Community Health Equity Outreach
Navigating Your Medi-Cal & Medicare Coverage
1. Incontinence Supplies (Medi-Cal Benefit)
Essential daily supplies are a covered Medi-Cal benefit at $0 out-of-pocket cost for eligible beneficiaries without a Share of Cost:
- Eligible Supplies: Adult briefs/diapers, protective pull-ups, disposable underpads (chux), bladder control pads, and wipes.
- Age Threshold (DHCS Guidelines): Beneficiaries aged 5 and older qualify for standard monthly allocations without prior authorization when managing chronic bowel or bladder incontinence.
- Practitioner Prescription: Orders may be written by a Physician (MD/DO), Nurse Practitioner (NP), or Physician Assistant (PA) responsible for the member's care. Documentation must include diagnosis/ICD-10 code, product type, and daily frequency.
2. Dual-Eligible Coverage (Medicare + Medi-Cal)
Patients enrolled in both Medicare and Medi-Cal (Medi-Medi) receive full federal and California statutory protection against out-of-pocket expenses for covered equipment:
Mandatory Balance-Billing Protection (Social Security Act § 1902(n)(3)(B) & Cal. Welf. & Inst. Code § 14019.4):
Medicare Part B covers 80% of the approved amount for medically necessary DME. Any remaining cost-sharing is processed through automated Medi-Cal crossover billing. Under California's reimbursement methodology, actual Medi-Cal crossover payments vary; however, qualified dual-eligible beneficiaries can never be balance-billed for any remaining coinsurance or deductible.
Medicare Part B covers 80% of the approved amount for medically necessary DME. Any remaining cost-sharing is processed through automated Medi-Cal crossover billing. Under California's reimbursement methodology, actual Medi-Cal crossover payments vary; however, qualified dual-eligible beneficiaries can never be balance-billed for any remaining coinsurance or deductible.
3. How to Order: Choosing the Right Documentation Path
To avoid administrative delays, documentation requirements depend on your primary coverage:
Pathway A
Medicare Part B Patients
Required Documentation:
- Documented Face-to-Face (F2F) clinical evaluation within 6 months.
- CMS-compliant Standard Written Order (SWO) signed prior to delivery.
- Clinical notes supporting specific medical necessity (e.g., patient transfer limitations).
Pathway B
Medi-Cal & Managed Care
Required Documentation:
- Prescription from treating practitioner (MD, DO, NP, PA).
- Straight Medi-Cal: J&J coordinates submission of the Treatment Authorization Request (TAR) to DHCS.
- Managed Care (L.A. Care, Health Net, Molina, CalOptima Health): We coordinate prior authorization directly with your assigned medical group or health plan.
Prescriber & Clinic Intake Protocol
Clinics, discharge planners, and case managers may transmit orders and Face Sheets directly to our intake department:
Intake Fax: (562) 278-0234
Customer Support: (562) 406-1028
Facility: 12440 Firestone Blvd, Suite 1025, Norwalk, CA 90650