Does Medicare Pay for Wheelchairs?

Medicare, a federal health insurance program, provides coverage for millions of Americans, primarily those aged 65 or older and younger individuals with certain disabilities. This program helps manage healthcare costs by covering a wide range of services and equipment. Understanding how Medicare covers these devices is important for beneficiaries.

Medicare Part B and Durable Medical Equipment

Medicare Part B, medical insurance, covers durable medical equipment (DME), including wheelchairs and scooters. DME refers to equipment that meets specific criteria established by Medicare. This equipment must be durable, withstand repeated use, and be used for a medical purpose. It is useful only to someone sick or injured, rather than generally useful to healthy individuals.

For Medicare Part B coverage, the equipment must be used in the home and is expected to last for at least three years. A physician or other healthcare provider enrolled in Medicare must prescribe the DME for use in the beneficiary’s home. This medical necessity ensures that the equipment is required to diagnose or treat an illness, injury, or condition, and meets accepted medical standards.

Types of Covered Wheelchairs and Medical Necessity

Medicare covers various types of wheelchairs and mobility aids, provided they meet specific medical necessity criteria for use in the home. Manual wheelchairs are covered if an individual cannot use a cane or walker safely, but possesses sufficient upper body strength to operate a manual wheelchair or has someone available to assist. Different types of manual wheelchairs, such as lightweight or heavy-duty, may be covered based on specific patient needs like weight or the need for individualized adjustments.

Power wheelchairs and scooters are considered for individuals who cannot use a cane, crutch, or walker safely, and are also unable to operate a manual wheelchair. For a power wheelchair, the individual must be unable to use a manual wheelchair and must be strong enough to operate the controls safely. Similarly, for a power-operated scooter, the person must be able to get in and out of it safely, and possess the strength to sit up and operate its controls. The home environment must also be suitable for the safe use of the power mobility device, with adequate maneuvering space.

Coverage extends to medically necessary accessories for wheelchairs, such as cushions, leg rests, batteries, and chargers. These accessories are covered if they are medically necessary and used with equipment that meets Medicare’s DME definition.

Meeting Coverage Conditions

To cover a wheelchair, Medicare requires several conditions and documentation requirements to be satisfied. A treating physician must submit a written order stating the medical need for the wheelchair or scooter for use in the home. This written order, also known as a Standard Written Order (SWO), must include the beneficiary’s name, a description of the item, the treating practitioner’s name or National Provider Identifier (NPI), the date of the order, and the practitioner’s signature.

A mandatory face-to-face examination with the treating practitioner must occur within six months prior to the written order. During this encounter, the practitioner must evaluate and document the beneficiary’s condition, specifically addressing how their mobility limitation impairs their ability to perform daily activities within the home. The documentation should explain why a cane, crutch, walker, or manual wheelchair cannot meet the beneficiary’s mobility needs in the home.

The equipment must be supplied by a Medicare-enrolled DME supplier. The supplier must accept Medicare assignment, meaning they agree to Medicare’s approved payment amount and cannot bill the beneficiary for more than the deductible and coinsurance. Some types of power wheelchairs and scooters may also require prior authorization from Medicare before they are covered. The DME supplier will typically work with the treating provider to submit the prior authorization request and all required documentation to Medicare for review.

Your Financial Responsibility

When Medicare covers a wheelchair, beneficiaries share in the cost. After meeting the annual Medicare Part B deductible, Medicare pays 80% of the Medicare-approved amount for the wheelchair. The beneficiary is then responsible for the remaining 20% coinsurance.

When a supplier accepts assignment, they agree to accept the Medicare-approved amount as full payment for the item or service. This ensures that the beneficiary is only responsible for the deductible and coinsurance, preventing unexpected higher charges. If a supplier does not accept assignment, they may charge more than the Medicare-approved amount, and the beneficiary would be responsible for the difference.

Supplemental insurance, such as Medigap policies or Medicare Advantage Plans (Medicare Part C), can help cover these out-of-pocket costs. Medigap plans are designed to pay some or all of the Medicare deductible and coinsurance amounts. Medicare Advantage Plans, offered by private companies, must cover at least the same benefits as Original Medicare, but may have different costs, rules, and network requirements for DME suppliers. Beneficiaries with these plans should contact their plan directly to understand their specific cost-sharing responsibilities and supplier networks.

Navigating the Acquisition Process

Obtaining a Medicare-covered wheelchair involves a structured process that begins with a medical evaluation. The first step is to discuss mobility challenges with a doctor, initiating a conversation about the need for a mobility device. This conversation should lead to a face-to-face examination where the doctor assesses the beneficiary’s medical condition and evaluates their ability to safely use a wheelchair or scooter. The doctor will then determine the most appropriate type of equipment based on the beneficiary’s specific needs.

Following the examination, the doctor will provide a written order for the medically necessary equipment. This order, along with the detailed medical documentation from the face-to-face visit, will be crucial for the coverage request. The beneficiary or their healthcare provider will then work with a Medicare-enrolled durable medical equipment supplier. The supplier coordinates with the doctor to ensure all necessary paperwork is complete and submitted to Medicare.

For certain power wheelchairs, the supplier will submit a prior authorization request to Medicare. This process involves Medicare reviewing the documentation to confirm eligibility and medical necessity before approving coverage. After approval, the supplier arranges for the delivery of the wheelchair and provides instructions on its proper use and maintenance.