Funding - Power Wheelchairs

POWER WHEELCHAIR FUNDING

GENERAL MEDICARE INFORMATION

Overview

Medicare is a federally funded health insurance program, designed to provide health insurance to people age 65 and over and certain people with disabilities. The Health Care Financing Administration (HCFA) runs the Medicare program, and the Social Security Administration helps by enrolling qualified participants into the program.

Medicare has two parts. Part B is the medical insurance part of Medicare that pays for Durable Medical Equipment (DME). In order for Part B carriers to be reimbursed for DME, two conditions must be met. First, the DME must be necessary and reasonable either in the treatment of an injury or illness, or in improving the function of an impaired body part. Second the DME must be for use in the individual's home. The necessary part of the first requirement is met by obtaining a doctor's prescription that includes the diagnosis and prognosis for the individual, the reasons behind prescribing the DME, and the length of time that the DME will be needed. The requirement for reasonableness is much more complex. The guidelines the Part B carrier can use in determining reasonableness include weighing the expense against the anticipated therapeutic benefits, investigating less costly alternatives, and determining if the DME will serve the same purpose as equipment readily available to the individual. If the DME fails the reasonableness test, reimbursement in full is usually denied.

Eligibility Requirements

Medicare is health insurance coverage for those persons who are either 65 years of age or older, who are blind, totally and permanently disabled and have been receiving Social Security disability payments for 24 months, or who have end-stage renal disease. Many Medicare recipients are also eligible for Medicaid benefits. In those cases Medicaid will pay the Part B insurance premiums plus the co-insurance and deductible amounts and other charges sponsored by Medicaid but not covered by Medicare.

Application Process

You can apply for Medicare at the local offices of the Social Security Administration.

Social Security

Power Wheelchair Reimbursement

Most power wheelchairs are recognized and qualify for potential reimbursement under Medicare and other Health Care Insurance Companies.

If you need a power chair for mobility and you meet your insurance's coverage guidelines, they may pay for all or part of the cost of the power chair. Coverage criteria and payment amounts will vary depending on the type of insurance you have. Most heath care insurance companies, including Medicare, have minimum requirements that need to be met before they will purchase a power chair for you.

Motorized/Power Wheelchair

Medicare Coverage Criteria

A power wheelchair is covered when all of the following criteria are met:

1. The patient' s condition is such that without the use of a wheelchair the patient would otherwise be bed or chair confined; and,

2. The patient' s condition is such that a wheelchair is medically necessary and the patient is unable to operate a wheelchair manually; and,

3. The patient is capable of safely operating the controls for the power wheelchair.

A patient who requires a power wheelchair usually is totally nonambulatory and has severe weakness of the upper extremities due to a neurologic or muscular disease/condition. If the documentation does not support the medical necessity of a power wheelchair the power wheelchair will be denied as not medically necessary. Options that are beneficial primarily in allowing the patient to perform leisure or recreational activities are noncovered. A power wheelchair is covered if the patient' s condition is such that the requirement for a power wheelchair is long term (at least six months). Payment is made for only one wheelchair at a time. Backup chairs are denied as not medically necessary. Reimbursement for the power wheelchair includes all labor charges involved in the assembly of the wheelchair and all covered additions or modifications. Reimbursement also includes support services, such as emergency services, delivery, set-up, education, and on-going assistance with use of the wheelchair.

If you feel you meet these requirements, you may be eligible to receive the most stylish, best performing and most reliable power chair available on the market today at little or no money out of pocket.

Beneficiary Information

Power Wheelchair

Dear Medicare Beneficiary,

You may be eligible to receive a portion of your money back from Medicare when you purchase a power wheelchair. To qualify you must have Medicare Part B coverage and meet certain medical coverage criteria as determined by your physician.

Here are some common questions regarding Medicare Reimbursement.

Will Medicare pay for a Power Wheelchair?

If you qualify, Medicare will pay for a portion of your power wheelchair.

If I qualify, how much will Medicare pay towards the purchase of a power wheelchair?

Medicare will pay 80% of a set allowable for a power wheelchair. The amount depends the type of power wheelchair you choose and on your state of residence. On average the amount reimbursed by Medicare is around $4,000.00.

How do I know if I qualify?

Medicare has certain medical criteria that need to be met before Medicare will pay for a power wheelchair. Medicare requires a Certificate of Medical Necessity, also known as a CMN, to be completed by your physician

How do I submit a claim to Medicare? What other information needs to be sent?

Once a completed CMN signed by the physician is obtained we will submit a claim along with the CMN to Medicare on your behalf. Medicare will process your claim and inform you of their payment decision in about 30-45 days.

Can I find out if I medically qualify before I purchase the Power Wheelchair?

No, Medicare does not have a Prior Authorization process available at this time.