Medicare Eligibility Criteria for Power Mobility Devices (PMDs)
Medicare’s criteria for eligibility for Power Mobility Devices (PMDs) have been revised recently. Here’s a brief explanation of how to determine if a beneficiary qualifies for a power mobility device under the Medicare program:
What Is a PMD?
A PMD is a wheelchair that is operated by a joystick or electronic device, or a power operated vehicle (POV), like a scooter, that is operated by a tiller. These are considered to be Durable Medical Equipment (DME) under Medicare part B benefits.
PMDs Are For Home Use
Medicare beneficiaries who want to be covered for a PMD must have either a permanent or temporary disability that impairs mobility, and the equipment must be used primarily in the home or a facility that is used like a home. A skilled nursing facility or a hospital does not qualify. The power wheelchair or scooter must be needed mainly to improve mobility for activities in the home. For example, the wheelchair allows access to the kitchen to prepare food and get to the bathroom. Such activities are called Mobility Related Activities of Daily Living (MRADL). Although the wheelchair can be used outside the home, the primary use must be in the home.
How To Qualify for a PMD
Medicare has an assessment tool that helps to identify who qualifies for a PMD. In addition to answering the questions, the Medicare beneficiary, the caregiver, and their clinician must meet face-to-face to determine the most appropriate power mobility device.
- Does the beneficiary have a mobility limitation that significantly hinders the ability to perform one or more MRADLs at home? This includes any risk of injury while attempting to perform MRADLs.
- Does the beneficiary have any other condition that limits the ability to perform MRADLs at home? This can include vision or mental problems that would not be helped by a PMD and that could limit the beneficiary’s ability to use the powered device safely.
- If the beneficiary does have these limitations, can they be compensated in some way that allows use of the PMD to significantly improve the beneficiary’s ability to perform MRADLs? The ability of a caregiver to minimize the limitations is taken into account.
- Does the beneficiary or caregiver demonstrate the ability and willingness to operate the PMD safely? Any previous history of unsafe behavior will be considered.
- Can the mobility limitation be adequately remedied by using a walker or cane?
- Does the beneficiary’s home environment support the use of PMDs? Factors considered include whether doorways are wide enough to accommodate the device, type of floor coverings, and obstacles in the home such as stairs.
- Does the beneficiary have sufficient upper body function to maneuver a manual wheelchair in the home to participate in MRADLs? The beneficiary’s upper body strength, range of motion, and endurance are considered, as are the caregiver’s ability to help maneuver the manual wheelchair safely.
- Does the beneficiary have sufficient strength and postural stability to operate a powered wheelchair? A PMD with a joystick requires less upper body strength.
- Are the additional features offered by a powered wheelchair needed to allow the beneficiary to perform one or more MRADLs? These features include the ability to make transfers easily and to accommodate various seating needs.
Face-to-Face Examination and Prescription Required
The treating practitioner must conduct a face-to-face examination before writing a prescription for a PMD. The practitioner must then write, sign, and date a prescription that must be received by a supplier within 45 days of the examination. If the beneficiary was recently discharged from the hospital, and a face-to-face examination was done during the hospital stay, there is no need for an additional face-to-face as long as the documentation and prescription are received by the DME supplier within 45 days of the date of discharge.
The prescribing physician will also have to provide additional documentation, including medical records or any other documentation that will aid in showing the history of the beneficiary's need for the device. Documentation should also show that the PMD will improve the beneficiary's mobility and that the beneficiary can use the PMD safely. CMS allows payment for the cost of the face-to-face examination as well as the cost of collecting the additional documentation. All of the required documentation should be submitted to the supplier before the supplier submits the claim to CMS. Suppliers must maintain this documentation for seven years.
Co-payment Responsibility
Beneficiaries should make sure the supplier they are working with is a Medicare supplier and that the supplier has a Medicare supplier number. Beneficiaries are responsible for a 20% co-payment of the amount authorized by Medicare. In addition, if the supplier does not participate in the Medicare physician/supplier assignment program (agreeing to accept Medicare's reasonable charge calculation as payment in full with the beneficiary paying only the 20% co-payment), the beneficiary may also be charged the difference between Medicare's reasonable charge calculation and the supplier's price for the PMD. Beneficiaries should make sure they are working with a participating supplier in order to minimize their out of pocket costs.
Rent Versus Purchase Option
The beneficiary has the option to purchase or rent their PMD. Regardless of their decision, Medicare coverage can not exceed 80% of the allowed purchase price. The decision to purchase or rent may depend on how long the beneficiary will need the PMD. The decision must be made either when the beneficiary first gets the PMD or after 10 continuous months of renting. If the beneficiary decides to purchase after the 10 month period, the 80-20 payment split between Medicare and the beneficiary continues for 3 months at which point the title to the chair is transferred to the beneficiary. If the beneficiary decides to rent, the title of the chair goes to the supplier, but they can not charge additional rental charges after 15 months.
Reimbursement
Currently, Medicare reimbursement of PMDs is determined by a yearly fee schedule. Suppliers are paid 80% of the federally established allowable for a PMD. Yet, Medicare reimbursement pays for more than just the cost of the PMD. There are costs associated with providing PMDs that are bundled into the Medicare allowable. These costs include, among other things, paperwork and documentation, delivery of the PMD, fitting of the PMD to the beneficiary, assessment of the beneficiary and their living environment, staff training and filing and adjudicating claims on behalf of the beneficairy.
The PMC works to ensure Medicare reimbursement is adequate to ensure Medicare beneficiaries have access to obtain the high quality PMD that best meets their needs. As Medicare explores other reimbursement options, including competitive bidding (which has been delayed until sometime in 2009), it’s important that Medicare include all costs associated with providing, transporting and servicing PMDs.
