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The Steps to Take to Qualify for a New Mobility Scooter or Power Wheelchair Through Medicaid

Medicaid is designed to provide health-related services to low-income individuals and families who cannot afford the costs of healthcare. It is funded through a joint venture between the individual states and the Federal government.

When qualifying for a power wheelchair through Medicaid, it is important to know that some state Medicaid plans may have different requirements. Medicaid has certain requirements that durable medical equipment (DME) suppliers must follow in order for patients to qualify for a power mobility device such as a scooter or power wheelchair.

Who Can Write An Order For a Mobile Chair

A physician, a physiatrist, neurologist, orthopedic surgeon, certified nurse practitioner, or a physician’s assistant may write an order for a power mobility device. But this is only the first step of the process. Qualifying for a new mobility scooter may take time due to the supplier needing to collect medical documentation from the ordering physician to establish medical necessity. Locating a DME supplier in the beginning stages of the process can make it easier since the company should be knowledgeable about the process. The state Medicaid plan can assist with locating a provider for Medicaid. Given some broad national guidelines, the Federal government sets forth, each state is responsible for:

  •  Establishing its own Medicaid eligibility standards
  • Determining the scope of Medicaid services
  • Setting the rate of Medicaid coverage
  • Administering its own Medicaid program

The Affordable Care Act sets up new regulations, based on a household’s modified adjusted gross income, for establishing income eligibility for Medicaid. The ACH made it easier for qualifying low-income households to enroll in the most suitable program. Provided that you qualify, assistive medical devices such as motorized chairs are covered under Medicaid. These devices can be bought as Durable Medical Equipment, or DME, with Medicaid. Here are the steps to take to see if you qualify for a new mobility scooter or power wheelchair through Medicaid.

Determine Your State’s Guidelines

Check with your states Medicaid health insurance program to learn the criteria for having them to pay for a new motorized chair. Typically, you will be eligible for a device if you cannot walk further than 10 feet, cannot use a walker or cane safely and/or are unable to operate a self-propelled wheelchair. However, this is just a general guideline and your state’s program may have somewhat different criteria. You can also check with an accredited local company that sells power chairs, known as an “assistive technology provider.” By being accredited the provider will know your state’s Medicaid standards.

Image result for doctors visit illustrationVisit Your Healthcare Provider

Schedule an appointment with your doctor for a face-to-face exam to discuss mobility limitations, ambulating ability, qualifying diagnosis, etc. The documentation must be noted that the patient is unable to use a cane, walker, or manual wheelchair. It is also important to understand that qualifying for a power wheelchair through Medicaid, the doctor must document that the power mobility device will be primarily used indoors for ADLs (Activities of Daily Living). This does not mean that the patient can not use the mobility device outside.

After The Visit

Once this visit is complete, the physician signs the documentation and provides it to the durable medical equipment supplier.  Medicaid also requires the patient to visit a physical or occupational therapist for a wheelchair evaluation. This evaluation is an in-depth visit usually completed on a form that Medicaid requires called a Certificate of Medical Necessity. The therapist will document the patient’s limitations, muscle tone, the range of motion, strength, stamina, and balance. While qualifying for a power wheelchair through Medicaid, the patient must demonstrate the ability to safely use and transfer to and from the mobility device, and demonstrate the ability to maintain postural stability and position on the device.

What the Doctor Prescribes

Based on the findings of the therapist, additional parts and accessories may be needed for the power wheelchair so the patient can sit comfortably for health and safety concerns. When qualifying for a power wheelchair through Medicaid, there are additional parts and accessories that may be requested that include, but not limited to, armrests, footrests, custom seating, lateral and thoracic swing away hardware, and headrests. If the patient is only qualifying for a new mobility scooter, there are no extra parts or accessories needed as it is considered all inclusive.

Making Sure To Get Approved

The PT/OT must complete the evaluation using Medicaid’s paperwork. If proper paperwork is not used, Medicaid will deny the mobility device until the proper paperwork is provided. Once the therapist has completed and signed the evaluation, the paperwork must now be signed by the ordering physician.  If your doctor sees the need he, or she, will write an order or prescription stating your mobility is impaired enough for you to need the device. Specifically, the order must state the required doctor’s visit took place and you need a motorized device in order to function in your daily routine. Some reasons include:

  • You have difficulty performing daily activities, like bathing and dressing
  • You are unable to use a manually operated wheelchair
  • You will be able to safely use a motorized chair

In some cases, Medicaid may require a caretaker if your doctor doesn’t think you can operate the motorized chair safely on your own. While the equipment must be necessary for you to function inside your home, you can also use the chair outside the home, such as when going shopping, for doctor’s visits and recreational activities. Note the date on the form your doctor signs should be no more than 45 days before the order for your device is made by the supplier.

Picking the Right Supplier

Once you have your doctor’s order you must choose the right type of supplier for your chair to be covered under Medicaid, as not all suppliers will accept Medicaid insurance for payment. Your physician may be able to help you locate a supplier that will take your insurance. Additionally, Medicaid may have a list of approved motorized chair suppliers. Based on the medical documentation, the DME supplier has an understanding of the patient’s needs and can narrow down the proper type of mobility device that will meet the patient’s needs.

Home Visits

There are many power mobility device manufacturers to choose from and many DME suppliers will visit the patient’s home with a demo unit to see which model meets the needs of the patient. The DME supplier will take measurements of the client to ensure proper fitting of the mobility device. Weight capacity plays a factor since Medicaid will only pay for what the patient actually qualifies for not what the patient wants. For example, if the patient weighs 200 lbs., Medicaid will only pay for a mobility device with a weight capacity of 250 lbs., even if the patient prefers a larger mobility device with higher weight capacity.

Selecting a Motorized Chair

Keep in mind it is always a good idea to use an accredited Durable Medical Equipment supplier when searching for a DME company. There are two types of motorized chairs: battery-powered mobility scooters and battery-powered wheelchairs. When choosing a mobility scooter or power wheelchair through Medicaid, it is important that you decide which type of motorized chair will work best for you, as Medicaid will not usually pay for a second device, except under very unusual circumstances. The debate about which type of device is better has raged on for decades. However, with today’s technology, the functional differences are negligible to nonexistent and the selection is more about personal style than actual function.

Electric Wheelchair

  • Stable with tight-turning radius
  • Handles tough terrain better
  • Operate with the touch of a hand

Mobility Scooter

  • More comfortable for long-distance travel
  • More customization options
  • Capable of faster speeds

While a power wheelchair has slight maneuvering advantages in tight spaces, like in a small kitchen or bath, many people prefer a mobility scooter for use outside the home. There are also three types of power wheelchairs, the traditional model that allows you to sit down, a standing wheelchair that you ride in the upright position, sort of like a Segway scooter, and a convertible model that can be transformed into a sitting and standing position.

Living Conditions Are Approved

When a patient is qualifying for a new mobility scooter or power wheelchair, an in-home assessment is required by the DME supplier. The supplier must document the type of home the patient lives in if it is accessible, widths of the doorways, including bathroom and bedroom, and types of flooring. It is important to note that if the patient resides in an LTCF (Long Term Care Facility), Medicaid may not consider this the patient’s home. Some Medicaid plans may only pay for a wheelchair that has custom seating while residing in an LTCF. Once all paperwork is complete and signed by the ordering physician, the last and final step is the supplier submitting a prior authorization request to Medicaid. Medicaid will review the medical documentation and make a determination. If approved, the supplier will order the power mobility device and deliver to the patient. However, if Medicaid denies, the supplier may appeal the denial of a favorable decision.