At Spinlife we hear that question repeated every day, by frustrated insurance beneficiaries just like you, trying to locate a Power Wheelchair supplier.
There isn’t a simple, short answer but I will do my best to explain. Let me add, this information is not intended as a policy statement from Medicare. This is an informational blog post written in plain language to help our readers understand a complex issue.
America’s largest group of insurance beneficiaries are covered under the Federal governments Medicare Plan A and Plan B (Hospitalization and equipment). When coverage guidelines are set by Medicare, the other private insurance companies will follow suit, and change their guidelines to follow those set by Medicare.
For many years Medicare paid for power wheelchairs as Direct Purchases. In other words, if your Physician documented beyond a doubt that you needed a Power Wheelchair to complete your activities of daily living inside your home, they would purchase the chair for you from your local Medicare Provider. Moreover, they would purchase from the Power Wheelchair supplier the chair deemed most appropriate for your individual needs, as long as those needs were also documented medically. Your local Power Wheelchair provider was able to work with your physician to obtain the documentation required to prove medical necessity and supply your power wheelchair.
The criterion to qualify changed periodically during those years, and medical necessity gradually became more difficult to substantiate. An unfortunate factor at work was that disreputable organizations were found to be “playing the system” or basically committing fraud against Medicare. Those organizations have thankfully been shut down, but in the aftermath of such activity, Medicare changed the method by which they would pay for Power Wheelchairs. Power Wheelchairs became “Capped Rental” items.
Changing power wheelchairs to Capped Rental items affected both the suppliers of the equipment and you, the beneficiary. For basic (group 1) power wheelchairs, suppliers are required to bill Medicare and the beneficiary (their co-payment) monthly for 13 months to pay for the equipment.
It’s like a rent-to own arrangement. During that time, the equipment still belongs to the supplier, not the beneficiary. After the 13 months is up, they transfer the title to the beneficiary and the item belongs to you. Limited options or customizations are offered on those basic rental chairs, and there is no requirement that the rental chair is new, either.