A wheelchair is covered by Medicare, but coverage is subject to specific conditions designed to ensure medical necessity. Wheelchairs, along with other items like hospital beds and oxygen equipment, are categorized as Durable Medical Equipment (DME). To be eligible, the device must be prescribed by a physician and intended for use in the patient’s home to address a mobility limitation resulting from an illness or injury. This process requires thorough documentation and compliance with federal guidelines.
Medicare Coverage for Durable Medical Equipment
Wheelchairs are covered under the Durable Medical Equipment (DME) benefit, which falls specifically under Medicare Part B (Medical Insurance). DME includes equipment that is built to withstand repeated use, serves a medical purpose, is not usually useful to a person without an illness or injury, and has an expected lifespan of at least three years.
To ensure that Medicare will pay its share, the supplier providing the wheelchair must also be enrolled with Medicare and must accept assignment. Accepting assignment means the supplier agrees to accept the Medicare-approved amount as full payment, limiting what they can charge the patient to the deductible and coinsurance.
For many types of DME, Medicare determines whether the item will be rented or purchased, often opting for a rental period first. For certain items like manual wheelchairs, a rental period of 13 months is typical, after which ownership transfers to the patient. Medicare will also cover repairs and maintenance for equipment that the patient owns, provided the repair cost does not exceed the cost of replacing the entire item.
Requirements for Establishing Medical Necessity
The most significant barrier to coverage is establishing that the wheelchair is medically necessary, which is determined by a strict set of criteria. The patient must have a medical condition or injury that significantly limits their ability to move around in their home. This limitation must impair the patient’s ability to perform Mobility-Related Activities of Daily Living (MRADLs), such as bathing, dressing, and using the bathroom, in customary locations within the home.
A key requirement is that the patient’s mobility limitation cannot be sufficiently and safely resolved by using a less complex mobility aid, such as a cane or a walker. The requirement for use in the home is a specific Medicare distinction, meaning the need for the device must primarily stem from improving mobility for activities that take place inside the residence.
The prescribing physician plays a central role, needing to document the patient’s medical condition and mobility status with a Detailed Written Order or prescription. This order must be written after a face-to-face examination with the patient, which assesses their physical condition and ability to safely use the device. The documentation must clearly link the patient’s impairment to the specific need for the wheelchair and confirm that the patient’s home environment can accommodate the device.
Distinctions in Coverage for Power Mobility Devices
While a manual wheelchair requires a physician’s prescription, Power Mobility Devices (PMDs) have significantly more stringent coverage requirements due to their higher cost and complexity. PMDs include both power-operated vehicles (POVs), often called scooters, and power wheelchairs (PWCs). Medicare will only cover a PMD if the patient cannot operate a manual wheelchair safely or effectively due to insufficient upper body strength, coordination, or endurance.
The process for a PMD requires a face-to-face examination with the prescribing physician, which must be specifically focused on the patient’s mobility needs. This examination must occur no more than 45 days before the written prescription is completed. For a scooter, the patient must demonstrate they can safely operate the tiller controls and have the trunk stability to sit upright and transfer independently.
Power wheelchairs, which are typically controlled with a joystick, are considered when a patient’s condition is more complex. The documentation must prove the patient needs the additional features of a power wheelchair, such as specialized seating or controls, because they cannot manage a manual wheelchair or a scooter. Some types of power wheelchairs and scooters may also require prior authorization from Medicare before they are provided.
Patient Financial Responsibility and Costs
Even when Medicare approves coverage for a wheelchair, the patient is still responsible for a portion of the total cost. The DME benefit falls under Medicare Part B, meaning the patient must first satisfy the annual Part B deductible. Once the deductible has been met, Medicare pays 80% of the Medicare-approved amount for the equipment. The patient is then responsible for the remaining 20% coinsurance of the Medicare-approved amount.
This financial responsibility applies whether the equipment is being rented or purchased. Many individuals have supplemental insurance, such as a Medigap policy or a Medicare Advantage Plan (Part C), which can help manage these out-of-pocket costs. Medigap plans often cover all or part of the 20% coinsurance that the patient would otherwise owe. Patients with Medicare Advantage Plans should consult their plan directly, as these plans are required to cover the same DME benefits as Original Medicare but may have different network rules and cost-sharing amounts.