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Medicare Policy on Coverage of Power Wheelchairs,
Scooters Draws Fire
Advocate says it is antiquated and illegal; industry
sees problems but says it’s step in right direction
May 7, 2005 – Medicare announced the final criteria
for coverage of mobility assistive equipment (MAE), which includes
wheelchairs and scooters, this week and the reactions, as expected, were
not all favorable. The primary objections were about requirements that
the devices must be necessary in the home. Robert M. Hayes, president of
the Medicare Rights Center said it is an “antiquated and illegal policy
that will keep tens of thousands of Americans in cruel and unnecessary
isolation.”
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The Restore Access to Mobility Partnership (RAMP),
an industry group, said, “Our initial response is to express some
disappointment in several areas.” In general, however, they concluded,
“Clearly, this is a step in the right direction. However, we fear that
some beneficiaries in need of mobility equipment may still fail to
receive it under this new coverage policy.
The Centers for Medicare & Medicaid Services
headlined the news release on the policy as “Medicare Improves Access to
Power Wheelchairs and Scooters.”
The new criteria, which are effective immediately,
adopt a function-based determination of medical necessity. This
determination looks at the ability of the beneficiary to safely
accomplish mobility-related activities of daily living, such as
toileting, grooming, and eating, with and without the use of mobility
equipment such as a wheelchair. The national coverage determination (NCD)
addresses the full range of MAE from simple canes and walkers to
sophisticated power wheelchairs, according to CMS..
“The steps we are taking today are part of our
efforts to ensure that seniors who need mobility help will get it
promptly, and that we are paying appropriately for mobility assistive
equipment,” said CMS Administrator Mark B. McClellan, M.D., PhD. “The
new functional criteria reflect current medical practice and mean that
beneficiaries will have the freedom to live better, more mobile lives,
without needing to fit into a rigid ‘bed or chair-confined’ standard.”
The new coverage criteria are part of a larger
three-pronged Modern Mobility Initiative announced in April 2004 focused
on improving coverage, payment and quality of suppliers of power
wheelchairs and other mobility aids, CMS said in the news release.
In addition to developing new coverage criteria,
CMS has developed new billing codes that will take effect January 1,
2006, to reflect the variety of wheelchairs now on the market.
CMS expects to issue new quality standards for
suppliers in 2006.“This coverage policy ensures that a beneficiary’s
functional status and individual circumstances are considered so that
the most appropriate technology for each beneficiary’s personal needs is
covered,” said Barry Straube, M.D., CMS’s Acting Chief Medical Officer
and Acting Director of the Office of Clinical Standards and Quality. "It
is also consistent with the documentation of the functional needs of the
patient that should be in medical records for our beneficiaries."
CMS plans to issue additional guidance in the near
future to help physicians and treating practitioners better understand
the new coverage criteria and CMS’s expectations about proper
documentation in the medical record. Because the new functional
criteria more explicitly refer to standard clinical evaluative methods,
CMS expects that the medical documentation generated during the patient
evaluation will more accurately be reflected in the beneficiary’s
medical record. It is CMS’s intent that this will make the power
mobility device coverage process more straightforward.
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“During the course of reviewing Medicare’s policies for power mobility
devices, CMS came to the conclusion that there are more accurate tools
to root out fraud and abuse,” said Kimberly Brandt, Director of CMS’s
Program Integrity Group. “The combination of the new NCD and the
planned enhanced educational outreach by Medicare to physicians and
treating practitioners, as well as to suppliers, will eliminate most
honest billing errors. More accurate claim submission will allow CMS to
better analyze claims data and focus claims review to target abusive
billers.”
What Industry Said
RAMP, representing an industry coalition, said “CMS
has declined to make increased mobility itself an activity of daily
living that can trigger Medicare coverage for a power wheelchair.
Clinicians, as well as advocates for people with disabilities have
repeatedly advised CMS that "mobility for mobility's sake'' should be
treated as an activity of daily living. Giving a Medicare beneficiary
increased mobility with a power wheelchair can be just as significant
for an individual as using the equipment to improve the ability to get
to the bathroom, eat, dress, groom, or bathe.
“CMS also chose not to change the requirement that
power mobility equipment be restricted to increasing a Medicare
beneficiary's ability to perform activities in their home. This
provision contrasts sharply with clinical practices. RAMP does applaud
the decision by CMS to eliminate language that required Medicare
beneficiaries to be "bed or chair confined'' to qualify for mobility
equipment.
“Clearly, this is a step in the right direction.
However, we fear that some beneficiaries in need of mobility equipment
may still fail to receive it under this new coverage policy. That would
be a travesty. RAMP will continue to review the new policy, and point
out additional concerns when that analysis is completed.
“Lastly, these new coverage guidelines make it
imperative that a clear and comprehensive documentation process be
quickly established so that all of the stakeholders - beneficiaries,
doctors, clinicians and providers - have a full understanding of what
medical documentation will be definitive for claims to be approved. We
hope that ultimately Medicare beneficiaries will have a coverage policy
and process that meets their needs.”
What Medicare Rights Center says
Hays of the Medicare Rights Center was more
concerned than the industry seemed to be about the new policy, which he
said, “…will keep tens of thousands of Americans in cruel and
unnecessary isolation.”
“That isolation will lead to greater illness,
dependence and higher health care costs.
“Today’s national coverage decision maintains a
long obsolete Administration policy that pays 80 percent of the cost of
a power wheelchair for a person with Medicare who needs it to move from
a bedroom to a kitchen, but not for a person who requires the wheelchair
to leave home for medical care, shopping or even employment. The policy
imprisons people in their homes and is based on an outdated reading of
the Medicare law.
“It is now the 21st century: changes in technology,
medicine and law require coverage of equipment that allows people with
disabilities to have a productive life outside the four walls of their
homes.
“It is time for the White House to intervene.
President George H.W. Bush championed the Americans with Disabilities
Act (ADA). President George W. Bush has repeatedly said he too supports
allowing maximum independence for people with disabilities.
“It is now apparent that CMS will not support a
realistic and humane policy that will free thousands of people with
disabilities to a fuller life in their communities without direction
from the White House or the courts.
“Existing law, common sense, and common decency cry
out to change a policy that sentences people with disabilities to
needless isolation.”
Editor’s Notes:
More information about these developments can be
found at the following website:
www.cms.hhs.gov/coverage under mobility assistive equipment (MAE).
Restore Access to Mobility Partnership is a
coalition representing power wheelchair providers and manufacturers.
Members include: the American Association for Homecare; Invacare
Corporation; the MED Group; Mobility Products Unlimited, LLC; Pride
Mobility; and Sunrise Medical. For more information contact Michael K.
Frisby, 202-625-4328
Details on these issues can be found in The
Medicare Rights Center’s study “Forcing Isolation: Medicare ‘In the
Home’ Coverage Standard for Wheelchairs,” at
http://www.medicarerights.org/policybrief_03162004_frameset.html.
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