Got Diapers? Diaper coverage by insurance

Posted Monday September 12, 2011 by Melissa

TENA_ULTRA_Adult_Diaper_Bri

Many MPS kids or other children with special needs never become potty trained. If they do, sometimes it is not for very long. So, diapers are a big deal to us parents. But who pays for your child’s diapers?

While most parents expect their child to be in diapers for 2, 3, or maybe even 4 years, no one is expecting the expense of diapers indefinitely. In addition, as your child grows, the diapers continue to get more expensive. Your sweet boy or girl can no longer squeeze into the Huggies size 7’s – the largest regular diaper out there that I know of. Sometimes you switch to the Goodnites that come in larger sizes but are pullup style, so thus, more difficult to put on a hyper and writhing child as well as more expensive than regular diapers.

Tena XS youth diapersWhen you have to make the switch to “medical” diapers like Tena or Tranquility, the cost can rise exponentially. And as MPS parents know, the toileting habits of our kids are often not those of a typical child, so you may need many more diapers and/or diaper liners as well.

So how do you afford diapers? Parents are often told that they have to pay for diapers themselves, even though their child may continue to need diapers their whole life. This is simply NOT true if your child receives Medicaid in the United States, no matter what state you live in. Read more below….

If your child does not have Medicaid or a Medicaid waiver, then the answer is not as simple. But, there are several alternative sources for funding diapers that I will discuss below.

These are the potential sources for funding diapers that I am aware of in the United States, although some states and localities may have additional sources as well. The best way to know is to speak with your child’s case worker or social worker, other special needs parents in your area, and the local Easter Seals and United Cerebral Palsy offices in your area.

MEDICAID

If your child under 21 receives Medicaid, a federal program called EPSDT covers medically necessary services including, according to the courts, diapers and incontinence supplies needed because of your child’s disability (even if your state’s Medicaid does not normally cover those services). It is unfortunate that many families are told that their state’s Medicaid does not cover diapers for their child or does not cover the amount or type that the child needs. For a good background on EPSDT, how it is connected with Medicaid, and how it helps your child, read this document from the Human Services Research Institute.

A reminder that even though you have the legal right to something doesn’t mean that the person on the other end of the phone understands the law or wants to be helpful. Several moms in Georgia found this out when trying to fight for diapers. The Children’s Disability Education Association discusses the issue and also directs you to Advocacy offices for every state that can be helpful in addressing access to health care issues for your child. Additional information on diapers being a covered service under EPSDT is also on their website.

Here is a presentation about EPSDT in Colorado – see slides 79-85 for information about diaper coverage.

EPSDT in Virginia – slides 53-54.

Some information about EPSDT in New Mexico.

You will likely need a prescription, a letter of medical necessity, and possibly other documentation. It may be helpful to call a DME company that deals with incontinence supplies in your area and see their process for getting it approved. They may even be able to help you with that process. We received our supplies through Edgepark Medical out of Ohio and they were always very helpful.

MEDICAID WAIVER

If your child has a Medicaid waiver, they usually have full Medicaid services and may also have additional services through the waiver. Sometimes the diapers are actually provided under a portion of the Medicaid waiver and that is an easier route than trying to make the EPSDT argument. If your child has the waiver, talk to his or her waiver case manager to find out if the waiver covers diapers and if so, how to get them. Don’t be afraid to make the argument for the number of diapers your child actually uses/needs even if they say, “well, it only covers 160 diapers per month.” Whether through the waiver or regular Medicaid, your child should get the amount of incontinence supplies he or she actually needs. Also, if there is a reason why your child needs one type of diaper over another (the fabric gives them a rash, they frequently “overpee” and may need booster liners, or something else), do not settle for an answer that does not give your child what they need simply because someone says that is all that Medicaid or the waiver provides in your state.

STATE HANDICAPPED / MATERNAL & CHILD HEALTH PROGRAMS

All states have some program that is funded by Maternal & Child Health grants issued by the U.S. government. A portion of those funds must be allocated for children with special health care needs (“CSHCN” for short) and many states use them to fund programs that pay for durable medical equipment, co-pays, and/or supplies like diapers. Some have financial qualification criteria and some do not, but often the criteria differ from Medicaid so just because you do or don’t qualify for Medicaid, this still could be another resource for your child! Here is a good summary of these programs and a contact for more information. I could not find a good state-by-state listing of programs, but here you can find a contact person for the CSHCN by clicking on your state then scrolling down to find the contact for the Title V Children with Special Health Care Needs program (you can also google CSHCN and the name of your state). In Tennessee, we have the program called Children’s Special Services, that does not actually cover diapers but has other services, but I never would have even connected with it had a friend not told me about it.

PRIVATE INSURANCE

Not many private insurance plans cover diapers. It is always worth it to (1) talk to your case management contact if your child has one [and he or she SHOULD if they have an ongoing, complex medical condition], (2) call customer service for your plan otherwise, and/or (3) talk to the human resource manager at your employer that has the coverage; he or she may have had this question before and have some knowledge or suggestions.

If all else fails…

Do not forget to call your local Easter Seals office, your local United Cerebal Palsy office, and speak to your child’s case worker or social worker at the local hospital or otherwise to see what suggestions they have. Many medical diapers can also be purchased on eBay for cheaper than from medical supply houses.

If you have additional insight or methods to obtain coverage for or access to diapers, please comment!

11 Responses to “Got Diapers? Diaper coverage by insurance”

  1. I may be in the wrong area, but I am the grandmother of Dominick, 3 1/2 years old, with Wolf Hirschhorn Syndrome, I have been trying to get diapers through Medicaid form him and well frankly nobody in Georgia seem to know how to go about it!
    I have sent emails to several people and organizations.
    I will not give up.
    Any suggestions

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    • Sheree Lynn,
      I hope you received my e-mail with some suggestions. Please comment with any additional insights, challenges, or successes you have! I hope that Dominick can get what he needs!

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    • Did you find any resources for the diapers in Georgia? The research I’ve done so far says that should be covered, but I’m being told no.

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    • I am on Medi-care/Medi-cal. Medi-cal (in California) is often called “Medi-caid” in many other areas. Anyway, someone asked how to go about getting diapers. Often times medical insurance will refuse to cover diapers until your child is like 5. After the normal age of potty training. So be prepared to cover diapers till around then. But how I got mine was I went to my doctor and explained I have a incontinence issue. I explained to my doctor that I am unable to afford my diapers and he was the one who told me about my insurance covering diapers. This was when I was living in new york back in 2002. He wrote me a prescription which I took to the CVS pharmacy and the pharmacist gave me like 10 bags of adult diapers (I forget the exact amount). It’s a bit different in California. Each state covers a different amount. In California I get 120 diapers for the month. If I use more than that, I have to pay for them out of pocket. Which I sort of do. To stretch the adult diapers which are expensive, I put the MUCH cheaper baby diapers in the front of my adult diaper to boost absorbency and thus make my diapers last longer between changes. To use the baby diapers as doublers/soakers I cut off the tape tabs at the back of them which would irritate your skin if you didn’t. And then using a razor blade I cut several small slits in the plastic backing of the baby diaper. That way once the baby diaper was full, the rest of the urine soaks into the adult diaper. The best diapers for this so far are the size 6 Huggies Overnites, and Parents Choice size 6 Overnites. I go with Parents Choice brand (sold by Walmart) because I can get 52 size 6 diapers for 14 dollars. VERY good price, and they are extremely absorbent. But unlike the Huggies Overnites, the Parents Choice do tend to swell up as they well fuller which can make walking a bit odd looking. But I don’t mind that much. I rarely let them get THAT full (short of wearing the diaper overnite), and most times by the time it starts getting that swollen I am back home from doing my errands and can change. So to recap, to get diapers covered, see your doctor and request a prescription for diapers. Either take it to your local pharmacy, or call a medical supply company from your area. Then if your child is using youth-adult diapers, to make them last longer put in a size 6 baby diaper in the front (for boys, between the legs for girls) to help you have to use less of the more expensive youth-adult diapers. The diapers (if I use more than what my insurance sends) I will buy quality diapers myself. My insurance company will only cover cheap store brand quality diapers. But the diapers I buy when paying out of pocket are better quality brands such as Wellness Briefs or Abena level 4’s as I am a heavy wetter and those brands hold close to 3 liters of urine and last 8-10 hours between changes which means less diapers. And hold more if used along with a baby diaper booster. Hope this info helps. :)

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  2. […] Medicaid programs did not technically cover items such as personal care services and diapers (see prior post on getting diapers through Medicaid), a federal law called EPSDT required that they do so. While […]

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  3. We are currently receiving diapers through medicaid for our disabled 6 year old boy. However they are now too small. The samples we have been sent of the next largest size, adult extra small swallow him. Can we get sames from you? He is around 50 pounds. Thanks. I can be reached by phone at850-368-1652

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    • Hi Sunni,
      I don’t personally have any samples but most companies like Tena and Tranquility will send you samples of several types. When our son was at 50lbs, Tena extra small briefs were the right size for him, so you might want to try there? Good luck and I hope you find something that works well for him!

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    • pampers size 7

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  4. Heather Routt // March 26, 2015 at 9:21 am

    Hello,
    I am trying to find out what I need to do in order to get incontinence supplies for my special needs daughter. We live in GA and can’t seem to find who I need to call in order to get this process started. Her Dr said he would write her a prescription for diapers, but none of the pharmacies around here said they can fill it. Is there a website or someone that can help me? Skyler has Cerebral Palsy and Epilepsy and we have tried potty training, but she can’t always feel when she has to go. She is wheel chair bound and that may be the problem for her sensation issues. Anyway, please get back to me when you can.
    Thanks, Heather

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  5. The company I used was called “Shield Health Care”. They ship diapers all over the county. Their website is http://www.shieldhealthcare.com/ When I was using them they also covered me a waterproof mattress protector every 6 months, and diaper doublers too. But they didn’t carry the brand I needed and I found someone who did locally. But the plastic sheet they gave me 5 years ago is STILL good. But then again, I RARELY have a leaky diaper. So it’s rare it needs washing.

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  6. Laura Lopez // July 7, 2015 at 2:48 pm

    Hi!..I was wanting to know if yalls company has adult diapers and if medicaid pays for it…i will truly appreciate it if i would hear from you soon…Thank you!

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