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Insurance Coverage for Mobility Assistive Devices

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Insurance Coverage for Mobility Assistive Devices

July 6, 2023
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The insurance coverage rules for wheelchairs and other mobility aids may vary by Health Plan and often change. Below are the commonly known criteria for insurance coverage of Mobility Assistive devices. Always check with your health plan directly and work with your physician and/or an authorized Durable Medical Equipment (DME) supplier to confirm your eligibility.

You can search for Medicare Approved DME Suppliers here by zip code or equipment type. 

 Product  Insurance Coverage Criteria
Standard Wheelchair

A standard wheelchair for home use is covered if all of the below criteria are met:

  1. The patient has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility related activities of daily living (MRADLs): such as toileting, feeding, dressing, grooming and bathing in the customary locations within the home 
  2. The patient’s mobility limitation cannot be sufficiently resolved by use of a cane or walker 
  3. The patient’s home provides adequate access between rooms, maneuvering space, and surfaces for use of a standard wheelchair
  4. The use of a standard wheelchair will significantly improve the patient’s ability to participate in MRADLs, and the patient will regularly use it inside the home
  5. The patient has not expressed an unwillingness to use the standard wheelchair 
  6. The patient has sufficient upper extremity function and other physical and mental capabilities to self-propel the standard wheelchair or has a caregiver who is available, willing, and able to provide assistance with the wheelchair
Lightweight Wheelchair The patient cannot self propel in a standard wheelchair and the patient can and does self propel in a lightweight wheelchair
Heavy Duty Wheelchair

Criteria for a standard wheelchair must be met and 

  1. The patient weighs more than 250 lbs or
  2. The patient has severe spasticity
Motorized Wheelchair

Motorized wheelchairs may be covered only under very specific conditions. 

  1. Meets the criteria for a mobility device and
  2. Does not have sufficient upper extremity function to self-propel an optimally configured manual wheelchair to perform mobility-related activities of daily living and
  3. Is not able to safely operate a Power Operated Vehicle (POV) or maintain postural stability and position while operating a POV and
  4. Is able to bring the power wheelchair into the home for use and storage or, if homeless, has demonstrated a plan to safely charge and store the power wheelchair
  5. Power wheelchairs may also be covered if the member has a caregiver who cannot push a manual chair but can propel the power chair, using the attendant control.
Tilt-in-Space Manual Wheelchairs 
  1. Is at high risk for pressure ulcers and is unable to perform a functional weight shift or
  2. Has increased or excess muscle tone or spasticity related to a medical condition that is anticipated to be unchanging for at least one year or
  3. Has decreased muscle tone related to a medical condition that inhibits their ability to sit up against gravity and requires tilt in space for head and trunk control
Rollabout or Transport Chairs
  1. The patient is not expected to be able to self-propel a manual or power wheelchair in the next five years and
  2. The patient has needs that cannot be met by a less-costly manual wheelchair and
  3. The proposed chair has casters of at least five inches in diameter and is specifically designed to meet durable medical equipment standards
Patient Lift (Hoyer Lifts)
  1. Patient transfer from bed to a chair, wheelchair, or commode requires the assistance of more than one person and 
  2. Without the use of a lift, the patient would be confined to the bed

Note: Electric lifts are not covered since they are considered a convenience
Lift chairs (Stairlifts)

Coverage rules vary. You and your physician will need to complete and submit aCertificate of Medical necessity

  1. The patient has severe arthritis of the hip or knee, or a severe neuromuscular disease
  2. The patient cannot  stand up on their own from a regular chair
  3. Without the chair, the patient would be confined to another chair or bed
  4. Once standing, the patient can walk independently or with the aid of a walker or cane
  5. Patient does not reside within a skilled nursing facility, hospice or nursing home facility
Hospital Bed
  1. The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed or
  2. The patient requires positioning of the body in ways not feasible in an ordinary bed to alleviate pain or
  3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or pulmonary aspiration. Pillows and wedges must be considered and ruled out or 
  4. The patient requires traction equipment that can only be attached to a hospital bed.

Other Considerations:

  1. The preferred first step should be to schedule a face to face physician evaluation, so they can assess the needs and recommend the appropriate assistive device or durable medical equipment (DME). The physician can certify to the medical necessity and write the appropriate prescription.
  2. Prior Authorization may be required prior to purchase. Check with your insurance and/or your primary care provider or DME supplier. For most value based primary care physician practices, the provider’s office will file the paperwork and get a Prior Authorization from the patient’s insurance, which can be taken to the DME supplier when buying the equipment. 
  3. The DME suppliers that are approved by the Centers for Medicare and Medicaid will file the insurance claim on behalf of the patient. Usually, Medicare covers 80% and the patient copay is 20% after Medicare Part B deductible is met.
  4. If you buy equipment online or from a pharmacy or equipment supplier, you may be able to submit a claim for reimbursement as long as the above criteria are met, and your physician can provide an attestation of medical necessity. It is better to get an evaluation from your physician prior to purchase.
  5. Some DME suppliers may carry only specific categories of products but not all equipment. Call the supplier and confirm they will accept your insurance. 
  6. Your insurance plan may also have a list of preferred brands of wheelchairs. You can get this information by talking to your health plan, your supplier and reviewing your Evidence of Coverage (EOC). If you are covered by your employer’s health plan, talk to your health benefits coordinator.
  7. Most DME purchases are Health Benefits Accounts eligible, so you may be able to pay for your out of pocket expenses with a FSA, HSA, and HRA card.
  8. Not all types of hospital beds or motorized wheelchairs may be covered, so check with your health plan and DME supplier before making the purchase.  
  9. Some standard and nonstandard accessories may not be covered by the health plan and you may have to pay extra. Standard options and accessories for manual wheelchairs include calf rests or pads, fixed-height arm rests, foot rests and footplates, hand rims with or without projection, and wheel lock assemblies. Nonstandard options and accessories for manual wheelchairs may include adjustable height armrests, leg rests, anti-rollback device, headrest extensions, nonstandard seat frames (standard is 15” – 19” width and depth), one-arm drive attachments, positioning accessories, push-activated power assist, safety belts or straps, protection seat, and back cushions.
  10. When buying an expensive DME from a Medicare approved DME supplier, check whether shipping, installation fees, and warranty costs will be covered by insurance and your total out of pocket costs.  
  11. Stairlifts may not be covered by insurance because it is considered a home update rather than a DME.
  12. Equipment that is typically not covered by insurance includes raised toilet seat, shower chair (with or without back), grab bars, transfer bench, bathtub rails, toilet seat cushion, TENS unit, knee walker, transport chair, and compression hosiery. When ordering a Rollator (walker with wheels and a seat), insurance does not pay for seat attachments. They will only cover the walker.

Curated by HHC team

Comment

  • Brian Hiatt
    July 6, 2023 at 1:55 pm

    This is very useful, thanks.

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