How to Get a Wheelchair Covered by Medicare
Navigating the health care system can be really difficult, especially when you don’t have any experience dealing with it. One of the most challenging processes to understand is getting a wheelchair or mobility device. Most health insurances pay for just a handful of adaptive devices that you would use at home but one that they do cover when medically necessary is a wheelchair. For the purposes of this article, we will focus on Medicare guidelines as it is the largest payer system in America and most of the other commercial insurances follow their guidelines as well.
Medical Necessity Meaning
The first thing that is important to understand is the meaning of medical necessity. Many think it means as long as a medical occurrence or health issue is the cause for needing the device, and one of your care providers (doctors, nurses, therapists) agrees that you need it then that qualifies as medical necessity. While we on your healthcare team would love that to be true - it’s not! Medical necessity is actually defined by the payer (Medicare). While they do require a prescription from a physician or nurse practitioner to help verify the need, Medicare also gets to set the rules as to when it is necessary to purchase a device.
How is Medical Necessity Proven?
It’s actually a collaborative process with multiple professionals. Let’s dig into each role.
Physician or Nurse Practitioner
You will need a face to face visit with your provider. It now can be done via video if your provider offers that! It can be your primary care doctor or a doctor you are seeing at the hospital or a speciality clinic. In the notes they write about your visit they will have to agree that a wheelchair is necessary and will need a statement about why. They will also need to write a prescription as well for the wheelchair and for a mobility evaluation to be completed by a physical therapist or an occupational therapist.
2. Occupational Therapist or Physical Therapist
The therapist will need to complete a detailed evaluation of your limitations and what daily tasks you are having trouble with in order to determine what types of device will be needed to help make you as independent and as safe as possible doing your everyday things. This can happen with any therapist at any level of care including in the hospital, home health or outpatient. Their goal is to be the expert about your needs so that the best device and components can be ordered to meet those needs. Their evaluation will go back to the physician for signature and to the wheelchair vendor who will be supplying the chair.
3. Wheelchair Vendor & Assistive Technology Professional (ATP)
This is the company that is going to do all the leg work and will be your contact for everything for the life of the chair. They usually are the ones to coordinate all the pieces including sending the paperwork to your physician for signature, helping you get your mobility device evaluation completed with a therapist, sending all the information off to Medicare for approval and finally providing you with a wheelchair. They are your point of contact if you have any issues with the chair once you have it and for the 5 years Medicare expects that you will have it before (if) a new one is needed. They are also usually the one with an assertive technology professional (ATP) on staff. The ATP is the expert on all the devices and components that are available so that they can collaborate with the therapist and match what equipment is available to solve the problems that the therapist identifies that you have or may have in the future.
Where Do I Start To Get a Wheelchair?
Of course to make this picture even muddier the answer is it depends on what’s easiest for you based on where you are. If you are in the hospital or rehab your team of therapists, physicians and case managers will help you. If you are working with a therapist in home health or in outpatient they can help get the process started. And if you are at home without any services yet, start with the wheelchair vendor and they will get everything rolling!
How Do I Get a Scooter On Medicare?
Its the same process. That’s why the visit that you have with the therapist and the ATP is called a mobility device evaluation. It’s their job to match your needs with the right type of device. Those devices include a manual wheelchair, scooter, standard power wheelchair or a complex power wheelchair. If you know you are interested in a scooter be sure you say that when you contact one of the professionals and they will help ensure it is going to be safe and appropriate for your needs.
How Long Does it Take to Get a Wheelchair?
Well again it depends on a few factors. This includes what type of device you need, the vendor you work with, how quickly all the steps and paperwork get done and how long your insurance takes to approve it. So for a standard manual chair you can get it right away as you leave the hospital. For a custom wheelchair it could be as little as 3 weeks but it could be up to 3 months.
Should I get a custom wheelchair?
We think you should always ask about a custom wheelchair first for two reasons:
1. Getting a chair that is built for your needs can make things much easier in the long run, although it takes more time up front. If you are going to use wheelchair for more than a couple months its worth it to try to get something that has some better features to meet your needs.
2. Medicare considers the life of a mobility device to be 5 years. So they don’t want to pay for another device within 5 years unless your ability level declines and it can be proven that the chair you have is not meeting your needs. So getting the best chair to start with keeps you from having to go through the process again.
The disclaimer though is that not everyone qualifies for a custom chair. Only your team of professionals can help prove that out. But you and your family are still your best advocates! So get all the information you can by asking the questions first!
Have More Questions Now?
Reach out to us at AccessAble Living. We serve as the occupational therapists that do the mobility device evaluation (see How is Medical Necessity Proven section above). So we can help get the process started and are very knowledgable to answer your questions based on your needs.
Proud to be your aging-in-place resource in Kansas City and Wichita for wheelchair ramps, shower chairs, and everything in between!