Power Wheelchairs and Medicare – Part II

In the last post, I discussed Medicare and their process of determining necessity. In today's post, I want to discuss wheelchair groups, as defined by Medicare, as well as potential Medicare benefits. In doing so, please remember that requirements and benefits can change and that I might have misinterpreted some of the information. Always check with your wheelchair supplier and Medicare before making any decisions.

Power Wheelchair Pricing

Powered wheelchairs, like most medical equipment, have a substantial markup. Often, with diligent shopping, you can find or negotiate a price substantially lower than the amount quoted by the supplier. The cost for a new power wheelchair can run anywhere from a $1,000 to upwards of $20-30,000 depending upon the make, model, capabilities, and accessories. Besides price, a major issue to consider is what would be the price of having the chair serviced if you do not buy it through a local supplier that provides in-home service. When working with a supplier and using Medicare's benefits, I recommend negotiating a price that provides the least out-of-pocket costs for you, but still offers an incentive for the supplier to provide excellent after-sale service (maintenance and repair).

Wheelchair Groups

Currently there are seven groups. Groups 4, 5 and 6 will not be discussed in this post since they are more specialized and the requirements and benefits are substantially different. Group 1 chairs will also not be discussed since these type chairs normally do not meet the needs of someone with Kennedy's Disease. My focus for this post will be on Groups 2 and 3 because most of us with Kennedy's Disease will have a need for these type chairs. You will soon see that Group 2 requirements and restrictions are substantially less than Group 3's. Within each group, there are several sub-groups, but I do not intend to go down to that level in this post.

Group 2 – Power Wheelchair – To be eligible for this type chair, you will need a Certificate of Medical Necessity (CMD) signed by your physician. You must also meet the basic criteria for a Group 2 chair as well as have an evaluation performed by a physical (PT) or occupational therapist (OT), or a physician with specific training in this area. If additional power options are required (tilt, ventilator, alternate drive control, etc.), than you must meet the additional criteria set out for these options. In Group 2, there are normal and heavy duty chairs for those patients that weigh over 300 pounds. Medicare benefits range, depending upon the power options required, normally from approximately $4,000 to $4,550. Under most circumstances, you will be required to pay for twenty-percent (20%) of Medicare's allowable amount cost.

Group 3 – Power Wheelchair – The criteria for a Group 3 chair is reserved for the severely impaired. Diseases included in this category include Amyotrophic Lateral Sclerosis (ALS), spinal cord injuries, stroke (CVA), late stage Parkinson's Disease, Multiple Sclerosis, Muscular Dystrophy, etc. Patients with diabetes related disorders including peripheral neuropathy are not eligible for Group 3 chairs because it is considered a symptom rather than a primary neurological condition.

The eligibility criteria (other than specified above) are also stricter and require additional evaluation. You will still need to have a physical or occupational therapist evaluation (someone qualified to evaluate Group 3 needs). Note: Your physical or occupational therapist must not have any financial relationship with the wheelchair supplier. If additional power options are required (power tilt or recline, ventilator, alternate drive control, etc.), than you must meet the additional criteria set out for these options. In addition, a Certificate of Medical Necessity (CMD) is required to be signed by a specialist (your neurologist, for example) rather than a general practice (GP) doctor. A home assessment is also required for this group. Furthermore, your mobility limitation must be due to a neurological condition, myopathy or congenital skeletal deformity. The wheelchair supplier must employ RESNA-certified Assistive Technology Professionals (ATP) who specialize in these type chairs.

Since Group 3 chairs are a little more sophisticated, seating, backrest, tilt, recline and other options are normally designed to fit the person the chair is being ordered for. A Seating Specialist (PT or OT) is encouraged because they are more familiar with the types of chairs and options available to fulfill your specific needs. Medicare benefits range, depending upon the power options required, normally from $5,170 to $5,570. Under most circumstances, you will be required to pay for twenty-percent (20%) of Medicare's allowable amount cost.

Important: Power lift seating is not covered under Medicare benefits. Helping a person to more easily transfer or stand is not considered a medical necessity. The cost for power seat lifts can run from $1,100 to $2,700.

Do you have Supplemental Health Insurance? If you are on Medicare, you might have secondary coverage that will also assist in paying for the chair. Always check with your health insurance provider for available coverage and any additional requirements.