Exceptions Unit — 1-800-392-8030, option 2
Exceptions requests considered during preliminary injunction will be granted if medical necessity is determined

Note

Prior Authorization Details Not Specified in Excerpt

The source materials reference prior authorization procedures and an electronic web-based DME authorization system (MO HealthNet PA Criteria) but the excerpt does not enumerate specific PA codes, web portal steps, or procedural codes. Providers should follow MO HealthNet DME/PA guidance and any current electronic authorization workflows when available.

MO HealthNet DME manual and provider bulletins discuss pre-certification and web-based authorization

Background & Case Context

The case was brought by four disabled, low‑income Missouri adults (ages ranged in the record from 22–49) who suffer bladder and bowel incontinence. Their treating physicians submitted documentation that incontinence briefs were medically necessary to prevent skin deterioration, infections, and to enable the plaintiffs to remain in the community. The complaint and evidence showed that, absent coverage, some plaintiffs relied on donations or reused briefs and that only one plaintiff was receiving waiver coverage, with no assurance waivers could accommodate the others.

Definitions and Related Programs

DME / incontinence briefs — definition & program materials

Definition (term)Durable Medical Equipment (DME) — Missouri defines DME as equipment that can withstand repeated use and MO HealthNet provider materials identify underpads, diapers, briefs and protective underwear/pull-ons (including 'adult sized disposable incontinence product') as DME.

Program materialsMO HealthNet DME Manual and provider bulletins (e.g., March 2009 'Physician and Durable Medical Equipment' bulletin and the Durable Medical Equipment Manual) specify coverage criteria and precertification procedures for incontinence supplies.

Statutory referenceMissouri law requires coverage of 'prescribed medically necessary durable medical equipment' under Mo. Rev. Stat. § 208.152.1(19).

Prior age-limited practiceProvider materials and State policy historically limited DME incontinence diaper coverage to participants ages 4–20, per MO HealthNet documents and bulletins.

Most actionableAdult incontinence briefs are treated as DME by MO HealthNet materials; therefore medically necessary adult diapers must be covered when prescribed and documented as medically necessary.

Coding

Covered HCPCS/CPT/ICD CodesmixedCovered

No codes listed

Revision History & Material Changes

2011-06-24court_order_permanent_injunctionLatest

Court granted summary judgment and issued a permanent injunction declaring Missouri's policy classifying adult incontinence briefs as 'personal hygiene items' for participants over age twenty unlawful, enjoining application of that policy and ordering the state to establish a fair process to provide medically necessary incontinence briefs to adult Medicaid recipients.

2011-06-24coverage_clarification_Olmstead

Court found that under Olmstead the state must provide Medicaid coverage of incontinence briefs to non-institutionalized adults when such coverage is provided to institutionalized adults, rejecting waiver availability as an adequate substitute.

Policy Summary

PayerADA

PolicyCoverage and authorization of adult incontinence briefs for MO HealthNet beneficiaries over age 21

Policy CodePolicy N/A

Change TypePermanent injunction and clarification requiring coverage to non-institutionalized adults when provided to institutionalized adults

Effective DateN/A

Next Review DateN/A

Key ActionUse the MO HealthNet Exceptions Unit to request authorization when a prescriber documents that incontinence briefs are medically necessary.

SourceLink

On This Page

No specific PA codes or step-by-step PA procedure listed in this excerpt — consult current MO HealthNet resources

Denial Risk

Denial Basis — "Personal Hygiene" Classification

Prior denials were based on labeling adult incontinence briefs for beneficiaries over age 21 as "personal hygiene" items rather than medically necessary DME, despite physician documentation of continuing medical need. Providers should document clinical necessity when submitting exceptions/PA requests to counter such denial rationales.

Historical denial rationale: "personal hygiene item" for >21-year-olds
Documented physician medical necessity was previously disregarded in some denials

Denial Risk

Denial Risk When Non‑Institutionalized Adults Are Denied

Failing to provide coverage of medically necessary incontinence briefs to non-institutionalized adults while institutionalized adults receive coverage risks violating federal law (including the ADA Olmstead integration mandate and the Medicaid Act's reasonable-standards requirement). Providers should be aware that coverage disparities can trigger legal and regulatory risk for the program and may support exceptions/appeals.

Court found Missouri must provide briefs to non-institutionalized adults if provided to institutionalized adults
Waiver programs are not an adequate substitute where not available or sufficient

Documentation Required

Required Clinical Documentation for Exceptions/PA

Required clinical documentation should include physician statements demonstrating continuing medical need — e.g., that briefs are necessary to prevent skin breakdown, infection, sepsis risk, or to enable community living. Include diagnoses, functional impact, frequency of changes needed, and any prior treatment attempts or complications from lack of briefs.

Physician documentation of continuing medical need to prevent skin breakdown, infection, sepsis risk
Explanation of how briefs enable community living and prevent higher level of care
Clinical notes on frequency of incontinence and prior complications if unmanaged

Note

Exceptions Eligibility Criteria

The Exceptions Process applies only when the item is considered an essential medical service or would otherwise exceed program limitations. Exceptions may be granted if one or more conditions are met: required to sustain life; substantially improve quality of life for a terminally ill patient; replacement after disaster; or necessary to prevent a higher level of care.

Exceptions Process limited to essential medical services or items exceeding program limits
Grantable conditions (any one): sustain life; improve QOL for terminal illness; replacement after natural disaster; prevent higher level of care

Step Therapy

Step Therapy / Waiver Programs

Step therapy is not described or required in the provided excerpt. The Court rejected reliance on waiver programs as an adequate substitute for direct coverage; do not substitute waiver enrollment for exceptions/PA coverage when the patient demonstrates medical necessity and is otherwise eligible.

No step therapy requirements specified for incontinence briefs in the excerpt
Waiver programs are not an adequate substitute if unavailable or insufficient

Integration mandate (ADA / Section 504)

Legal mandateIntegration mandate under the ADA and Section 504: public entities must not exclude qualified individuals with disabilities from community-based services; Olmstead requires community-based services when appropriate, desired by the individual, and reasonably accommodated.

Olmstead applicationIf the State covers incontinence briefs for institutionalized adults, it must also provide coverage to non-institutionalized adults to avoid forced institutionalization in violation of the integration mandate.

Statutory parallelsTitle II of the ADA (42 U.S.C. § 12132) and Section 504 of the Rehabilitation Act (29 U.S.C. § 794) impose the same non-discrimination and integration obligations on public entities and recipients of federal funds.

Criteria for community careOlmstead factors: services appropriate, individual does not oppose community-based treatment, and reasonable accommodation given resources and other needs (Olmstead v. L.C., 527 U.S. 581).

Medicaid waiver programs — in‑home/community supports and limits

Program typeMedicaid waiver programs provide in-home and community supports intended to prevent institutionalization.

Limitations — eligibilityWaiver coverage is limited by participant eligibility; not all Medicaid recipients qualify for waiver enrollment.

Limitations — slot availabilityWaiver programs have enrollment caps and limited slots; the record shows only one of four plaintiffs received waiver coverage and the State could not demonstrate available slots for others.

Court findingThe Court found waiver programs are not an adequate substitute for direct Medicaid coverage when eligibility and slot limits force individuals to seek institutionalization to obtain supplies.

Practical consequenceReliance on waivers alone may leave eligible community-dwelling individuals without access to medically necessary incontinence briefs absent direct Medicaid coverage.