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Mobility plays a critical role in the independence and well-being of senior citizens and individuals with disabilities. A wheelchair can be essential for day-to-day living, from moving around the house to going out for essential tasks.
If you’re wondering whether Medicare can assist with the cost of a wheelchair, the short answer is yes, though there are important details to consider and understand.
Wheelchair Coverage under Medicare
Medicare Part B (Medical Insurance) pays for wheelchairs as part of its Durable Medical Equipment (DME) coverage. Here’s what you need to know to access this essential coverage.
Eligibility Criteria
Certain conditions must be met to qualify for a wheelchair under Medicare Part B:
- Medical Necessity: Your treating physician must submit a written order stating that you have a medical need for a wheelchair to be used in your home.
- Limited Mobility: You must have a health condition that significantly hampers your ability to move around within your home.
- Activities of Daily Living: Your condition should render you unable to perform essential daily activities such as bathing, dressing, or using the bathroom, even with the aid of mobility aids like a cane, crutch, or walker.
- Safety Concerns: You or someone living with you should be capable of safely operating and transferring someone on and off the wheelchair.
Documentation Requirements
Documentation is crucial for establishing eligibility and receiving coverage:
- Written Medical Order: A written order from the doctor treating your condition is required. It must specify that you have a medical necessity for a wheelchair in your home.
- Home Assessment: Your doctor or supplier must conduct an in-person visit to your home to verify you can safely use the wheelchair and that it fits within your home environment.
Suppliers and Enrollment
Choosing the right supplier is crucial to ensuring that Medicare covers your wheelchair.
- Medicare-Approved Suppliers: To qualify for coverage, you must purchase your wheelchair from a Medicare-approved supplier. Check the Medicare Supplier Directory to locate one near you.
- Cost Sharing: Once you’ve paid your Part B deductible for the year, your out-of-pocket cost is generally 20% of the Medicare-approved amount for the wheelchair. Medicare will cover the remaining 80%.
- Medicare Advantage Plans: Refer to plan details if you have Medicare Advantage coverage. Consult your healthcare provider for information on cost-sharing information in-network DME suppliers.
Types of Wheelchair Coverage
Understanding the types of wheelchairs covered by Medicare can help you make an informed decision about the best option for your specific needs. Medicare distinguishes between manual and power wheelchairs and has distinct coverage rules for various subtypes.
Manual Wheelchairs
Coverage for standard manual wheelchairs is available if you meet certain criteria. If you cannot safely use a cane or walker but either have enough upper body strength or have someone available to assist you, you may qualify for a Medicare-covered standard manual wheelchair.
In terms of costs, after your deductible you’ll be responsible for 20% of the Medicare-approved amount.
Basic Power Wheelchairs
Qualifying for a basic power wheelchair through Medicare involves a more stringent process. If a manual wheelchair isn’t a feasible option due to your medical condition, a basic power wheelchair could be considered.
To qualify, you’ll need a face-to-face examination with your physician to establish your specific needs and capabilities. You must also be able to safely get in and out of the wheelchair, and have the strength to sit up and operate the controls. Your doctor will have to submit a written order confirming that you have a medical need for a power wheelchair and can operate it safely.
Complex Power Wheelchairs
These wheelchairs have customized features to meet specialized medical needs. If you don’t qualify for a standard power wheelchair, you might be eligible for a complex one. Again, a face-to-face exam and written order are required.
Note: Customized features often come with higher costs, so be prepared for a greater financial commitment even though Medicare will typically cover 80% of the approved amount after the deductible.
Getting a Wheelchair through Medicare
The following is a step-by-step guide designed to navigate you through the process of obtaining a wheelchair covered by Medicare. Each step highlights important considerations and actions you should take for a smooth and successful experience.
- Enrollment: Ensure you are enrolled in Medicare Part B, which covers medical services and supplies like wheelchairs.
- Medical Consultation: Schedule a doctor’s appointment for a Certificate of Medical Necessity. Discuss why you need a wheelchair and ensure you can operate it safely.
- Wheelchair Type: Decide on the type of wheelchair that best suits your needs based on your doctor’s recommendation.
- Deductibles & Costs: Confirm that you’ve met your Part B deductible. You’ll be responsible for 20% of the wheelchair cost once that is paid for.
- Supplier Selection: Check Medicare’s online directory or call 1-800-MEDICARE (1-800-633-4227) for supplier options.
- Rental or Purchase: Discuss with your doctor and supplier whether to rent or buy. Medicare will cover rental costs for up to 13 months.
Advance Beneficiary Notice (ABN)
An ABN form may be required if there’s a possibility Medicare might not cover the cost of your wheelchair. This form outlines what Medicare may or may not cover, so you can decide whether to proceed with the purchase knowing the potential out-of-pocket costs.
Reach out to CoverRight for further information about wheelchair coverage under Medicare. We’re your trusted partner for customized Medicare solutions from eligibility to enrollment.
Frequently Asked Questions
Who is eligible for a wheelchair under Medicare?
You’re eligible for a wheelchair under Medicare if you are enrolled in Medicare Part B and have a medical need for the wheelchair in your home. You’ll need a signed Certificate of Medical Necessity from a doctor, who will assess whether you are eligible based on your inability to complete daily activities like bathing, dressing, or using the restroom, even with assistance.
How do I find a Medicare-approved supplier for a wheelchair?
You can find a Medicare-approved supplier by checking Medicare’s online supplier directory. Alternatively, you can call Medicare directly at 1-800-MEDICARE (1-800-633-4227) for a list of approved suppliers in your area.
Can I upgrade my wheelchair features if medically necessary?
Yes, upgrades may be possible if your physician deems they are medically necessary. Additional costs may apply, and Medicare might not cover all upgrades. Consult with your healthcare provider or Medicare-approved supplier to explore your options.
What if Medicare denies coverage for a wheelchair?
If Medicare denies your claim for a wheelchair, you have the right to appeal the decision. You’ll need to submit a formal request for a redetermination, usually within 120 days of receiving the denial notice. It’s advisable to consult with your healthcare provider for supporting documentation to strengthen your appeal.
