Nebraska Department of Insurance

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THE NEBRASKA HEALTH INSURANCE INFORMATION, COUNSELING, AND ASSISTANCE (NICA) PROGRAM

JUNE 2002 NICA NEWS

ISSUES

Medicare Coverage of Wheelchairs

There are many types of wheelchairs covered by Medicare. In general, standard wheelchairs are covered if the patient would be confined to a bed or chair without the wheelchair.

Most wheelchairs are "capped rental" items. The capped rental program allows payment on a monthly rental basis only. Payment is limited to 80% of the allowed fee schedule amount, or the charges submitted, whichever is lower. A standard fee is established for each item by state.

A capped rental item may be converted to a purchase after paying ten continuous months of rental. The capped rental reimbursement method prevents the purchase of items that may only be needed for a short time.

If the beneficiary chooses to purchase the wheelchair, Medicare will pay up to 13 months of rental. After that time, title to the wheelchair is transferred to the beneficiary. Rental payments are applied to the purchase price.

If the beneficiary does not accept the purchase option, Medicare will pay up to 15 months of rental. After 15 months of rental has been paid, the supplier must continue to provide the item without charge (other than maintenance and servicing fees) until the medical necessity ends or Medicare coverage ceases.

After 15 months of rental have been paid and six months have passed, the supplier can begin to bill for maintenance twice a year. Medicare payment is allowed for maintenance and service whether or not the wheelchair is serviced. If the beneficiary requires

Service or repair, they must contact the supplier. Under the rental contract, the supplier agrees to provide any necessary repairs to the equipment.

Medicare payment may be allowed for the outright purchase of the following types of wheelchairs: a) ultra-lightweight, b) electric, and c) customized. The patient must meet Medicare guidelines to be covered.

The supplier must keep a Certificate of Medical Necessity (CMN), which has been filled out, signed, and dated by the treating physician, on file. The supplier must get the CMN before submitting a claim for the wheelchair.

Payment is made for only one wheelchair at a time. Back-up chairs are not considered medically necessary. However, one month's rental of a wheelchair is covered if a patient-owned wheelchair is being repaired. Wheelchair upgrades that are primarily beneficial by allowing the patient to perform leisure or recreational activities are not covered. Payment is based on the allowance for the least costly medically acceptable alternative.

Reimbursement for wheelchairs includes all labor charges involved in the assembly of the wheelchair. Reimbursement also includes support services, such as emergency services, delivery, set-up, education, and ongoing assistance with use of the wheelchair.

Medicare coverage guidelines are based on local medical review policy. Below is a summary of the Medicare coverage guidelines for various types of wheelchairs.

Manual Wheel Chairs

Standard hemi (low seat) wheelchair. Covered when the patient requires a lower seat height because of short stature or to enable the patient to place his feet on the ground for propulsion.
Lightweight wheelchair. Covered when a patient cannot self-propel in a standard wheelchair using arms and/or legs, but the patient can and does self-propel in a lightweight wheelchair.
High strength, lightweight wheelchair. Covered when a patient meets the criteria for a lightweight wheelchair while engaging in frequent activities that cannot be performed in a standard or lightweight wheelchair. The patient must also require a seat width, depth or height that cannot be accommodated in a standard or lightweight or hemi-wheelchair, and spends at least two hours per day in the wheelchair. Note: This wheelchair is rarely considered medically necessary if the patient will need it for less than three months.
Ultralightweight wheelchair. Coverage is determined on an individual consideration basis. Generally, patients that are highly active require this type of wheelchair.
Heavy-duty wheelchair. Covered if the patient weighs more than 250 pounds or the patient has severe spasticity.
Extra heavy-duty wheelchair. Covered if the patient weighs more than 300 pounds.
Custom manual wheelchair/base. Covered only if the feature needed is not available as an option to an already manufactured base. Note: When the above criteria for coverage are not met, a claim will still be considered if there is additional documentation that justifies the medical necessity for the wheelchair in that individual's case.

Motorized/Power Chairs

Power-operated wheelchairs are covered when all of the following criteria are met:

The patient's condition is such that without the use of a wheelchair the patient would otherwise be bed- or chair-confined; and
The patient's condition is such that a wheelchair is medically necessary and the patient is unable to operate the wheelchair manually; and
The patient is capable of safely operating the controls.

A patient who requires a power wheelchair is usually non-ambulatory and has severe weakness of the upper extremities due to a neurologic or muscular condition. The patient's condition is such that the requirement for a power wheelchair is long-term (at least six months).

Power-Operated Vehicles

Power-operated vehicles (POV), like scooters, can be covered. A POV is covered on a rental or purchase basis. When rented, Medicare payment is made up to the purchase amount.

The supplier is required to obtain a written order prior to delivery for a POV. The supplier is also required to obtain a CMN. The CMN may serve as the written order if it contains all the necessary information.

POVs have been appropriately used in the home setting for vocational rehabilitation and to improve the ability of chronically disabled persons to cope with normal domestic, vocational, and social activities. They may be covered if a wheelchair is medically necessary and the patient is unable to operate a wheelchair manually.

A specialist in physical medicine, orthopedic surgery, neurology, or rheumatology must provide an evaluation of the patient's medical and physical condition and a prescription for the POV to assure that the patient requires the vehicle and is capable of using it safely. When such a specialist is not reasonably accessible (e.g., more than 1 day's round trip from the patient's home), or the patient's condition precludes such travel, a prescription from the patient's physician is acceptable.

A POV is covered when all of the following four criteria are met:

The patient's condition requires a wheelchair to get around in the home;
The patient is unable to operate a manual wheelchair;
The patient is capable of safely operating the POV controls; and
The patient can transfer safely in and out of the POV, and has adequate trunk stability to ride it safely.

Specially-Sized WheelChairs

The patient must meet the basic requirement for wheelchair coverage: their condition is such that without use of the wheelchair they would otherwise be bed- or chair-confined.

A national coverage decision exists for specially-sized wheelchairs as follows:

"Payment may be made for a specially-sized wheelchair even though it is more expensive than a standard wheelchair. For example, a narrow wheelchair may be required because of the narrow doorways of a patient's home or because of a patient's slender build. Such difference in the size of the wheelchair from the standard model is not considered a deluxe feature.

A physician's certification or prescription that a special size is needed is not required where the carrier can determine from the information on file or other sources, that a specially-sized wheelchair (rather than a standard one) is needed to accommodate the wheelchair to the place of use or the physical size of the patient.

The Sandwich Generation

While a majority of Americans take care of aging or sick relatives, adults 45-55-years old are the most likely to end up helping both their aging parents as well as their children. In this age group, 54 percent care for children, parents or both, and 22 percent focus exclusively on a parent.

The highest rate of caring for parents is among Asians, with 42 percent giving care or financial help. They are followed by Hispanics at 32 percent, blacks at 28 percent and whites at 22 percent.

--adapted from USA Today and the Minneapolis Star Tribune