Navigating the healthcare system and its processes may prove difficult more so when you don’t have any experience dealing with them. Getting a wheelchair is one of those challenging processes to undertake. However, most health insurances pay for adaptive devices when medically necessary, including a wheelchair.
Medicare is a government program that provides healthcare coverage for people who are either 65 or above. In some cases, medicare also offers coverage to certain younger people who have disabilities. In addition, it is offered to people with permanent kidney failure who undergo dialysis or require a kidney transplant, a condition referred to as End-Stage Renal Disease (ESRD).
This program has been around since 1966 and is managed by the Centers of Medicare and Medicaid Services. It has about 35 private insurance companies affiliated with it and is funded by the federal budget and the taxes you pay on your pay stubs.
If you have a disability and face mobility problems, your doctor may recommend a wheelchair to help you get around. Medicare Part B covers up to 80% of the allowable charges as long as you have met all your deductibles and satisfied specific eligibility requirements.
We will go deeper into what exactly this means and also look at what your wheelchair options are as a Medicare beneficiary. Read on to learn more.
Will Medicare Pay for a Wheelchair?
Yes, Medicare can pay for a wheelchair. The federal Medicare program provides coverage for a number of durable medical equipment, including wheelchairs when determined to be medically necessary for you by your doctor.
As long as you meet your deductibles and have a doctor’s prescription, you will get compensated.
However, only manual wheelchairs fall under the durable medical equipment bracket. Medicare pays for power wheelchairs when a beneficiary is deemed unable to operate the manual wheelchair by a doctor.
Types of Medicare Plans
There are four main types of Medicare plans that vary in their services and administrators.
However, the members eligible for Medicare can choose between the Original Medicare Plan and Medicare Advantage Plan.
The United States government manages the Original Medicare Plan. It is a fee-for-service option designed for people who require medical services from both parts of an insurance plan. Members under this option are at liberty to visit any health facility in the United States and receive insurance coverage.
On the other hand, Medicare Advantage Plans are provided by private companies that contract with Medicare.
Here are the most common plans under Medicare:
Medicare Part A (Hospital Insurance)
Medicare Part A covers inpatient hospital care for people who pay Medicare taxes while working. One can also purchase this plan.
This plan includes:
- Inpatient care up to 90 days in a general hospital and up to 190 days in a Medicare psychiatric hospital.
- Up to 100 days of skilled nursing care in a nursing facility.
- Unlimited time of intermittent care or up to 100 days of home healthcare services.
- Certified hospice care for terminally ill patients.
Medicare Part B (Medical Insurance)
Medicare Part B requires payment of a monthly premium. Deductibles and co-payments can also apply to his plan.
This plan includes:
- Durable medical equipment such as wheelchairs and scooters.
- Provider services from a licensed health professional.
- Preventive services such as screening and counseling.
- Occupational therapy services.
Medicare Part C – Medicare Advantage Plans
Medicare Part C covers services offered by private companies. This plan covers Parts A and B and may also provide Part D coverage.
These plans include:
- Health Maintenance Organizations (HMO)
- Preferred Provider Organization (PPO)
- Special Needs Plans
- Private Fee for Service Plans (PFFS)
- Medicare Medical Savings Account (MSA)
Medicare Part D – Prescription Drug Coverage
Medicare Part D covers prescription drugs from private companies that have the approval of Medicare.
This plan is optional and requires a monthly premium from members.
When Does Medicare Cover Wheelchairs
Wheelchairs are covered under Medicare Part B as durable medical equipment (DME). This follows a doctor’s prescription in treating a medical condition at home.
In this case, hospital care under a Medicare plan or a nursing facility will not qualify as your home. However, a long-term care facility would suffice.
A medical examination by your doctor, which can be via telehealth or in person, must be done before a written prescription is given.
The doctor’s prescription will emphasize that:
- You have difficulty in mobility, impeding your ability to get around your home. However, Medicare will not cover a wheelchair if you only need it for recreational activities or leisure.
- You have someone to help you use the wheelchair, or you can physically use the equipment on your own safely.
- Both the equipment supplier and the doctor who orders the wheelchair are Medicare-authorized and participate in the program.
How Medicare Coverage Works with Wheelchairs
Under Medicare guidelines, wheelchairs are considered durable medical equipment (DME). These are covered under Medicare Part B.
Generally, you are required to pay 20% of the Medicare-approved service, called coinsurance. This is after meeting your Part B deductibles for the year. The Medicare Plan will pay the remaining balance of 80%.
However, the amount payable may vary depending on the DME in question. Medicare gives you the option of either renting or buying a wheelchair.
Understanding Durable Medical Equipment Under Medicare
Any equipment that is used repeatedly for your health needs qualifies as durable medical equipment. Although Medicare does not cover all of the durable medical equipment that you may need, it does wheelchairs.
If your primary care physician prescribes a wheelchair, then your DME supplier will send Medicare the documents for you.
However, you can forward the request and documents to Medicare yourself if you so wish. Once Medicare has gone through your request and reached a decision, your wheelchair supplier will receive a letter that will outline the determination.
You can also contact the wheelchair supplier and Medicare directly to collect the decision letter.
There are limits regarding the functionality that is covered. Therefore, it is important when looking at your coverage options on wheelchairs to help with your medical condition and seek more information concerning durable medical equipment.
You can learn more about durable medical equipment covered by Medicare at medicare.gov.
Criteria for Medicare to Cover a Replacement for Durable Medical Equipment
For you to be covered for any replacement of your wheelchair under Medicare, the equipment supplier must be Medicare-approved.
Here are the criteria to qualify for a wheelchair replacement:
- If your wheelchair is lost.
- If your equipment is stolen.
- If your equipment has experienced extensive damage.
- If your wheelchair is more than five years old.
Understanding Part B Medicare Coverage for Wheelchairs
Generally speaking, medically necessary wheelchairs are covered by Medicare Part B. Medicare Part B program is the part of Original Medicare covering outpatient healthcare costs.
Wheelchairs fall under outpatient healthcare costs, so it makes sense that this is where wheelchair coverage will come from.
Where you are unable to perform your daily activities because of mobility issues, a wheelchair will be covered.
Requirements for Medicare to Pay for Your Wheelchair
Medicare covers durable medical equipment that is reusable. This includes wheelchairs that your doctor has prescribed as medically necessary.
Here are some requirements for Medicare to pay for your wheelchair:
- Be a citizen of the United States or be a legal permanent resident for at least five continuous years.
- A doctor must prescribe a wheelchair.
- Under durable medical equipment, only manual wheelchairs are covered.
- Power wheelchairs are covered only when determined to be medically necessary.
- You may either purchase or rent a wheelchair.
- The wheelchair must be deemed appropriate for home use.
- The wheelchair must be able to withstand repeated use and last for three years or more.
- The wheelchair must serve a medical purpose.
Types of Wheelchairs Covered by Medicare Plan
Let’s look at what wheelchairs are covered by Medicare:
Manual wheelchair
A manual wheelchair is basically a wheelchair that either you or someone else has to push to enable you move around your house. Your doctor might order a manual wheelchair where he has ascertained that you have enough upper body strength or someone available to help you.
This is when you can not use a walker or cane to help you move around safely. You may rent an appropriate manual wheelchair first and eventually buy it.
Power-operated wheelchair
The final wheelchair covered under Medicare is a power or electric wheelchair. You may be eligible for this option if you can not operate a manual wheelchair and do not qualify for a power-operated wheelchair.
However, your physician must submit a written order after a face-to-face exam to Medicare detailing why you need the device and certify that you are physically capable of operating it.
In general, a power wheelchair can be approved when your upper body is not strong enough to operate a manual wheelchair, and you are not able to sit up and operate it safely.
Power wheelchair
The final wheelchair covered under Medicare is a power or electric wheelchair. You may be eligible for this option if you can not operate a manual wheelchair and do not qualify for a power-operated wheelchair.
However, your physician must submit a written order after a face-to-face exam to Medicare detailing why you need the device and certify that you are physically capable of operating it.
In general, a power wheelchair can be approved when your upper body is not strong enough to operate a manual wheelchair, and you are not able to sit up and operate it safely.
Prior Authorization of Wheelchairs Under Medicare
Certain wheelchairs may require you to get prior authorization before Medicare can cover them. These include different kinds of power wheelchairs.
Medicare will usually ask for prior authorization from your wheelchair supplier to ascertain whether or not you are medically eligible.
Your wheelchair supplier will send all the required documents together with a request to Medicare.
However, you can get all the required documents from your doctor and wheelchair supplier and submit the request yourself.
Medicare will vet your application to make sure that you are eligible and all requirements for the device have been met.
With prior authorization, your Medicare coverage and benefits do not change, and there should be no delays in getting the wheelchair that you need.
How to know if the prior authorization request is approved
Once the prior authorization request has been approved, Medicare will send a decision letter to your wheelchair supplier.
You may also contact your wheelchair supplier about the decision by calling 1-800-MEDICARE (1-800-633-4227).
Also, your wheelchair supplier may send you a decision letter.
What can make your request be declined?
Your request for prior authorization may be denied if:
- Medicare finds it that you do not medically require a wheelchair.
- If you do not provide all the information required by Medicare to make a decision.
Conclusion
If you have a medical condition preventing you from freely moving around your house, a wheelchair might solve your mobility issues.
In such a situation, Medicare covers wheelchairs up to 80%. You only pay for the other 20% if you use Medicare Part B.
Medicare Part B covers allowable charges for different types of wheelchairs as durable medical equipment (DME) under certain conditions. The doctor must be enrolled in Medicare and conduct a face-to-face evaluation to determine whether you have a medical necessity and can operate a wheelchair before Medicare can pay for it.
