Volume 13, No. 3, Summer 2005	Previous Issues Subscribe to AT Messenger Download PDF Viewer
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Medicare Wheelchair Coverage Modified

Eliza Hirst, Staff Attorney
Disabilities Law Program

After experiencing widespread fraud regarding wheelchair coverage, the Center for Medicaid and Medicare Services (CMS) plans to implement a broad policy change for funding wheelchairs, scooters, and other power operated vehicles effective July 5, 2005. 1 CMS overhauled its current coverage determination system to consider more individualized circumstances and functional limitations of Medicare beneficiaries. Most significant among the changes is the elimination of the requirement that a beneficiary be "bed or chair confined" to receive Medicare coverage for a wheelchair. Although the new approach for determination of wheelchair coverage may be more burdensome and not as sweeping as many disability advocates would want, CMS's policy change is nonetheless a positive step to increase self-sufficiency, mobility, and greater integration for individuals with mobility impairments.

Background for the CMS Policy Change

Medicare funds mobility assistive equipment (MAE) that is "reasonable and necessary for beneficiaries who need assistance with mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home."2 MAE includes wheelchairs, power operated vehicles, and scooters. However, the federal regulations regarding MAE limit funding to equipment that has a medical purpose and is appropriate for use in the home. 3

Currently, Medicare pays over $1.2 billion every year for wheelchairs and other mobility assistive equipment. The cost of a single wheelchair is upward of $5,000. Not surprisingly, with a burgeoning budget and the threat of Medicare insolvency estimated for 2020, 4 CMS is making every effort to reduce costs. Prior to the policy change, CMS confronted excessive abuses in requests for wheelchair coverage. During the last five years, CMS has recovered over $84 million in wheelchair fraud through "Operation Wheeler Dealer." CMS found that fraud stemmed from the loose standard for Medicare's coverage of wheelchairs.

Therefore, in an effort to revamp its policy on wheelchair coverage and safeguard against fraud, CMS created a Modern Mobility Initiative in April 2004. This initiative included three major changes. First, CMS changed the definition of when a patient meets the criteria for coverage. Second, CMS changed the caps for Medicare payments of wheelchairs, based on individual needs and circumstances. Third, CMS created standards and an accreditation program for bidders and suppliers of wheelchairs to root out fraud. With a new "algorithmic approach" in place, CMS plans to broaden its assessment for qualified beneficiaries.

The New Approach

CMS created an algorithmic approach to determine Medicare coverage, which asks nine questions of potential beneficiaries regarding use of a wheelchair "in the home:"

1. Does the beneficiary have a mobility limitation causing an inability to perform one or more mobility-related activities of daily living in the home?
2. Are there other conditions that limit the beneficiary's ability to perform mobility-related activities of daily living at home?
3. If these other limitations exist, can the use of mobility equipment enable the beneficiary to perform mobility-related activities of daily living in the home?
4. Is the beneficiary willing and able to consistently operate the wheelchair safely?
5. Will the purchase of a low-tech piece of AT (e.g., cane) be more cost effective and efficient?
6. Does the beneficiary's home support the use of a wheelchair?
7. Is the beneficiary able to use a manual wheel-chair for tasks during a typical day?
8. Is the beneficiary able to use a power-operated vehicle (POV or scooter) for tasks during a typical day?
9. Are the additional features provided by a power wheelchair needed to allow the beneficiary to perform one or more mobility-related activities of daily living?

Benefits of CMS's Policy Change

The new approach will calculate an individual's need based on his or her independent functional ability without assistance. 5 More specifically, a beneficiary will be deemed eligible for wheelchair funding if the beneficiary is unable to move through her home. CMS will also provide wheelchair coverage for a beneficiary who is able to walk with the assistance of a caregiver, but can not walk independently without support.

Despite CMS's elimination of the "bed and chair confined" requirement, CMS still determined it is limited to funding wheelchairs for activities of daily living for use "in the home." However, a beneficiary is not limited to use the equipment strictly inside of the home. The beneficiary is entitled to use the wheelchair out in the community or in a variety of settings. With this policy change, CMS believes that it will not only crack down on fraud, but also will "ensur[e] that a beneficiary's functional status and individual circumstances are considered so that the most appropriate technology for each beneficiary's personal needs is covered..." 6

Criticism of the CMS Changes

While CMS's change to wheelchair coverage is a step in the right direction, the change falls short of what many advocates and people with disabilities hoped would be an opportunity to create greater access to wheelchairs. Critics of the new policy believe that many individuals with mobility impairments will continue to be left in the lurch because the policy ignores the realities and the challenges people with disabilities face on a daily basis outside of their homes. 7

First, many advocates believe that CMS construed the "in the home" requirement for wheelchairs too rigidly. The "in the home" requirement was originally placed in the regulations to distinguish Medicare Part B services from Medicare's funding for equipment in an institutional or residential treatment facility. 8 The "in the home" requirement was never intended to mean that the wheelchair equipment be limited to use in a beneficiary's home. Advocates, such as ARC, United Cerebral Palsy, and the Assistive Technology Law Center, remain concerned that individuals who have the ability to move around in some form in their home with the use of a cane, crutch, or a manual wheelchair will not be candidates for power wheelchairs under the new approach, even if these same individuals need power wheelchairs to navigate outside of their homes. 9

Second, many advocates believe that CMS should include mobility as an activity of daily living, since it is such an essential part of self-sufficiency.9 Completion of activities such as feeding, grooming, and dressing requires individuals to travel outside of their homes to buy food, toiletries, and clothes. Unfortunately, CMS's new policy may still restrict people with mobility impairments from going to doctors' appointments, running errands, or performing other functions related to activities of daily living if they are denied wheelchair coverage under the new approach. 9 In addition, CMS's new approach does not adequately account for when a caregiver is unavailable, or when individuals with a mobility impairment cannot move around in their homes due to a temporary change in circumstances.

Third, and of greatest concern for many advocates, is that CMS's new policy continues to isolate people with mobility impairments. People with disabilities will not only continue to be dependent on inhome caregivers or antiquated equipment to navigate through activities of daily living, but will also continue to be excluded from participating in community activities such as going to the movies, visiting with friends, attending religious services, or going to work on a daily basis. 9 As society shifts toward more acceptance and awareness of people with disabilities, CMS's policy may ultimately fail to respond to our communal obligation to break down existing barriers for people with disabilities.

Conclusion

At this stage, it is far too early to determine whether the change in CMS's National Coverage Determination for wheelchairs will have a dramatic effect on creating greater independence for individuals with mobility impairments, or whether the change will lead to continued isolation. On the whole, the policy overhaul is a step in the right direction to remove obstacles for individuals with mobility impairments in their homes, and to a greater extent, in the community. However, governmental change often happens slowly through incremental steps. CMS's elimination of the harsh "bed or chair confined" standard is likely to increase coverage to a larger number of beneficiaries in need of mobility assistance. In the meantime, the disability community can continue to encourage CMS to expand wheelchair coverage for use outside of the home as part of our commitment to foster self-sufficiency and increase community participation for people with disabilities.

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1. Throughout the article, I will refer to wheelchairs broadly to include all power operated vehicles.
   
2. 42 U.S.C. Section 1395x(n)
   
3. 42 C.F.R. Section 414.202
   
4. Estimates range from 2019 to 2024, www.house.gov/budget_democrats/pres_budgets/fy2002/april_analysis/solvency.htm.
5. Steve Phurrough, Louis Jacques, Shamiram Feinglass, Karen Daily: Decision Memo Medicare Improves Access to Power Wheelchairs
   and Scooters, Part III History of Medicare Coverage and Figure 1(8) Public Comments, May 5, 2005, available at
   http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=143.
   
6. Barry Straub, M.D., CMS Acting Chief Medical Officer and Acting Director of the Office of Clinical Standards and Quality CMS
   Office of External Affairs, May 5, 2005, Medicare Improves Access to Power Wheelchairs and Scooters.
   
7. Center for Medicare Advocacy, Inc., Restrictions Remain on Power Wheelchairs and Other Assistive Devices, 2005, available at
   www.medicareadvocacy.org.
   
8. Comments regarding the CMS Proposed Criteria issued on Feb. 3, 2005, James Sheldon, Steven Elliot, Jennifer Giesen, March 7,
   2005, page 18.
   
9. Comments from The Assistive Technology Law Center, The American Association of People with Disabilities, The ARC, United
   Cerebral Palsy, and American Academy of Physical Medicine and Rehabilitation, Public Comment for Mobility Assistance Devices
   available at http://www.cms.hhs.gov/mcd/viewpubliccomments.asp?nca_id=143.