How To Get A Wheelchair Through Medicare

Navigating the Medicare system to obtain a wheelchair can be a bit daunting, but with the right information and a step-by-step approach, it becomes manageable. Whether you need a wheelchair for temporary use or as a permanent mobility solution, understanding Medicare's coverage options and requirements is crucial.

Medicare Coverage for Wheelchairs

Medicare is a federal health insurance program primarily for people aged 65 or older, but it also covers certain younger people with disabilities and those with End-Stage Renal Disease (ESRD). It's divided into several parts, but Parts A and B are the most relevant when it comes to wheelchairs.

Medicare Part A vs. Medicare Part B

1. Medicare Part A - This covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. However, Part A does not typically cover wheelchairs unless you are in a hospital or skilled nursing facility.

2. Medicare Part B - This part concerns outpatient care, medical supplies, and preventive services. It is the part that generally covers Durable Medical Equipment (DME), which includes wheelchairs.

Requirements for Wheelchair Coverage

Medicare Part B covers a portion of the cost of a wheelchair if:

• The wheelchair is deemed medically necessary by your doctor.
• You have a written order from your doctor that follows Medicare’s guidelines.
• The wheelchair meets your medical needs as outlined in the doctor's order.

Step-by-Step Process to Obtain a Wheelchair Through Medicare

Step 1: Doctor's Appointment

• Begin with scheduling an appointment with your healthcare provider. Discuss your mobility challenges and why you need a wheelchair. It’s important to get a written prescription or order from your doctor.

Step 2: Medical Evaluation

• During your visit, your doctor will evaluate your specific needs and determine whether a wheelchair is medically necessary. If approved, they’ll provide a written prescription or order, which is crucial for Medicare coverage.

Step 3: Selecting the Wheelchair

• There are two main types of wheelchairs: manual and power wheelchairs. Deciding which is right for you depends on your condition and capabilities. Manual wheelchairs are generally easier to transport and less expensive, while power wheelchairs offer greater ease for those lacking upper body strength.

Step 4: Finding a Medicare-Approved Supplier

• Choose a supplier that accepts Medicare assignments. It’s vital to ensure that the supplier is Medicare-approved to guarantee coverage. Use Medicare’s supplier directory to find one near you.

Step 5: Submitting Documentation

• Your Medicare-approved supplier will require the doctor’s order, any relevant medical records, and Medicare information to process your wheelchair requisition. Ensuring all documents are in order expedites the approval process.

Step 6: Insurance Approval and Payment

• Medicare Part B typically covers 80% of the allowable amount for the wheelchair once the annual deductible is met. You’ll be responsible for the remaining 20%, unless you have additional Medicare Supplement Insurance (Medigap) or other insurance that covers these costs.

Table 1: Comparison of Manual vs. Power Wheelchairs

Understanding Medicare's Guidelines

Medicare has precise guidelines when it comes to covering wheelchairs:

• Medically Necessary: Your need for a wheelchair must be documented as medically necessary. This means the wheelchair is essential for you to function in your home.
• Face-to-Face Exam: You may need to undergo a detailed exam with a qualified medical professional, ensuring that all aspects of your mobility limitation are considered before Medicare approves the wheelchair.

FAQs About Wheelchairs and Medicare

Q: What if I'm denied coverage for a wheelchair?

• If your request for a wheelchair is denied, you have the right to file an appeal. The denial notice will include instructions on how to proceed with an appeal.

Q: Will Medicare cover repairs and maintenance?

• Generally, Medicare covers wheelchair repairs and replacement parts unless the cost of the repair exceeds the cost of a new wheelchair.

Q: What is the competitive bidding program?

• In certain areas, Medicare has a competitive bidding program for select durable medical equipment, including wheelchairs. Suppliers in these areas must bid to provide equipment, ensuring costs remain reasonable. It’s essential to work with these suppliers if you live in a competitive bidding area.

Resources for Further Reading

• Official U.S. Government Site for Medicare
• Book: "Aging and Disability: Access to Durable Medical Equipment" which provides insights and guidance on obtaining necessary medical devices.
• Organizations such as the National Council on Aging and local Area Agencies on Aging can provide support and guidance on navigating Medicare benefits.

Making the Most of Your Medicare Advantage Plan

While this guide primarily applies to Original Medicare, those enrolled in Medicare Advantage Plans should also check their policy’s guidelines. Medicare Advantage Plans are required to cover everything that Original Medicare covers, but they might have different rules and may cover additional services or incur different costs.

By following these steps and being informed about the Medicare system, you can successfully secure a wheelchair through Medicare, enhancing your mobility and quality of life. Remember, it’s always beneficial to communicate thoroughly with both your healthcare provider and medical supplier to ensure the process goes smoothly.