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