Medicare Buts on Wheelchairs
Some good to know facts when chasing Medicare down for a wheelchair. We were not quite sure if the correct spelling was "Buts" or "Butts", so we erred in favor of less typing.
*The term wheelchair is a generic term used to describe manual wheelchairs, powered wheelchairs, and Scooters |
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| •In The Home |
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Medicare pays for a wheelchair when needed for "In the home" use only. This means that they will not consider anything that you need to do, want to do, or would be able do outside of your home if you had the correct wheelchair.
But- Many organizations such as Right Wheelchair, ITEM Coalition, and Clinician Task Force, are working to change this. Why aren't you helping them?
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| •Activities of Daily Living Requirement |
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In a recent decision in May 2005, Medicare decided that mobility, unto itself, is not a medical necessity. For Medicare to purchase a wheelchair it would have to help you accomplish an ADL (activity of daily living).
But- If you can stumble into your kitchen to make a sandwich, fall into your bathroom to comb your hair, or crawl into your closet and grab some clothes to wear. Well then, your going to be out of luck.
Butt- If you have no problem with performing these activities but just need to get to the right place to do them, hmmm, that doesn't look real good in Medicare's eyes either. You may be out of luck there also. The logic- The wheelchair needs to enhance your ability to "perform" these activities. In this case it doesn't. You are already able to perform them. You just can't get there to do it.
Buttt- Regardless of all of the above, Medicare will still not consider any of your wheelchair and mobility needs outside of the home.
Medicare held open forums and requested input prior to making this decision. A large number of wheelchair users and organizations along with some of the nation's brightest clinicians and some of the wheelchair industries sharpest people commented on this issue. These concerned parties were universally against Medicare on this issue. They did it anyway. Medicare has sent a clear message that they are not concerned with the welfare of their clients or the opinion of organizations and professionals.
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| •Certificate of Medical Necessity (CMN) |
This is an order that your physician "must" complete in order for Medicare to pay for your wheelchair. It contains information on your disability, the type of wheelchair you need, and the medical justification for the wheelchair. Your wheelchair dealer must have a signed copy of the certificate from your doctor in order to further process your wheelchair claim.
But- If anything is left out or if any of the information or dates are incorrect, guess what? Medicare will deny the claim and you are back to square one. In certain cases, including those where an honest mistake or oversight was made on the certificate, your physician or wheelchair dealer may be accused of submitting a fraudulent claim.
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| •Your Medical Record |
Your medical record must contain sufficient documentation of your medical condition that substantiates the need for the wheelchair. The record should include diagnosis, duration of the condition for which the wheelchair is needed, prognosis, nature and extent of your functional limitations, other therapeutic interventions that have been tried and results, and information on any other similar device that you have tried. A copy of the Certificate of Medical Necessity (CMN) should also be included in your medical records.
But- The information on your medical record is not enough to get the wheelchair claim approved and paid for. It is a component of the entire documentation process. Medicare can always ask for more detailed documentation, disagree with any part or all of the documentation, and even declare it fraudulent.
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| •The Wheelchair Dealer |
The wheelchair dealer or supplier not only supplies the wheelchair but they are also the ones who gather up all the information, double check it for accuracy, make sure that it meets Medicare's guidelines and then pack it all off to the eagerly waiting Medicare folks.
But- If there are mistakes or incorrect information the claim will be denied by Medicare and the supplier may have to absorb the dollar cost of part or all of the wheelchair. Medicare may also declare the claim to be fraudulent and even impose fines on the supplier.
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| •Advance Determination of Medicare Coverage (ADMC) |
You or your wheelchair supplier can request that Medicare make a determination prior to delivery of the wheelchair to find out whether Medicare will pay for the wheelchair. Medicare has 30 days to respond to this request. Not a bad thing for you or your supplier to know...
But- This determination is not the official last word. Things can change depending upon what they see when they receive the entire documentation package. If Medicare returns the ADMC, and changes need to be made to better explain or justify your need for a wheelchair, then keep a calendar close by since you can only submit this request once every six months. Even if you get an affirmative answer from Medicare, the thumbs up does not extend to the price of the wheelchair. Hey, I'm not making this stuff up, they are.
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| Durable Medical Equipment Regional Carrier (DMERC) |
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The DMERC's are the ones who will ultimately decide if you get the wheelchair that your physician, therapist and equipment dealer have recommended for you. They will also be the last word on how much Medicare will pay for the wheelchair. Medicare has divided the nation into four regions, each region has a DMERC that is responsible for handling claims in certain states assigned to them.
But- The DMERC's are not government or Medicare departments. They are private sector companies that have been contracted by Medicare to manage these programs. Medicare issues guidelines and policies that they follow. The DMERC regions are identified by the letters A, B, C, and D. Presently the DMERC contractors are:
| DMERC's |
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| Region A- Healthnow New York, Inc. |
www.umd.nycpic.com |
| Connecticut, Delaware, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. |
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| Region B- Adminastar Federal, Inc. |
www.adminastar.com |
| IL, IN, MD, MI, MN, OH, VA, WI, WV and Washington DC |
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| Region C- Palmetto GBA |
www.pgba.com |
| Alabama, Arkansas, Colorado, Florida, Georgia, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas and the Virgin Islands. |
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| Region D- CIGNA |
www.cignamedicare.com |
| Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Mariana Island, Missouri, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming. |
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| •Medically Necessary or Unnecessary? |
| Medically necessary or unnecessary are the responses most often used by Medicare to describe items they approve for funding and those that they do not. It is based on whether or not they determine, by their rules and interpretations, if the wheelchair is or is not medically needed, and if it meets the needs of the intended user. |
| But- There is a dramatic difference between a wheelchair being medically necessary by Medicare's standards and by the medical and clinical communities standards. If you are able to push your manual wheelchair well enough within your home to accomplish (to some extent) your daily in-home tasks and activities then Medicare would decide that a power wheelchair was "Medically unnecessary". The fact that a powered wheelchair would make you more functional and independent in general doesn't count. The fact that you are unable to push your wheelchair to the doctors office 1/2 mile away, or to the pharmacy around the corner, or to the grocery store up the block, or even to your shrink's office in the next apartment doesn't matter much to Medicare either. Medicare's regulatory interpretations dictate that they consider only those activities and functions that take place "in the home". Right back to square one again. |
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