If you need a wheelchair, and you have Medicare, can you count on them to pay for your needs? The short answer is “yes and no”. As with most insurance programs, there are guidelines and restrictions in place with Medicare that can limit your choices in wheelchairs.
If you have Medicare part B or part C (aka: Medicare Advantage) you can get wheelchair coverage. If you have purchased a supplemental Medigap plan, it may offer some assistance to pay for some part, or even all, of your wheelchair expenses.
While you might think that Medicare part D, which covers prescriptions, would cover your prescribed wheelchair, this is not the case. Don’t waste your time pursuing this.
In this article, we discus what you can and cannot expect from Medicare when purchasing a wheelchair. Read on to learn more.
Questions to Consider When Seeking Wheelchair Assistance from Medicare
1. What is inaccessible to you?
If you’re having difficulty taking care of activities of daily living in your home, and your cane, crutches or walker will not suffice, you may need to get a wheelchair. In this case, if you have Medicare part B or C, you can count on Medicare to help you.
If you are having mobility problems outside your home, Medicare part B or C will not help you.
2. Do you have authorization?
Even when Medicare part B or C would pay for your wheelchair, you cannot simply tell them you need one. You have to get a prescription or order from your primary care physician.
The order should clearly state that:
Your doctor must further certify that he or she is an authorized Medicare provider and that the medical equipment supplier you plan to use is, as well. This information can be verified by checking the Medicare authorized providers lists.
3. Will Medicare part B or C cover any kind of wheelchair?
Medicare covers durable medical equipment (DME) that is needed in the home. It is very important that your doctor be very specific when writing an order for a wheelchair for you. The chair you receive should be the right type to meet your specific needs.
There are basically three choices in types of wheelchairs that are potentially covered by Medicare part B or C.
- 1A manual wheelchair might be the right choice for you if you are able to maneuver it on your own or if you have full time assistance in the home. This type of chair might be the right choice if your lack of mobility involves weakness in your legs, dizziness, lack of balance, etc.
- 2A power scooter can be a good choice if you are able to mount and dismount on your own and have good balance and upper body strength. You’ll need to visit with your doctor for an evaluation to determine if you are a good candidate for a power scooter.
- 3A power wheelchair can be a good choice for someone who is unable to transfer unassisted but has an attendant to help with personal care needs and transferring morning and evening. Once you are set up in the chair in the morning, you can carry out all of the activities of the day in your wheelchair and then have your assistant help you with bedtime preparations and getting into bed in the evening.
Just as with a scooter, you’ll need to visit your doctor for an evaluation to be sure a power chair is the right choice for you. Your doctor’s order must confirm that you need the chair and that you are capable of using it safely.
What about reclining or tilt-in-space wheelchairs?
Reclining and tilt in space wheelchairs which can be extremely beneficial in terms of comfort, enhanced circulation, reduced pressure sores, blood pressure management and much more may be covered by Medicare parts B or C; however, it is very important that you, your doctor and your medical equipment provider present a clear, thorough and detailed case stating your absolute need for this type of wheelchair.
Can you get the chair as soon as your doctor okays it?
In some cases, you could be safe to go ahead and get your wheelchair and count on reimbursement, but in other cases, you will need prior authorization or approval from Medicare to be sure that the chair you want will be covered.
When this is the case, your doctor will need to submit a prior authorization request form and your medical equipment supplier will also need to fill out and submit forms as requested. Overall, it’s safer to wait until all possible hoops have been jumped through before renting or purchasing anything.
When prior authorization is needed, you will need to get all your paperwork together and submit it to the Durable Medical Equipment Medicare Administrative Contractor (DME MAC). If all your paperwork is correct and all goes well, you should have your approval within ten days.
What happens if Medicare won’t approve your request?
You can appeal any decision Medicare makes. You would do this by submitting a written request and documentation further illustrating your need for the equipment. This paperwork can come from you, your doctor and/or your medical equipment provider.
Will Medicare part B pay completely for a wheelchair?
If you qualify for wheelchair assistance, Medicare part B will pay for eighty percent of your expense. You will need to pay the rest out of pocket and/or through a Medigap plan. Additionally, if you encounter copays along the way, you’ll need to pay them on your own.
How reliable are these rules and guidelines?
It is possible for the rules to be changed temporarily by your state’s governor, the Department of Health & Human Services (HHS) or by the office of the president of the United States in the event of a disaster or emergency declaration.
You can find out if the rules in your area have been changed or affected by such an unexpected turn of events by calling 1 (800) MEDICARE (800-633-4227).
Alternately, you can check the HHS emergency website [https://www.hhs.gov/programs/emergency-preparedness/index.html] or the website of the Federal Emergency Management Agency (FEMA) [https://www.fema.gov/fact-sheet/critical-needs-assistance] if you find yourself in need of a wheelchair because of an emergency or disaster.
Medicare’s Wheelchair & Scooter Benefit
Medicare Coverage of Durable Medical Equipment & Other Devices