Mobility scooters and power-operated vehicles offer a solution for individuals experiencing difficulty with independent movement. Since these devices involve a high upfront cost, insurance coverage is a major concern for beneficiaries. Understanding the specific requirements and processes Medicare has established is important for anyone seeking financial assistance for this mobility equipment.
Coverage Under Medicare Part B
Medicare covers mobility scooters, classifying them as Durable Medical Equipment (DME) under Part B (Medical Insurance). To qualify as DME, the item must be durable, used for a medical reason, and generally not useful to someone who is not sick or injured. The equipment must also be utilized in the home setting and expected to last for a minimum of three years.
Power-operated vehicles (scooters) and power wheelchairs are both covered under the DME benefit. Coverage requires a physician to determine that the patient’s mobility limitation necessitates a motorized aid to function within their residence. The distinction between a scooter and a wheelchair often relates to the patient’s ability to operate a tiller-style control versus a joystick.
Establishing Eligibility and Medical Need
Securing coverage requires demonstrating medical necessity, starting with a face-to-face examination by the treating physician. This consultation documents the patient’s physical condition and mobility limitations. The physician must confirm the patient has a health condition that severely impairs their ability to move around within the home environment.
The core requirement is proving the patient cannot perform Mobility-Related Activities of Daily Living (MRADLs) in their home, even with less complex aids. MRADLs include activities like bathing, dressing, using the restroom, or getting in and out of a chair. Documentation must show that simpler devices, such as a cane, walker, or manual wheelchair, are insufficient to meet this in-home mobility need.
The patient must also possess the mental and physical capability to safely operate the scooter, including the strength to maintain proper posture. Additionally, the patient’s home must be accessible, allowing the scooter to maneuver through doorways and hallways. Medicare typically denies coverage if the device is solely sought for use outside the home, such as for shopping or community access. The physician’s documentation must explicitly state the necessity of the power-operated vehicle for navigating the patient’s primary residence.
Steps for Approval and Receiving Equipment
After the physician establishes medical necessity, the approval process begins with submitting a written order, or prescription, to a supplier. The treating provider must issue this prescription within 45 days following the in-person evaluation. This serves as the official documentation of the patient’s need for a power-operated vehicle.
The patient must select a Medicare-enrolled DME supplier who agrees to accept assignment, meaning they accept the Medicare-approved amount as full payment. The supplier works with the provider to submit all necessary documentation to Medicare. For higher-cost equipment, a prior authorization request may be necessary before delivery.
Prior authorization requires the supplier to send documents to the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for review. Medicare reviews this information to confirm eligibility and compliance with all criteria. The approval process, from initial examination to final delivery, typically takes between 30 and 90 days. If approved, Medicare usually rents the equipment for 13 months, after which the patient takes ownership.
Financial Responsibility for the Patient
Even with Medicare approval, the patient retains financial responsibilities for the mobility scooter. The patient must first satisfy the annual Medicare Part B deductible before Medicare begins payment. Once the deductible is met, Medicare generally covers 80% of the Medicare-approved amount for the equipment.
The patient is responsible for the remaining portion, which is typically a 20% coinsurance of the approved cost. Because this out-of-pocket expense can be significant, many beneficiaries seek supplemental insurance. Medicare Supplement Insurance (Medigap) or a Medicare Advantage Plan (Part C) may cover some or all of this 20% coinsurance. If coverage is denied and the patient receives the scooter without a signed Advance Beneficiary Notice (ABN), they are responsible for the entire cost.