Medicare is a Federal health insurance program managed by the Center for Medicare and Medicaid Services. Medicare is designed to cover medical and hospital care for elderly Americans above the age of 65 and for disabled citizens of all ages. In 2010, 48 million Americans benefited from Medicare. 40 million of these were aged 65 and over, and 8 million comprised of younger disabled citizens.
Medicare has 4 parts of which Part B covers medical insurance. Enrolment in Part B is voluntary and entails a monthly premium. Encompassed in Part B is coverage for Durable Medical Equipment (DME) which includes wheelchairs, mobility scooters, rolling canes and rollator walkers for those with mobility issues. These devices are classified as Mobility Assistive Equipment (MAE). Power Operated Wheelchairs and scooters, which come in this classification, are known as Powered Mobility Devices (PMDs)
How do I determine if I am eligible for MAE?
In 2005 guidelines were changed. MAE was since considered reasonable and necessary for those with mobility deficits enough to prevent them from performing what are known as Mobility-Related Activities of Daily Living (MRADL). Mobility deficits included common and necessary activities of daily life like dressing, grooming, feeding, bathing and toileting in familiar areas in the home. To determine whether a person is eligible to benefit for MAE, treating practitioners and physicians are required to follow a prescribed procedure called the Clinical Criteria for MAE Coverage. This requires adequate documentation in support of a recommendation and justification for an appropriate device.
What do Clinical Criteria endeavor to determine?
The procedure is well defined, exhaustive and structured to determine answers to the following questions. Each question does have sub-sections in more detailed guidelines, indicating the precise nature of the information being sought.
- Does the beneficiary have a mobility limitation which impairs him/her from performing one or more MRADL in the home?
- Does the beneficiary have any other conditions which prevent him/her from performing one or more MRADL?
- If these limitations exist will a MAE assist the beneficiary sufficiently to perform, or participate, in that particular MRADL or others?
- Is the beneficiary or caregiver capable of, and willing to use the MAE consistently and will they be able to operate it safely?
- Could the functional mobility deficit be resolved with a cane or walker?
- Is the beneficiary’s environment conducive to using a PMD which might be a wheelchair, scooter or other POV?
- Does the beneficiary have sufficient mobility function to be able to operate a manual wheelchair?
- Is the beneficiary strong and stable enough to operate a POV/Scooter?
- What are the additional features required to enable the beneficiary to safely use the POV and participate in MRADL?
Beneficiaries who do not meet these criteria will not be eligible for Medicare coverage of the MEA. If the beneficiary desires the PMD for recreational or leisure activities it is outside the scope of Medicare coverage. Medicare does not cover any device exclusively for outside use.
What is Medicare’s definition of a PMD?
Medicare defines a PMD as an item of Durable Medical Equipment (DME) that falls in a class of wheelchairs which includes powered wheelchairs, controlled through an electronic device or joystick for turning and maneuvering. PMD also means a POV or motorized scooter with three or four wheels and a tiller steering.
Can I purchase a PMD from any supplier of DME?
No, you are limited to making your purchase only from a Medicare-approved supplier of Durable Medical Equipment. In an effort to cut costs, stricter guidelines have been put in place for both suppliers and doctors related to Medicare covered PMDs.
For overview of Medicare Benefits and your eligibility, please visit the official government website for more details.
