What You Should Know About Wheelchair Reimbursement

Getting a power wheelchair can seem complicated, but if you follow the right path, it doesn’t have to be difficult. It’s helpful to know something about what Medicare and most health insurance companies require right from the start.

Most power wheelchairs qualify for potential reimbursement under Medicare Part B and health insurance. If you need a power chair for mobility and you meet your insurance coverage guidelines, all or part of the cost of the power chair may be covered. Criteria and payment amounts may vary depending on the type of insurance you have. Most health care insurance companies, including Medicare, have minimum requirements that need to be met before they will purchase a power chair for you.

Medicare has changed the coverage criteria and documentation requirements for Power Mobility Devices (PMD) for dates of service on or after May 5, 2005. They have modernized the policy and replaced the “bed or chair confined” requirements; now the beneficiary’s ability to safely participate in one or more mobility related activities of daily living (MRADLs) can be considered.

A face-to-face examination with your referring physician is required before a PMD can be prescribed. Your doctor must document the physical need for a wheelchair and refer you to a physical or occupational therapist who is a wheelchair seating specialist.

Medicare looks for the following information from your physician:

• What is the patient’s mobility limitation and how does it interfere with the performance of activities of daily living?
• Why can’t a cane or walker meet the patient’s mobility needs in the home? 
• Why can’t a manual wheelchair meet the patient’s mobility needs in the home? 
• Why can’t a power-operated vehicle meet the patient’s mobility needs in the home? 
• Does the patient have the physical and mental abilities to operate a power wheelchair in the home?

Once the prescription is written, the prescription and medical records documenting the in-person visit and evaluation must be sent to the equipment supplier within 45 days after the completion of the evaluation. It typically takes about 3 to 4 months to get a power wheelchair.

There are a wide range of commonly asked questions:

• 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 on the type of power wheelchair you choose and on your state of residence. 
• 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 a claim along with the CMN is sent to Medicare. 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? At this time, Medicare offers advance determination of Medicare coverage (prior authorization) for certain types of power wheelchairs. The power wheelchairs eligible are those that come with a power tilt or power recline seating system or some type of specialty control device. If your physician prescribes a power wheelchair with one of these options, a request to Medicare to see if you qualify can be sent in advance. Medicare will let you know within 30 days if you medically qualify.

For more information, contact Alisa Brownlee, AT, at abrownlee@alsa-national.org.