WHAT IS COVERED?

Medicare Part B covers the rental or purchase of a manual or power wheelchair or scooter for use primarily at home or a facility that is used like a home. Equipment may be used outside the home, but improving mobility for activities that take place in the home is primary. Care must be Medically necessary, ordered by a licensed physician or medical provider, and Medicare must agree that it is necessary and proper.

Medicare does not consider a skilled nursing facility or a hospital a home. A beneficiary who is in such a facility is not eligible.

Beneficiaries can have either a permanent or temporary disability that impairs mobility.  The beneficiary need only show capacity and willingness to use the equipment in a safe manner in the home, and that it will improve mobility and therefore health.

Improvements to health through the use of a PMD include using the PMD to assist in performing personal care tasks such as grooming, feeding and bathing (MRADLs).

FIRST: UNDERSTAND THE VOCABULARY

Here are a few acronyms and their definitions that help you understand coverage criteria.

The Centers for Medicare & Medicaid Services (CMS): The government agency that administers Medicare.

Mobility Assistive Equipment (MAE): CMS uses MAE to refer to a variety of items including canes, crutches, walkers, manual wheelchairs, power wheelchairs and scooters.

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Power Mobility Devices (PMDs): A PMD is a class of wheelchairs that includes a power wheelchair or a power operated vehicle, like a scooter.  The distinction between the two devices is whether the PMD is operated by a joystick or electronic device (motorized wheelchair) or a tiller (scooter).

 Mobility Related Activities of Daily Living (MRADLs): Personal care tasks where the inability to perform them independently would have a negative effect on one’s health.  These include grooming, feeding, and bathing.

CMS ASSESSMENT TOOL

The CMS Assessment Tool is used to determine if a particular MAE will improve the health of the beneficiary by allowing them to continue to perform Mobility Related Activities of Daily Living on their own.  The Tool includes nine questions. Answers should be supported by documentation when possible.

1. Does the beneficiary have a mobility limitation that significantly impairs his/her ability to participate in one or more of the MRADLs in the home?
2. Are there other conditions that limit the beneficiary’s ability to participate in MRADLs at home?
3. If these limitations exist, can they be ameliorated or compensated sufficiently such that the additional provision of MAE will be reasonably expected to significantly improve the beneficiary’s ability to perform or obtain assistance to participate in MRADLs in the home?
4. Does the Beneficiary or caregiver demonstrate the capability and the willingness to consistently operate the MAE safely?
5. Can the functional mobility deficit be sufficiently resolved by the prescription of a cane or walker?
6. Does the beneficiary’s typical environment support the use of wheelchairs including scooters?
7. Does beneficiary have sufficient upper extremity function to propel a manual wheelchair in the home to participate in MRADLs?
8. Does the beneficiary have sufficient strength and postural stability to operate a scooter?
9. Are the additional features provided by a power wheelchair needed to allow the beneficiary to participate in one or more MRADLs?

IN PERSON EXAMINATION, PLUS PRESCRIPTION

The Beneficiary, their caregiver, and their clinician must meet face-to-face to determine the appropriate MAE. The practitioner must conduct a face-to-face examination before writing a prescription. The prescribing physician will also have to provide additional documentation.

RENT OR PURCHASE 

Beneficiaries should make sure the supplier they are working with is a Medicare supplier and that the supplier has a Medicare supplier number in order to minimize their out-of-pocket costs.

Medicare Part B pays 80% of the Medicare-approved amount for equipment rental.  During the rental period, the supplier maintains and repairs the equipment at the patient’s home or may pick it up and return it.

Payments are capped at 13 months total, after which the patient owns the equipment.  Medicare will pay for maintenance and repair.