Electric wheelchairs, often categorized as Power Mobility Devices (PMDs), restore independence for individuals with severe mobility impairments. These motorized devices, which include power wheelchairs and scooters, allow a person to navigate their daily life more effectively. Medicare covers PMDs, but coverage is strictly conditional. The device must be deemed medically necessary for use within the home environment. The qualification process requires detailed medical documentation from a treating physician before the device can be approved.
Coverage Under Medicare Part B
Electric wheelchairs and scooters are covered under Medicare Part B, the medical insurance component of Original Medicare. These items fall under the category of Durable Medical Equipment (DME). DME is reusable equipment necessary for a medical reason and appropriate for use in a home setting. To meet the Medicare definition, DME must withstand repeated use and have an expected life span of at least three years.
Part B coverage for DME means Medicare pays 80% of the Medicare-approved amount for the device. The beneficiary is responsible for the remaining 20% coinsurance after the annual Part B deductible is met. Medicare Advantage Plans (Part C) must cover at least the same benefits as Original Medicare Part B, but cost-sharing rules and approved suppliers may differ by plan.
Establishing Medical Necessity for Coverage
Establishing medical necessity is the cornerstone of Medicare coverage, focusing on the beneficiary’s ability to function within the home. The individual must have a severe mobility limitation that significantly impairs their ability to participate in Mobility-Related Activities of Daily Living (MRADLs) in customary home locations. MRADLs include essential personal care tasks like bathing, dressing, grooming, feeding, and using the toilet.
A physician must document that the patient is unable to move around in their home even with less supportive devices, such as a cane, walker, or manual wheelchair. The documentation must specifically explain why the patient lacks the upper body strength or coordination required to self-propel a manual wheelchair. Coverage requires the device to be needed for mobility within the home, though the beneficiary is permitted to use it for trips outside the home.
The treating practitioner must perform a face-to-face examination to evaluate the patient’s mobility needs and ability to safely operate the device. This consultation must result in a written record detailing the patient’s medical condition. It must explain why a PMD is the least supportive, yet most effective, option. This documentation ensures the need for the electric wheelchair is directly tied to the patient’s medical impairment and functional limitations within their residence.
Steps to Obtaining an Approved Device
The process begins with the required face-to-face examination conducted by the prescribing physician. Following this visit, the physician must prepare a detailed medical record and a Standard Written Order (SWO) certifying the medical need for the specific device. This order, which serves as the prescription, must be transmitted to a Medicare-enrolled DME supplier within 45 days of the encounter.
The DME supplier coordinates the necessary documentation and works with Medicare. Certain types of power wheelchairs, particularly advanced or custom models, require Prior Authorization from Medicare before delivery. This pre-approval step, managed by the supplier, ensures the specific device meets all coverage requirements before costs are incurred.
The supplier is also responsible for conducting a home assessment to verify the electric wheelchair can be maneuvered safely within the patient’s residence. This assessment confirms that the home environment, including doorways and floor surfaces, can accommodate the device. The entire process, from examination to delivery, must be meticulously documented to ensure Medicare covers the claim.
Patient Financial Responsibility
Once the electric wheelchair is approved, the patient is responsible for a portion of the cost under Original Medicare Part B. The beneficiary must first satisfy the annual Part B deductible before coverage begins. After the deductible is met, the patient’s coinsurance is 20% of the Medicare-approved amount for the device.
It is important to ensure the DME supplier is enrolled in Medicare and agrees to “Accept Assignment” for the claim. Accepting assignment means the supplier agrees to accept the Medicare-approved rate as the full payment. This protects the beneficiary from being balance-billed for charges above the approved rate beyond the deductible and 20% coinsurance.
If a supplier does not accept assignment, they can charge the patient more than the Medicare-approved amount, resulting in significantly higher out-of-pocket costs. Choosing a participating supplier who accepts assignment is the most effective way to limit financial liability to the 20% coinsurance and the Part B deductible.