Funding for Wheelchairs
Written by: Mary Ellen Buning, PhD, OTR/L, ATP; Mark R. Schmeler, MS, OTR/L, ATP; and Barb Crane, MS, PT, ATP.
The prescription and evaluation parts of the process of getting a new wheelchair have been discussed. It is now time to learn something about getting funding for a wheelchair or wheelchair-related equipment.
For an overview, look at this table of "Sources of Funding for Wheelchairs"
The Rehabilitation Technology Suppliers (RTS are the professionals who sell, service, deliver and adjust your wheelchair... sometimes they are called Durable Medical Equipment [DME] salespersons) know the funding systems very well. In fact, larger RTS companies usually hire a funding or reimbursement specialist to help their customers and work with their customer's insurance companies. Insurance is the primary way RTS companies get payment for their products and they are familiar with the rules and regulations of Medicare, Medicaid and many private health insurance companies.
A new trend is for a managed care organization (MCO) or health maintenance organization (HMO) to own and refer its clients to the Durable Medical Equipment (DME) company that the MCO/HMO owns. If the MCO/HMO places a high value on the functional outcomes and the quality of life of its customers and supports a quality DME business then this can be a good thing. If this is not the case then this could be a reason to avoid a certain health care provider, especially if you know that your ongoing health and wellness needs will involve using and/or replacing a wheelchair.
Private health insurance used to mean "fee-for-service" or an indemnity plan. You went to the doctor, and then either you or the physician billed your insurance for the cost of the visit. This has all gotten much more complex with the arrival of managed care. Managed care has blended health insurance with the actual delivery of health care services. This has created new categories of health care service delivery and alphabet names like PPO, MCO, and HMO. If you are ready to educate yourself about the current situation with health insurance, check out some excellent consumer information like: Health Insurance Association of America Guide to Health Insurance and another one entitled: Choosing & Using A Health Plan from the Health Insurance Association of America.
All insurance policies have statements written into their policies about whether they will or won't cover wheelchairs and other durable medical equipment. Usually within the list of what they will cover is a statement of what they won't cover. It is important to get a copy of your policy and see exactly what is said about your coverage for things like wheelchairs. In fact, if you know that your ongoing health and wellness needs will involve using and/or replacing a wheelchair this can be a reason for choosing or not choosing a health insurance company.
Since larger DME dealerships hire a reimbursement or insurance specialist make use of this person to help you. This is a person who is familiar with insurance company policies and procedures. They can ask the right questions of claims adjusters at your insurance company. The procedural knowledge of a funding specialist can be very helpful to both individuals who need wheelchairs and to the professionals who want to see their patients get a good match with the right wheelchair.
As defined in Title XIX of the Social Security Act, Medicaid is a joint Federal-State program which pays for medical services to eligible low-income and vulnerable families and individuals. Medicaid is managed at the Federal level by CMS, the Center for Medicare and Medicaid Services, which is a good source of basic information about this source of funding. Each State must offer basic services in order to receive Federal matching funds, but it is important to remember that the Medicaid program varies from State to State. Check here for a link to Medicaid resources for all 50 states which could help you find the program in your state. The Medicaid Clearinghouse is another useful site which has the goal of educating and informing those who have an interest in making the Medicaid more effective.
Though covered services for adults can vary between states, all states are required to offer a comprehensive set of services for children ages birth to 21. Medicaid is required to meet Federal requirements for coverage of children's health care under their program called Early Periodic Screening, Diagnosis and Treatment (EPSDT). This commitment to children can make Medicare a strong source of funding support for children who use wheelchairs. Waivers, generically called "Katy Beckett Waivers," are available in most states. This waiver allows families who have a family income that is larger than the poverty level to apply for a waiver. The waiver makes the child eligible for Medicaid funding which is used in combination with the family's health insurance. Other kinds of waivers are available to provide for the complex needs of children with certain diagnoses or disabilities.
A related program managed by HCFA is the Children's Health Insurance Program (CHIP) which has been adopted in most states for the purpose of making health insurance affordable for all children. The family income guidelines are more liberal and the premium is very low.
Medicaid is a "vendor payment" program, and States usually pay for Medicaid services through HMOs or directly to pre-authorized providers. When you are buying a wheelchair or related equipment, the RTS company must accept the Medicaid payment rate as "payment in full." States may elect to impose deductibles, coinsurance, or co-payments on Medicaid recipients for some services.
Medicare is one important source of funding for wheelchairs and durable medical equipment. First, it is important to understand your basic Medicare benefits. Use the Medicare website, which is the official US Government Site for Medicare Information. It contains all of their publications and one in particular "Medicare and You 2000" gives an excellent overview to the process.
Essentially, Medicare Part A covers you while you are in the hospital or getting skilled nursing care. If you need a wheelchair in those kinds of health care facilities you will use what they provide for you to use. Medicare Part B for those who are eligible covers a range of outpatient health care services like a health insurance policy. This is the part of Medicare that pays for wheelchairs.
When it comes to information about durable medical equipment, consumers and rehabilitation technology suppliers must deal with the Durable Medical Equipment Regional Carrier (DMERC) that serves your state. Part B of Medicare divides the United States into 4 regions with a contractor within each region who administers and processes all of the claims for durable medical equipment within the region. Your first job is to determine which DMERC is responsible for your state. This DMERC Link will give you the toll free number for the DMERC for your state. Besides an 800 number, each DMERC has information in various formats to help you with any questions regarding equipment, a claim or an appeal.
All DMERCs use the same codes (called K codes) and the same reimbursement rates. However, each of the four DMERCs implements and manages the Medicare reimbursement process a little differently than the others. This means there will be some differences in procedure or implementation between regions. For example, a new policy will soon be implemented in Region B for all claims for power wheelchairs. The new procedure will require an OT or a PT to be involved in the evaluation and justification for any power wheelchair. The procedure is designed to add a professional assessment to protect the consumer from a wheelchair retailer who may not take the time to truly assess the patient's needs.
Medicare has some very clear guidelines about buying wheelchairs. The wheelchair must be required in order to provide a safe and functional means to get around inside the house. Medicare is only interested in funding wheelchairs for use within the home. Therefore all documentation, the letters of justification and the Certificates of Medical Necessity (CMN), must support and explain the need for the wheelchair within the home. The fact that it can also be used outside of the house is incidental and is actually irrelevant. The mobility device, whether motorized or manual, must be required for moving around within the home. The question Medicare asks on the CMN is: "Does the patient require and use the w/c to get around the home?"
If Medicare is your primary health insurance then there are some additional things that you should know if you want Medicare to pay for your wheelchair. Medicare has strict rules when it comes to payment for durable medical equipment. They have a list of authorized or "pre-approved" wheelchairs. These wheelchairs appear on the HCPCS (pronounced "HicPics") list and are the only ones for which Medicare will pay. However, most brands of wheelchairs fit into one of their categories. Medicare pays 80% of the cost of a wheelchair and either you or your secondary insurance pays the other 20%.
Medicare uses a coding system in which products are given a number or a "K Code" based on their features. The K Codes include:
The most common categories of wheelchairs purchased by Medicare are the standard wheelchair (K0001), the standard hemi wheelchair (K0002) (which has a low seat so it can be propelled with the feet), the lightweight, and the lightweight wheelchair (K0003) or the active duty lightweight wheelchair (K0004). To avoid buying these wheelchairs (when they may only be needed for a short time) Medicare pays to rent these wheelchairs for you for the first 10 months that they are used. At the end of this period, if the wheelchair is still needed Medicare will go ahead and purchase the wheelchair if the user wishes it to be purchased.
Medicare will send out what is called a "rent/purchase" option letter which allows the individual using the chair to determine if it will be purchased or will continue in a rental status. Medicare will then pay the rental fee for another three or five months (depending on the option selected). The person using the chair will be able to use it for as long as they need it. In the case of the purchased chair, it is owned by the individual and in the case of the rental chair it is owned by the vendor or RTS. Regardless, the individual using it has use of it for as long as they qualify for this chair under Medicare's rules.
Medicare must see a relationship between the consumers mobility and seating needs and the "K Code" of the wheelchair or cushion that is being recommended by your clinician. For this reason a letter of justification or of medical necessity is a very important part of getting you the equipment that you really need.
There are six more categories of wheelchairs which have features such a being light weight, or heavy duty or powered or reclining, etc. However, Medicare requires extensive documentation and strong letters of justification based on your evaluation before it will pay for them. Their decision to fund these more expensive or custom wheelchairs is based on the clearness of the documentation of the consumer's needs. These codes also are purchase codes -- meaning that these chairs may be purchased outright for the consumer and do not have to go through the rental period. Suppliers may choose to offer these chairs as rental items, but they do not required to do so.
If your Medicare coverage is provided through an HMO, then the HMO may regulate this process. Your HMO may bypass the DMERC process by limiting which DME company you can go to purchase a wheelchair. It is important to know, however, that your HMO must supply a minimum of what Medicare would cover -- they cannot supply less.
The DME (Durable Medical Equipment) companies sell a lot of the standard wheelchairs paid for by Medicare. Within the Medicare system, the characteristics of the categories (K Codes) of wheelchairs are linked to the patient's potential for independence within their daily living environments. If Medicare is your only source of payment or you are financially limited you really don't have much choice beyond the models of wheelchairs that Medicare has approved. However, it is important for you to realize that even though the K Code category is already limited, there are differences among the features, of the 5 or 6 brands of approved wheelchairs in that K Code. You should realize that a DME dealer will only show you the wheelchair brands in that K Code that are in the line-up of brands sold by the company he or she represents.
Of all the forms of insurance, Medicare does the strictest reviews of medical necessity. It does not do any "predetermination" or deciding ahead of time whether or not it will authorize a particular mobility device. A claim for a wheelchair must be submitted, after the provision of the equipment, and it will either be accepted or downgraded or denied based on the CMN and the case that is made in the letter of justification. Medicare is expecting the therapist or the doctor to "paint them a picture" of why they should not deny the claim.
Reimbursement for a wheelchair is a combination of having
In categories, K0001 through K0003 just fill out the forms correctly and no letter is needed to justify any special needs. All wheelchairs in these K Codes will always go out for the first 9 months as a rental wheelchair. On the 10th month the consumer can either accept the wheelchair and let Medicare pay for it or they can continue to let Medicare rent it for them (Rent/purchase option explained before).
All K0004 (the code for a lightweight wheelchair which means that it weighs less than 36 lbs.) wheelchairs and scooters (note: these regulations can vary by region) must be authorized by a physician specialist like a Physiatrist, a neurologist, a rheumatologist , an orthopedic surgeon or a cardiologist. It is very important to have a strong letter of justification and a supporting evaluation to justify the purchase of any lightweight or custom ultralightweight manual (K0005) wheelchair or any power wheelchair or scooter.
Another strategy that was previously used when getting Medicare to pay for a wheelchair was called "accepting assignment." The Federal Law, effective September, 1990, changed the way that this strategy was implemented. Now, under the Federal Law it is the responsibility of the Supplier to file Medicare claims. Durable Medical Equipment suppliers must either choose to be "participating" or "non-participating" with Medicare. Most suppliers are participating.
If the Supplier is participating they must accept "assignment." Accepting assignment means that they have to wait to be reimbursed by HCFA for the approved 80% of the Medicare allowable. The Supplier cannot charge the consumer more than the 20% co-payment of the allowable price approved by Medicare.
Non participating suppliers or providers can decide whether or not to accept assignment. The consumer may have more flexibility in getting funding for higher levels of wheelchairs with a non-participating provider. If a provider decides not to accept assignment on a purchase, the consumer can pay for the device up front and the supplier will complete all of the Medicare claims information and submit it to Medicare. Medicare will then remiburse the consumer for the product directly. The supplier cannot charge the consumer more that the "reasonable and customary" charge for the device. The decision must made in November or December of the year prior to the year the supplier wants to become participating. For example, to be a participating supplier in 2001, the supplier will need to have enrolled in November or December of 2000. Both participating and non-participating providers are obligated to complete the HCFA paperwork and submit it to Medicare on behalf of the beneficiary.
In fact, the only time the participating supplier can request any payment from the Medicare consumer before first filing a claim with Medicare is if the Medicare consumer has not paid his or her annual Part B deductible. Even then, that payment total is not to be more than the Medicare Part B annual deductible plus the Medicare approved 20% co-payment amount for that claim. You can find the most current information regarding Medicare assignment in the HCFA's handbook to Medicare Beneficiaries. The handbook is presently titled "Medicare & You 2000." Refer to page 6 (What you Pay for Home Health Care) and page 34-35, Q10-12 (The Original Medicare Plan).
The Paralyzed Veterans of America (PVA) has created a comprehensive resource for those who may be covered for wheelchair beneifits through the Veterans Administration. This 1997 resource, entitled "Wheelchairs: your options and rights," is available on the PVA website.
Because a wheelchair can often be a key piece of equipment for returning to work or continuing to work, Vocational Rehabilitation can be a source of funding for eligible consumers. We have written a summary about Vocational Rehabilitation which describes more about the kinds of services that counselors can offer to the clients on their caseloads. It also includes a link to a WWW search to help you find a vocational rehabilitation office in your state if you think this might be a source of funding for a wheelchair or wheelchair-related equipment or service such as an evaluation.
It is important to realize that wheelchairs are retail products that are sold to customers--people who are buying wheelchairs. Many salespersons are very informed and ethical and highly motivated to offer their customers excellent service. Others are less so. Some DME dealers will only know about a certain line of products or they may limit the products that they show you. Some will have a favorite product or a narrow idea about what they think is best for you. If that product meets your needs and you are happy with it then the outcome can be OK. But, when you are in vulnerable position as an inexperienced consumer, it is good to know that your trust is not being used against you.
This is where the issue of working with a provider who is credentialed can be very important. A company or a salesperson who cares enough to become certified offers you a very high probability that they are trustworthy and knowledgeable. They are assuring you that they are committed to professionalism. The best DME companies are credentialed by the National Registry of Rehabilitation Technology Suppliers (NRRTS). This trade association has a code of ethics and assures the competency of its members by requiring them to get periodic training and continuing education. Reputable companies usually encourage their sales staff to get the NRRTS credential: a Certified Rehabilitation Technology Supplier (CRTS).
Another organization that gives a credential is RESNA, the Rehabilitation Engineering and Assistive Technology Society of North America. RESNA is the professional association in the field of assistive technology, and offers a pair of credentials: the Assistive Technology Supplier (ATS) and the Assistive Technology Provider (ATP). Their website can also help you locate someone with this specialty certification.
The Assistive Technology Supplier (ATS) is usually earned by experienced DME suppliers who have not only technical skills but are committed to understanding and meeting the needs of their customers. The Assistive Technology Provider (ATP) certification is usually earned by OTs, PTs, and rehabilitation engineers who want to demonstrate that they have advanced training and practice skills. RESNA's credentials were also designed to help indicate knowledgeable and professional assistive technology service providers and help safeguard the public.
A letter of medical necessity is usually written by a physician and is addressed to your third-party payer. It tells them that a piece of equipment (usually some kind of medical equipment) is needed because of an authentic or verifiable medical condition or impairment.
A letter of justification is usually written by a person very familiar with the consumer/client and the product recommended.Usually it is a therapist but in some cases experienced rehabilitation technology suppliers write them.
This kind of letter takes the recommendations that come out of the evaluation and correlates them to the features of a recommended wheelchair or seating system to "paint a picture" for the payer. It is a letter that helps the third-party payer understand why certain features or characteristics of the recommended equipment are important.
A letter of justification is an expert opinion about what is best for a particular consumer! If a therapist or supplier is good at writing this kind of a letter that makes them a very valuable resource for helping you get the kind of equipment that you really need.
Go to the WheelchairNet Discussion Area to ask questions or share your thoughts on this topic with others.
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Last Updated: 3-2-2006