When it comes to obtaining Medicare coverage for Mobility Assistive Equipment (MAE),[1] coverage criteria, particularly patient assessment standards, continue to be misunderstood by providers and beneficiaries. The spectrum of fraud and abuse complicates matters. In addition, over the last several years, the Centers for Medicare & Medicaid Services (CMS) has modified its rules for covering Mobility Assistive Equipment under Medicare Part B. These changes were sparked in part by an increase in fraud cases related to power wheelchairs and scooters, items referred to by CMS as Power Mobility Devices (PMDs).
A PMD is defined as 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). These items are a component of the Durable Medical Equipment (DME) category of Medicare benefits.
PMDs Must be Used Primarily in the Home
Beneficiaries who want to get coverage for a PMD can have either a permanent or temporary disability that impairs mobility. Medicare Part B will cover the rental or cost of purchasing a PMD as long as the equipment is used primarily in the home or a facility that is used like a home. Beneficiaries should keep in mind that Medicare does not consider a skilled nursing facility or a hospital a home and thus a beneficiary who is in such a facility would not be eligible for a PMD (or for other Durable Medical Equipment).
Many beneficiaries have been confused by the use of the term "in the home," believing it means that their scooter or wheelchair can't be used outside of the home. The term, however, relates to whether the need for the PMD is based primarily on improving mobility for activities that take place in the home. Additionally, the fact that a beneficiary lives alone, with family, or in a facility that is not a SNF, does not impact eligibility. The beneficiary need only show capacity and willingness to use the PMD in a safe manner in the home, and that the PMD 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 where inability to perform them independently would otherwise have a negative effect on one's health. Personal care tasks include grooming, feeding and bathing or what CMS calls Mobility Related Activities of Daily Living (MRADL).
Assessment Tool for Determining Eligibility for PMDs
In 2005, CMS created a new assessment tool that takes into account a variety of factors in helping to determine if a PMD (or any MAE) is appropriate for a given beneficiary. The assessment 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. An assessment should only be made for a beneficiary who is willing to use the device. The assessment tool includes nine questions and a flow chart that will help practitioners determine the best MAE for the beneficiary. This tool accounts for the individual needs of the beneficiary better than an earlier tool, which was often referred to as the "bed or chair confined" standard. The Beneficiary, their caregiver, and their clinician must meet face-to-face to determine the appropriate MAE. The following are the nine assessment questions, in bold, which focus on a determination for a beneficiary who hopes to qualify for a PMD. When possible, the answers to each should be supported by documentation.
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?
This includes assessing ability to perform the tasks as well as risk of injury in attempting the MRADL. The amount of time it takes the beneficiary to perform a MRADL can also impact the determination of their being limited.
Are there other conditions that limit the beneficiary's ability to participate in MRADLs at home?
This includes vision or cognition problems which would not be helped by a PMD and may limit the beneficiary's ability to use a PMD safely.
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?
This includes caregiver assistance in use of the PMDs. In addition, if there is a way to minimize conditions identified in question 2, above, that require the beneficiary to comply with treatment, coverage could still be denied if the condition is not improved enough to allow the beneficiary to use the PMD safely or if the help of the caregiver does not minimize the effects of the condition.
Does the Beneficiary or caregiver demonstrate the capability and the willingness to consistently operate the MAE safely?
This is not just a determination of the beneficiary's safety while using the PMD but also that of people around them. Any prior history of unsafe behavior is also considered. This may be assessed by having the beneficiary use a variety of other devices that may help improve their independence.
Can the functional mobility deficit be sufficiently resolved by the prescription of a cane or walker?
These criteria will help assess the best device for the beneficiary, both from the stance of improving the health outcome and from a safety consideration.
Does the beneficiary's typical environment support the use of wheelchairs including scooters/Power-Operated Vehicles (POVs)?
The living environment will be assessed including physical layout, surfaces and obstacles that may make using the PMD harder. Changes and improvements to the beneficiary's "home" may be necessary.
Does the beneficiary have sufficient upper extremity function to propel a manual wheelchair in the home to participate in MRADLs during a typical day?
The manual wheelchair should be configured to best suit the beneficiary (seating options, wheelbase, device weight and other appropriate accessories). This will include an assessment of the beneficiary's upper body strength, endurance and range of motion. In addition a care giver who is able to help propel the manual wheelchair will also be considered. Ability to use the chair safely and the layout of the home environment will also be considered.
Does the beneficiary have sufficient strength and postural stability to operate a POV/scooter?
Beneficiaries have to show they can maintain stability to adequately operate the scooter. The PMD that has a joystick operation will require less upper body strength.
Are the additional features provided by a power wheelchair needed to allow the beneficiary to participate in one or more MRADLs?
The features of a PMD which can make them more appealing are the ease of transfers and accommodating a variety of seating needs. These are an important part of determining if the PMD is going to improve the beneficiary's mobility.
Face-to-Face Examination and Prescription Required
The treating practitioner must conduct a face-to-face examination before writing a prescription for a PMD. The practitioner must then write, sign, and date a prescription that must be received by a supplier within 45 days of the examination. If the beneficiary was recently discharged from the hospital, and a face-to-face examination was done during the hospital stay, there is no need for an additional face-to-face as long as the documentation and prescription are received by the DME supplier within 45 days of the date of discharge.
The prescribing physician will also have to provide additional documentation, including medical records or any other documentation that will aid in showing the history of the beneficiary's need for the device. Documentation should also show that the PMD will improve the beneficiary's mobility and that the beneficiary can use the PMD safely. CMS allows payment for the cost of the face-to-face examination as well as the cost of collecting the additional documentation. All of the required documentation should be submitted to the supplier before the supplier submits the claim to CMS. Suppliers must maintain this documentation for seven years.
Advanced Determination of Medical Coverage (ADMC)
Practitioners and beneficiaries may want to obtain an Advanced Determination of Medical Coverage (ADMC) from their Durable Medical Equipment Regional Carrier (DMERC). Obtaining an ADMC does not require the same level of documentation that is necessary for a determination of Medicare coverage. It can, nevertheless, help the beneficiary to assess any potential issues that may be an impediment to coverage. It is important to note, however, that a positive ADMC does not mean that coverage is guaranteed, since the full assessment and other supporting documentation may reveal a reason for the denial of the PMD.
Co-payment Responsibility
Beneficiaries should make sure the supplier they are working with is a Medicare supplier and that the supplier has a Medicare supplier number. Beneficiaries are responsible for a 20% co-payment of the amount authorized by Medicare. In addition, if the supplier does not participate in the Medicare physician/supplier assignment program (agreeing to accept Medicare's reasonable charge calculation as payment in full with the beneficiary paying only the 20% co-payment), the beneficiary may also be charged the difference between Medicare's reasonable charge calculation and the supplier's price for the PMD. Beneficiaries should make sure they are working with a participating supplier in order to minimize their out of pocket costs.
Rent Versus Purchase Option
The beneficiary has the option to purchase or rent their PMD. Regardless of their decision, Medicare coverage can not exceed 80% of the allowed purchase price. The decision to purchase or rent may depend on how long the beneficiary will need the PMD. The decision must be made either when the beneficiary first gets the PMD or after 10 continuous months of renting. If the beneficiary decides to purchase after the 10 month period, the 80-20 payment split between Medicare and the beneficiary continues for 3 months at which point the title to the chair is transferred to the beneficiary. If the beneficiary decides to rent, the title of the chair goes to the supplier, but they can not charge additional rental charges after 15 months.
Conclusion
Beneficiaries who want Medicare coverage for a Powered Mobility Device (PMD) will be successful provided they can show mobility limitations that impair their ability to engage in Mobility Related Activities of Daily Living (MRADLs), that their use of the PMD will improve their ability to do MRADLs and that the PMD can be used safely within the home. In addition, beneficiaries should remember that the PMD can be used outside of the home, but its primary purpose must be improvement in their ability to do MRADLs in the home. Beneficiaries should make sure that their practitioner provides the Medicare supplier with all supporting documentation, including the prescription for the PMD within 45 days of the face-to-face consultation. Powered Mobility Devices can mean a great improvement in the quality of life for a beneficiary, so knowing the Medicare coverage rules is essential in order to help individuals obtain the necessary equipment.
[1]CMS uses MAE to refer to a variety of items. According to the CMS webpage the category includes "canes, crutches, walkers, manual wheelchairs, power wheelchairs and scooters. This list however is not inclusive."