Vol. 2, No. 6, Nov/Dec 1994	Previous Issues Subscribe to AT Messenger Download PDF Viewer
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FINANCING ASSISTIVE TECHNOLOGY: Delaware Medicaid Coverage Standards for Motorized Wheelchairs/Powered Mobility Devices

Ron Sibert, Funding Specialist, DATI

The prominent role that Medicaid and other insurance carriers play in the provision of all types of durable medical equipment (DME) is fairly well-known. However, the Medicaid procedures and coverage criteria for "powered wheeled mobility devices" differ in subtle but important ways from those that apply to standard DME. Powered wheeled mobility devices (PWMDs), which include motorized wheelchairs and tricarts, require somewhat special treatment.

Medicaid requires all DME to be prescribed by a physician. However, the PWMD can only be covered if the prescribing doctor is one of the following types of specialists:

• Physiatrist (physical medicine specialist)
• Cardiologist (heart specialist)
• Neurologist (nervous system specialist)
• Rheumatologist (doctor specializing in diseases affecting joints and their supporting structures)
• Orthopedist (specializes in disorders of body parts related to "movement," e.g., limbs, bones, joints, muscles, tendons, etc.)

Next, the device must be a product that "appropriately" meets the medical/functional needs of the person for whom it is prescribed. This is where an informed, well written justification for the equipment is crucial. The Medicaid claims review team gives primary consideration to prescriptions/certificates of medical necessity (CMNs) and letters of justification that are signed by the physician. Documentation provided by therapists or other health care professionals may support the doctor's prescription, but the team's decision is based primarily on the documents that bear the doctor's signature. This may present a problem when communication is lacking between the prescribing doctor and the therapist. In many cases, the therapist is the actual source of the equipment recommendation, and is often more familiar with the device and its appropriate use than the doctor who is charged with prescribing it. Ideally, doctors and therapists should collaborate in developing the necessary documentation. In practice, however, it may be simpler for the therapist to compose the letter/statement of medical necessity for doctor's review, comment and signature. Delaware Medicaid's current claims processing policies permit (that is, do not prohibit) this approach. In any event, Medicaid will only purchase (or rent) a PWMD for a Medicaid beneficiary if the appropriate specialist certifies in writing that the patient is "nonambulatory" (unable to walk) and unable to propel a standard wheelchair manually due to a related medical condition.

Assuming the doctor provides a proper prescription/letter of medical necessity, the patient takes it to an equipment dealer who is (must be) a Medicaid DME provider. The dealer copies the pertinent information from the doctor's prescription, and forwards it to the doctor for signature. Once the signed CMN is returned to the dealer, it is forwarded to Medicaid for an authorization number, which permits the dealer to bill Medicaid for the PWMD. Depending on the amount and type of information the doctor provides on the original prescription, the dealer may forward a copy of it along with the CMN.

Once the patient has been using the device for awhile, it may need to be repaired or replaced. Medicaid has different coverage policies depending on whether the chair was originally purchased or rented. If Medicaid originally purchased a chair which now requires repair, the doctor must certify on a CMN that the repair is necessary in order for the cost to be covered. The equipment supplier may then effect repairs and bill Medicaid under code E1350.

The Medicaid policy "caps" PWMD rentals at 15 months. That is, Medicaid will pay the supplier a set rental fee for a maximum of 15 months. After that, the beneficiary may continue using the chair as needed at no personal cost, and the supplier may only bill Medicaid the equivalent of 1 month's rental once every 6 months for routine repair and maintenance. When such a device actually requires repair, the supplier is responsible for doing so at no additional cost to the beneficiary or to Medicaid.

Finally, if the PWMD needs to be replaced, Delaware Medicaid will provide a replacement regardless of the amount of time that has elapsed since the device was originally provided-but only if the doctor certifies in writing that the current chair no longer meets the needs for which it was originally prescribed, and/or that the chair is damaged beyond repair.

Footnote

If the chair is not a type that appears on the provider listings, the supplier must use code E1399 and provide the manufacturer's name and the product or model number.