If you’ve been injured, suffered a surgery, or your mobility has been compromised and you now have a disability that calls for the use of a compact folding wheelchair or some other similar in-home medical equipment, you can rest assured that your Medicare insurance covers a portion of the cost of such systems.
Although it does not cover the power wheelchairs required for use outside the home, it does offer a few wheelchair benefits. If that’s your case and you don’t know what to do to get the wheelchair you need to move around through Medicare, read today’s post to learn more about the steps you should take to enjoy such benefits.
The first thing you need to do is to get on Medicare. If you are a U.S. citizen over 65 and you have paid into Social Security for 10 years, you can enroll in one of the four Medicare plans. When applying for Social Security benefits, you will be automatically enrolled in Medicare Parts A and B.
Part A includes hospital care coverage whereas Part B will cover medical supplies and services, which is also the plan you should focus on if you’re in need of a wheelchair. It covers manual wheelchairs and scooters that a doctor prescribes for home use. Therefore, only wheelchairs that are designed for indoor use will be covered through Medicare insurance.
You will have to pay only 20 percent of the Medicare-approved amount of a wheelchair as the deductible applies for the rest of it, that is 80 percent. To enjoy this benefit, though, you must pay the Part B deductible which is now $185 per year (as of 2019).
Visit the official Medicare website or ask for a professional’s help if you need additional information. Your final costs may vary depending on other insurance you may have, the wheelchair supplier, and so on.
There are different ways in which Medicare pays for durable medical equipment (DME) and that depends on whether you want to buy or rent the equipment yet we will cover that below. Also, to enjoy the Medicare wheelchair coverage, your wheelchair supplier and doctor should be enrolled in Medicare.
Getting the Certificate of Necessity
If you’re enrolled in Medicare and you’ve made sure that your doctor is enrolled as well, you will have to see your doctor for a signed Certificate of Necessity. Let him/her know about your condition and detail your inability to accomplish daily tasks when not using a wheelchair.
Ensure that a wheelchair is the piece of equipment most appropriate for your health condition and not a walker or a cane. If you can’t operate the wheelchair properly and safely, you might consider finding a professional nurse or a family member to help you with that.
Determine the type of wheelchair that best suits your needs. Wheelchairs are generally divided into three types: manual wheelchairs, power wheelchairs, and power-operated vehicles or scooters.
Manual wheelchairs will require you or someone else to push the chair. If you have enough strength to maneuver it or you have an assistant to help you with that, you might qualify for this type. To get a scooter, though, you will have to demonstrate that you can sit up, get in and out of the scooter safely, whether with or without help, and use the controls properly.
In case your mobility is greatly limited and none of these types would help you, you might need and qualify for a power wheelchair. In such cases, you will have a face-to-face examination in order for your doctor to submit the written prescription.
As we’ve said before, even if you’re enrolled in Medicare and you meet the deductible, you will still need to cover 20 percent of the wheelchair cost. In case you don’t have the possibility to pay the 20 percent, try the Medicare Savings Program for additional assistance. Depending on the state you live in, the amount of money you receive if you qualify may vary.
When seeing your doctor to get examined, try to determine wheelchair use time. This will help you decide whether to rent or buy a wheelchair. Renting one will cost you less in the short term yet buying one is a better idea if you need to use it for a long time. The medical supplier will give you more details regarding the payment options.
Make sure you opt for a supplier that is approved by Medicare. The official Medicare website includes a supplier directory where you can find information on approved suppliers. Moreover, you might get the equipment you need at a lower price through the Competitive Bidding Program.
In certain states, Medicare-approved suppliers submit bids and thus offer you the possibility to pay even less for the needed equipment. However, you need to be enrolled in Part A and Part B, also known as the Original Medicare plan. In case you’re enrolled in Part C, you may not have access to such a program, therefore, call Medicare directly and ask for the needed information.
Once you have the signed Certificate of Necessity and you have decided on a supplier and the wheelchair type, you can call the supplier. Make sure you do so within 45 days, though. The company should send a representative before delivering the equipment you want to buy in order to measure your house and make sure the model you’ve ordered is the right one.
If the initially ordered wheelchair does fit your place and needs, the supplier will make the required payment and delivery arrangements. In case the wheelchair type you want does not fit the way your house is designed and the space you have at disposal, the company should recommend you a more appropriate model.
If you are not eligible for Medicare coverage and assistance regarding such equipment, it is still more affordable to rent a wheelchair than to buy one. However, this depends on your personal condition, financial possibilities, and other such aspects.
When applying for Medicare, there is a chance that you will be affected by a program known as “prior authorization.” Due to this program, your DME supplier will be required to request “prior authorization” for K0856 and K0861 wheelchairs. Apart from the actual request, the supplier will also be asked to send a number of documents to Medicare.
If this is the case, you have the possibility to get the needed documents and to submit them alongside the actual request yourself. Once the documents are received, Medicare will start the process of assessing them and determining whether or not you meet the required standards.
Under the request “prior authorization” program, the costs and the benefits that you will receive stay the same. Plus, this will not, in any way, delay or interfere with your ability to get the items that you need.
As we have mentioned earlier, in all 50 states, only two types of wheelchairs require “prior authorization”, K0856 and K0861models. K0856 units are power wheelchairs group 3 that have a single power option and a total weight capacity of 300 lbs.
K0861 devices are also group 3 wheelchairs that feature, however, multiple power options. These units have the same weight capacity as K0856 models.
If you live in Arizona, Florida, California, Illinois, Georgia, Kentucky, Indiana, Maryland, Louisiana, Missouri, Michigan, New Jersey, New York, North Carolina, Pennsylvania, Ohio, Washington, Tennessee or Texas, your supplier or your doctor is required to get prior authorization for other power-operated wheelchairs or scooters as well.
Beware of fraud attempts
Even though most equipment suppliers, doctors, and health care providers work with Medicare correctly, there are a few who are not as honest. For instance, there are cases in which some of the suppliers try to offer expensive equipment to people who do not actually qualify for these devices.
Also, in an attempt to cheat the system, some suppliers try to bill you for more expensive devices and they end up delivering cheaper models. To avoid these situations, it is recommended that you are well informed about your rights and responsibilities and that you make sure that you are billed for the correct equipment.
What is more, you should beware of medical equipment suppliers that contact you, without your permission, to offer you their services. This practice is known as “cold calling” and it is not legal.
If you want to protect yourself and your loved ones against fraud, it is recommended that you never give your Social Security Number, your bank information, and your Medicare number to anyone during phone call conversations. If you do so, you risk having your personal information used without your knowledge in an attempt to cheat the program.
It is also important to know that Medicare will never call you personally and that it will never ask you to give your personal information over the phone. If you suspect abuse or fraud you can call 1-800-633-4227, or you can access Medicare.gov/fraud to report it. Users of Medicare also have the right to file a complaint if they are discriminated against.