Medicare coverage is comprised of four main types of insurance, called Parts A, B, C and D. Part A is often called hospitalization insurance and people over 65 usually get automatically enrolled in it and have no premium to pay. Part C is usually known as Medicare Advantage, which is expanded coverage offered by private insurance companies for a monthly premium. Part D is optional expanded coverage for prescription drugs. It is part B, which covers various out-patient expenses (medical expenses when not in a hospital), that can cover things like wheelchairs.
Part B Medicare insurance covers medical expenses such as doctor visits, x-rays, lab tests, some medicines and also items classified as “durable medical equipment (DME)”. Unlike Part A, the patient must actually enroll for coverage and there is a monthly premium payment required. DME are items needed by the patient for their medical care or health and safety while at home (and sometimes in a nursing care facility). Items to aid or provide mobility for the patient, including wheelchairs, can be covered by Part B under certain circumstances as will be discussed below.
Most of the time Medicare will cover a wheelchair, especially a regular, manual (not motorized) kind. However, Part B will pay for a wheelchair only for mobility issues inside your home. It won’t pay for a wheelchair if you are only having trouble getting around outside your home. The rules and requirements for coverage of a wheelchair are:
The doctor treating your condition submits a written order to Medicare stating that you have a medical need for a wheelchair for use in your home.
• Plus, you have documented limited mobility and meet all of the following conditions:
– You have a health condition that causes significant difficulty moving around in your home.
– You’re unable to do activities of daily living (like bathing, dressing, getting in or out of a bed or chair, or using the bathroom) even with the help of a cane, crutch, or walker.
– You’re able to safely operate and get on and off the wheelchair or have a care provider who is always available to help you safely use the wheelchair.
– The doctor who is treating you and the wheelchair supplier (vendor) are both enrolled and approved in Medicare.
– You can safely and properly use the wheelchair within your home (for example, it’s not too big to fit through doorways in your home or blocked by floor surfaces or things in its path).
There are two main types of wheelchairs – manual or motorized. Most manual wheelchairs are somehow portable (usually can at least partially collapse or fold for transport), and some motorized ones are portable in this way as well. Medicare is much more liberal in covering the cost for a manual wheelchair compared to a motorized one.
For Medicare to cover a motorized wheelchair, the rules and regulations listed above all have to be met, plus:
– Your doctor prescribes and documents that it is medically necessary that you use a motorized wheelchair.
– The doctor states that you cannot use a manual wheelchair but that you can safely use a motorized wheelchair.
– The doctor examined you in person within 45 days prior to the prescription for the motorized wheelchair.
– Medicare often requires a “prior authorization” before obtaining the motorized wheelchair. That means you need Medicare’s approval before you can purchase or rent the device. It usually takes around 10 business days to get this approval back from Medicare.
In addition to the payments required for Part B premiums, you must also first meet your deductible before Medicare will pay anything. After the deductible is met, Medicare will usually pay for 80% of the cost and the patient pays the other 20%. Again, payments will only be made by using a Medicare enrolled and approved medical equipment supplier. In most cases, Medicare will cover either rental or purchase of the wheelchair. It should also be noted that Medicare will not pay for any needed wheelchair ramps or related items and that only one wheelchair can be covered at any one time.