Power Wheelchairs and Medicare – Part I

Not on Medicare? If you are in the market for a chair and are not on Medicare, check with your health insurance provider to determine their requirements before purchasing a chair. Alternatively, you can also find good new and used chairs on the Internet or in your local newspaper, often at a substantially reduced price. Before buying a chair, however, make certain you have someone in your area that can service it. Do not just decide that any local dealer or supplier will service a wheelchair. Call the dealer or supplier, explain your situation and your plans to purchase a new or used chair and determine if they will service it or offer you a chair for a similar cost.

 

Power Wheelchairs - there is so much to know and understand about them especially when it comes to using Medicare to help purchase a chair. I have been educating myself with the help of the internet and my wheelchair provider. I thought it might be good to share some of what I discovered in case you are ever in the market for one.

When talking "wheelchair-ees," it is important to understand how Medicare determines if there is a need for and whether the product selected will fulfill that need.

• Basic Requirements for Medicare Eligibility

In Home Use Only: Medicare helps pay for a wheelchair if it is needed for "in home use." Any needs outside the home are not considered. Mobility is not, by itself, considered a medical necessity. Medicare will only assist you with the purchase of a wheelchair if it helps you accomplish any daily living activity. A wheelchair needs to enhance your ability to perform basic activities in the home. If you can somehow manage to stumble or crawl to the kitchen or bathroom, then, by Medicare's definition, you do not need a wheelchair. If you need a wheelchair to go to the supermarket or drugstore, for example, that, in Medicare's definition, also does not qualify you for support in purchasing a wheelchair.

Certificate of Medical Necessity (CMN): This form must be completed by your physician before Medicare will even consider helping you purchase a chair. The form contains information regarding your disability, the type of chair needed, and the medical justification for the chair. Before a wheelchair provider (dealer) can apply for benefits from Medicare, they must have a signed copy of the CMN. If anything is left out or if any information or dates are incorrect, Medicare will deny the claim.

Medical Record: Your medical record must contain sufficient information and documentation of your medical condition that substantiates the need for a wheelchair. The information required includes your diagnosis, duration of your condition for which the chair is needed (how long), your prognosis, the nature and extent of your limitations, other therapies provided including the results of these therapies, and any other devices (i.e., cane or walker) tried before and the results of using these items.

Even if you have complied with all the information stipulated above, Medicare might still ask for more information or further documentation to make certain it meets the Medicare guidelines. Any mistakes made on the forms including wrong dates or missing information could result in a denial of the claim.

Medically Necessary: The terms "medically necessary" or "unnecessary" are normally used in responses from Medicare when they approve or deny funding for a chair. Medicare, based upon the information submitted and their policies and guidelines, decides if a wheelchair is medically needed and if it will meet the needs of the intended user. You or your doctor's determination that a chair would make life easier or makes you more independent or functional normally does not matter.

• Wheelchair Supplier or Dealer

The supplier is the one that collects all of this information, makes certain the forms are filled out correctly and signed, makes an initial determination that you meet the Medicare guidelines, and submits the information to Medicare for processing. Once again, any mistakes could result in the claim being denied.

Advance Determination of Medicare Coverage (ADMC): Most often, the supplier will submit the information to Medicare prior to ordering a chair to determine if you are eligible and how much Medicare's benefit will be. Medicare has thirty-days to respond to an ADMC. Even if Medicare initially accepts the information, that does not mean they will honor the commitment once the final paperwork is submitted. Medicare could decide that more information is required, or that changes in your condition no longer warrant the chair ordered, or they could state the benefit is less than originally projected. Once again, Medicare only considers those activities and functions that would take place in your home. 

• Durable Medical Equipment Regional Carrier (DMERC)
  

Medicare has set up four regional offices across the country to process any benefit claims. Each DMERC has responsibility for processing claims within a specific region. DMERC's are not government or Medicare offices. They are contracted, private sector, companies that manage these programs. Medicare issues guidelines and policies, and it is up to the regional DMERC to follow and administer the program. The DMERC's have the final say on whether you will receive a Medicare benefit and the benefit amount.

In my next post, I will discuss wheelchair groups and potential benefits.