Medicare

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• Accessing Wheelchairs Through Medicare
  • Wheelchair Purchase
  • Roles and Responsibilities of Team Members
  • Wheelchair Repairs
  • Repairs to a Rented Wheelchair
  • Repairs to a Purchased Wheelchair
  • Need for Additional Wheelchair Components
  • Medicaid as Secondary Insurance
  • Fee-For-Service Medicaid
  • Medicaid MCO
  • Denials/Appeals

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Accessing Wheelchairs Through Medicare

Wheelchair Purchase

The following chart outlines the process for obtaining wheelchairs through Medicare. The steps progress in a sequence from the time the AT need is identified to when the equipment is provided. This is a process that involves many team members. Their roles and responsibilities are outlined following the chart.

Chart: Obtaining Wheelchairs - Medicare:  PDF   |   Text

Roles and Responsibilities of Team Members

Facilitator*

*The facilitator is the person who drives the process. The person could be the consumer, a family member, a case manager, etc.

• Completes the Essential Information Form. Detailed instructions for completing this form are included.
  • Essential Information Form | PDF | Large Print | Text
• You will need:
  • Consumer identification information
  • Consumer support/contact information
  • Insurance information
  • Physician information
  • A prescription
• Identifies the service provider options based on the following criteria:
• Medicare provider
• Provides services to the relevant MCO(s)
• Delivers the type of service needed.
• If the consumer is currently using a wheelchair, identifies the vendor who provided the current wheelchair. The vendor will provide important information as to whether the wheelchair had been rented or purchased through Medicare. If the chair had been rented, it belongs to the vendor who provided the chair. If the chair had been purchased, you may select another vendor for the new chair, or rely on the service provider to determine the vendor.
• Calls the service provider and schedules the evaluation, providing all of the information outlined on the Essential Information Form as well as the specific reason for the evaluation.
• Once an appointment is scheduled, informs the appropriate parties (family members, care staff, etc.) of the appointment. Key informants (such as a primary caregiver or case manager) must attend and participate in the evaluation.
• Arranges for transportation to the evaluation, if necessary.
• During the intake process, the consumer will be asked to provide written permission allowing the service provider to bill Medicare and accept the assignment of benefits.
• Since Medicare covers 80 percent of the costs of the allowable service, the consumer and/or a secondary payor (Medicaid, other insurance, state agency) will be responsible for the remaining 20 percent balance. If the consumer has Medicaid coverage, the vendor will get the relevant information from the Essential Information Form. If the consumer does not have Medicaid as a secondary insurance, other arrangements for the 20 percent will need to be made. The facilitator will need to make arrangements for this payment if the consumer does not have Medicaid as a secondary insurance.
• Secures a copy of the LMN from the vendor, signifying that the claim submission process for the AT device has been completed. If a copy of the LMN is not received within 30 days of the evaluation, contacts the vendor.
• If there has been no action on the claim after 30 days of the submission of the LMN, contacts the appropriate Medicare Intermediary office.

Service Provider

• Verifies insurance information provided on the Essential Information Form and schedules the appointment.
• Reviews the intake information and obtains signatures on the assignment of benefits form on the day of the evaluation.
• Requests a copy of the prescription (Rx) for the evaluation from the facilitator, consumer or physician. Without an Rx, the service (PT, OT, SP) will not be provided.
• Completes the evaluation with input from the facilitator, the consumer, and the caregiver(s).
• Provides the facilitator and the caregiver/consumer with a summary of the recommendations. Recommendations should include the following:
  • The specific type of equipment and component(s) needed
  • Estimated date of delivery
  • Training that is needed once the equipment is obtained.
• Completes an evaluation report and sends a copy to the facilitator, the physician, the vendor, and the consumer/caregiver.
• Sends information to the physician to support formulation of the LMN.
• Contacts the consumer/facilitator to schedule an appointment when the equipment is ready to be delivered.
• Adjusts, "fits," or customizes the new equipment per the specifications outlined in the assessment.
• Provides information about the care and the operation of the equipment as well as warranties, repairs, and follow up upon delivery.

Vendor

The vendor is a member of the assessment team and is responsible for submitting the documentation related to the medical claim for the equipment to the insurance company. The vendor must be enrolled as a DME provider with Medicare and, if the consumer is covered under an MCO, the vendor must be a participating provider with that MCO.

• Receives a copy of the Essential Information Form.
• Contacts the physician to request the LMN if it has not been received.
• Completes the appropriate CMN and obtains the appropriate signatures.
• Submits all paperwork to Medicare and Medicaid (if the consumer is using Medicaid to pay for the 20 percent co-payment).
• Orders the equipment.
• Contacts the facilitator, the service provider, and the caregiver/consumer when the equipment is ready to be delivered.

Physician

• Provides a prescription for the evaluation, equipment, and/or services needed.
• Provides LMN to vendor based on results of the evaluation.
• Completes the CMN for wheelchairs, power-operated vehicles, scooters and all augmentative communication systems. CMNs are also required at such times that repairs/modifications are needed.

  CMN for Manual Wheelchair*
  CMN for Motorized Wheelchair*
  CMN for Power Operated Vehicles *

*Taken from the Supplies and Durable Medical Equipment Program Provider Manual on the Delaware Medical Assistance Program Website: http://www.dmap.state.de.us/downloads/manuals/DME.Provider.Specific.pdf.

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Wheelchair Repairs

The process for managing and processing the repairs to a wheelchair depends on whether the wheelchair was purchased or rented through Medicare. Do not assume that the wheelchair was purchased until you have contacted the vendor who provided the chair.

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Repairs to a Rented Wheelchair

Repairs are covered under Medicare only when the wheelchair is rented through Medicare. The rental payment to the vendor includes repairs and maintenance to the frame of the wheelchair. Wear and tear on removable parts is not usually covered under the rental agreement. The facilitator must work with the vendor who provided the wheelchair in order to have the repairs covered under the Medicare rental agreement.

In addition to the information on the Essential Information Form, the facilitator must provide information about the make, model, and serial number of the wheelchair.

Some repairs will require a prescription and some require a CMN. The vendor will be able to provide guidance about what will be needed.

When a prescription is needed it should include:

• The consumer's diagnosis that necessitates wheelchair use
• A projection of the timeframe in which the person will need to use the wheelchair
• The person's height and weight
• The doctor's name, address, UPIN number, and Medicare number.

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Repairs to a Purchased Wheelchair

When a wheelchair has been purchased through Medicare, repairs that are needed to the chair are not covered under Medicare. All repairs are "unassigned," meaning that the patient will be billed for the repairs.

To arrange for repairs to a wheelchair, contact the vendor and provide the same information that is outlined on the Essential Information Form.

Identify the source of funds to be used for the repairs.

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Need for Additional Wheelchair Components

If the need for the component can be justified as medically necessary, then the process is the same as the one used for an evaluation.

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Medicaid as Secondary Insurance

If the vendor does not have accurate Medicaid information, the consumer will be responsible for the costs of the repairs.

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Fee-For-Service Medicaid

Repairs under $300 do not require a pre-authorization. Vendors can be contacted and they will provide the labor and parts needed to complete the repair.

Repairs over $300 require a pre-authorization. In order to get a pre authorization; a CMN must be completed. The CMN includes the patient's name, identification number, diagnosis, dates of service, service codes, supplies/equipment provided, and physician's signature.

The request goes to Medicaid where the information is reviewed and the claim is either approved or denied.

Doctors have to write the LMN (no therapist involved in the process.)

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Medicaid MCO

When an individual has a Medicaid MCO as a secondary insurance, the vendor must get prior authorization from the MCO for the repair. To get a pre-authorization you must have a prescription and an LMN. The facilitator at the insurance company reviews the Rx and the LMN and provides pre-authorization.

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Denials/Appeals

Wheelchair vendors do not get involved in denials or appeals for repairs. The consumer will need assistance with the appeal process from the facilitator.

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