As you age, there may come a time when you need help getting around. A cane, walker, or even a wheelchair could all be in your future. When that time comes, will Medicare cover the mobility device you need? Like most questions about Medicare coverage, the answer is, “it all depends.”
Find your answers as we guide you through the basics of Medicare coverage for mobility assistive devices, the steps to take to ensure the equipment you need is covered, and what to do if that coverage is denied.
What Mobility Assistive Devices Does Medicare Cover?
Medicare covers mobility assistive devices and equipment, like wheelchairs and scooters, under Part B’s coverage for durable medical equipment, based on medical necessity. Depending on your needs and doctor’s recommendations, the mobility assistive equipment and devices covered include:
- Crutches: Covered for both temporary and long-term use
- Canes: Covered based on mobility impairment and needed support while walking
- Patient Lifts: Covers hydraulic or electric lifts to assist patients who can’t transfer between bed, chair, and standing positions
- Walkers: Covers standard walkers, rolling walkers, and walkers with seats based on level of medical necessity
- Manual Wheelchairs: Covered if physically unable to use a cane or walker
- Power Wheelchairs: Covered if physically unable to use a cane, walker or manual wheelchair
- Power-Operated Scooters: Covered if you have a condition that limits the ability to move around and therefore can’t use a cane, walker, or wheelchair
Who Qualifies for Mobility Assistive Device Coverage?
When it comes to Medicare “covering” wheelchairs, scooters, or any other mobility assistive devices you need, Medicare pays 80% of the approved cost, and you are responsible for the remaining 20% after meeting the yearly Part B deductible.
To ensure Medicare will in fact cover their portion of your mobility device, be sure you meet the coverage requirements below:
Doctor’s Diagnosis and Prescription
The mobility device must be deemed a medically necessary mobility aid due to a doctor- diagnosed medical condition. The specific device or equipment must then be prescribed by your Medicare-enrolled doctor or health care provider for use in your home.
In-Person Exam
If you’ve been suffering from mobility issues, your doctor may have already completed a face-to-face exam to determine your level of mobility. For some mobility equipment, including power-operated wheelchairs and scooters, Medicare requires a face-to-face evaluation with a doctor before approving coverage. This in-person exam with your doctor should assess your mobility needs and determine if you can safely operate the wheelchair or scooter, or if you need to always have someone with you to help. Additionally, you are required to have a home visit by a doctor or device supplier to verify that you can use the equipment within your home.
Medicare-Enrolled DME Supplier
Once your doctor provides the prescription for your wheelchair or scooter, that prescription must be filled by a Medicare-approved durable medical equipment (DME) supplier. Just like a pharmacy filling your medication prescription must accept or be in-network with your Medicare Part D or Medicare Advantage Plan for the cost to be covered, the DME supplier of the wheelchair or scooter must accept Medicare or your Medicare Advantage Plan. Otherwise, you could be paying the full cost of the device.
What is the Process for Getting a Wheelchair or Scooter Through Medicare?
Once your doctor determines that you need a wheelchair or scooter, the paperwork process begins for you to get your Medicare-covered mobility device.
Step 1: Get a Written Order with Documentation
Your doctor must complete the written order, or prescription, telling Medicare why you need the wheelchair or scooter. This written order must include documentation supporting both your medical necessity and the need for the particular device.
For manual wheelchairs, this documentation must support that:
- You have a health condition causing significant difficulty moving about
- You cannot walk safely with a cane or walker
- You can safely operate and use the wheelchair, or have someone at home to assist you
For power wheelchairs and scooters, this documentation must support that:
- You have completed the “face-to-face mobility evaluation” with a detailed assessment from your doctor and/or an occupational/physical therapist
- You cannot use a manual wheelchair
- You cannot walk safely with a cane or walker
- You can safely operate the device, or have someone at home to assist you
Step 2: Submit the Written Order to a Medicare-Enrolled DME Supplier
The prescription and supporting documentation must be submitted to and filled by a Medicare-approved DME supplier. The supplier will then submit the request to Medicare for coverage approval.
Step 3: Get Prior Authorization (if required)
In some cases, prior authorization is required before you can receive certain power wheelchairs or scooters. If this is needed, your DME supplier will work with your healthcare provider to submit the prior authorization request along with the necessary documentation. Medicare will then review this information to determine if you are eligible and meet the requirements for the equipment. Medicare will then send a decision letter to your DME supplier.
Step 4a: Approved: Pay Your Share:
Congratulations! You’re getting the wheelchair or scooter you need! You’ll be responsible for 20% of the cost (after meeting the deductible) with Medicare Part B covering 80%.
Step 4b: Denied: Resubmit and Appeal:
If Medicare coverage of your wheelchair or scooter is denied, don’t panic! You can resubmit the request and file an appeal if necessary.
First, you need to know why the coverage was denied. If you have a Medicare Advantage Plan, this can be in your Explanation of Benefits, or you may receive a denial notice. If you have Original Medicare, look for the denial reason in your quarterly Medicare Summary Notice (MSN). This should be printed next to the denied item—in this case, your wheelchair or scooter.
The most common denial reasons include:
- “Not medically necessary”
- “Insufficient documentation”
- “Prior authorization not obtained”
If your prior authorization request was denied, it could be for similar reasons—Medicare deemed the device not medically necessary, or Medicare didn’t receive the needed documentation. If more information is needed, your DME supplier can resubmit your authorization request.
Whatever the “denial reason” may be, your next step is to contact your doctor and/or DME supplier. Check that they submitted the required information and ask them to resubmit the claim, with updated or additional supporting documentation if needed.
If resubmission still results in denial, you can appeal. The appeals process varies slightly based on the type of Medicare coverage you have.
The initial appeal in Original Medicare is called a “Redetermination,” and you’ll need to complete and submit the Redetermination Request Form. On a Medicare Advantage Plan, the initial appeal is called “Health Plan Reconsiderations.” Follow the directions provided in the initial denial notice or your plan’s policy materials to initiate your appeal.
Whether you have Original Medicare or a Medicare Advantage Plan, there are five levels of appeals you can go through if your appeal is denied. Hopefully, you never have to go that far to get coverage for the mobility device(s) you need!
Get Medicare Assistance in Lakeland with Wandacare
Still have questions or concerns about Medicare coverage for wheelchairs and scooters? Wandacare has you covered! Our team of expert advisors can help you navigate Medicare’s mobility benefits, from demystifying Medicare parts and coverage to assisting with claims submission or the appeals process.
Wandacare is your trusted, independent Medicare agents in greater Lakeland and Polk County.
Schedule your personalized consultation with Wandacare today!
