Imagine needing help to move around your home but not knowing if Medicare coverage will help cover the cost of a wheelchair. For many seniors, this is a real concern. Wheelchairs provide crucial support, offering freedom, mobility, and an improved quality of life that would otherwise be difficult to maintain. But figuring out whether Medicare will cover a wheelchair isn’t always straightforward. There are specific rules, requirements, and steps you need to follow to even be considered.
So, does Medicare cover wheelchairs, and what do you need to know before getting one? Stick around as we dive into the details and explain what it takes to get Medicare to cover this essential piece of equipment.
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Does Medicare Cover Wheelchairs?
Yes, Medicare does cover wheelchairs under Medicare Part B as part of durable medical equipment (DME), but specific conditions, such as proving medical need, must be met.
Medicare Eligibility Criteria for Wheelchair Coverage
Medical Necessity and Doctor’s Prescription
For Medicare to cover the cost of a wheelchair, it must be considered medically necessary. This means your doctor must confirm that your mobility is severely limited and that a wheelchair is essential for you to perform activities of daily living safely in your home. Additionally, the doctor must submit a Certificate of Necessity to Medicare, confirming the medical need for the wheelchair. Medicare requires you to have a face-to-face examination with your doctor, where they will assess your condition and determine if other mobility aids like a cane or walker aren’t sufficient.
Once your doctor decides that a wheelchair is necessary, they will write a prescription that complies with Original Medicare requirements. This prescription explains why a wheelchair is needed and confirms that you can safely use it or have someone available to assist you. This prescription is a key requirement, as Medicare won’t cover the cost without it.
Additionally, the wheelchair must fall under Durable Medical Equipment (DME), and both your doctor and the supplier must be enrolled in Medicare. This ensures that the wheelchair meets Medicare’s standards, preventing you from paying out-of-pocket for a non-approved item.
Prior Authorization for Power Wheelchairs
When it comes to power wheelchairs, Medicare has specific rules in place to ensure the equipment is both necessary and safe for the individual. One of the key requirements is prior authorization, which means that Medicare must approve the purchase or rental of the power wheelchair before they cover the cost.
The process begins with a face-to-face evaluation with your doctor, who will assess your mobility needs and determine if a power wheelchair is medically necessary. If your doctor believes you qualify, they will write a prescription and submit the necessary paperwork to your Durable Medical Equipment (DME) supplier. The supplier will then submit a prior authorization request to Medicare.
Medicare reviews the request to confirm that all criteria are met. These include whether your mobility is significantly impaired, you cannot use a manual wheelchair, and you can safely operate a power wheelchair in your home. Medicare typically responds within 10 business days, either approving or denying the request.
If approved, your DME supplier will provide the wheelchair, and you’ll be responsible for your Part B deductible and 20% of the Medicare-approved cost. However, if Medicare denies the request, you and your supplier may resubmit with additional supporting documentation or explore other options.
Types of Wheelchairs Covered by Medicare
Medicare covers a variety of wheelchairs under its Durable Medical Equipment (DME) benefit, provided they meet certain medical necessity requirements. Here are the primary types covered by Medicare:
Manual Wheelchairs
A manual wheelchair is powered by the user or someone else pushing it. If you have enough upper body strength to operate the wheelchair yourself, or if you have someone to help push you, this option might be suitable. Manual wheelchairs are generally covered by Medicare if your doctor determines that they are medically necessary to help you move around within your home. This type of wheelchair is typically more practical for indoor use and shorter distances.
Power Scooters
For individuals who don’t have the strength to operate a manual wheelchair but can still sit up and use their hands to steer, a power scooter might be the best option. These scooters are designed to be operated using a handlebar (tiller) and require some upper body strength. Power scooters are typically better for outdoor use and can travel longer distances. However, they may be less maneuverable than manual or electric wheelchairs indoors.
Power Wheelchairs
For those who are unable to use a manual wheelchair or a power scooter due to lack of upper body strength, Medicare Part B covers power wheelchairs. These power chairs are motorized and controlled with a joystick or other controls, providing more independence for users who need mobility assistance both indoors and on relatively flat outdoor terrain. Power wheelchairs are typically covered if a doctor deems them medically necessary after a face-to-face evaluation.
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Costs Associated with Wheelchair Coverage
When it comes to covering the costs of a wheelchair under Medicare Part B, there are two key expenses you should be aware of: the deductible and coinsurance.
In 2024, the annual Medicare Part B deductible is $240. This means you’ll need to pay the first $240 of any covered medical expenses, including durable medical equipment like a wheelchair, out of your own pocket. After you’ve met this deductible, Medicare will cover 80% of the Medicare-approved cost of the wheelchair. This is where the coinsurance comes into play.
Once the deductible is paid, you’re responsible for 20% of the remaining Medicare-approved amount unless you have Medicare Advantage or Medigap coverage, which can help reduce out-of-pocket costs. For example, if the approved cost of a wheelchair is $2,000, Medicare will cover $1,600, leaving you with a coinsurance of $400.
The Takeaway
Wrapping up, it’s clear that Medicare does cover wheelchairs under certain conditions, but there are specific steps and rules to follow to ensure that coverage. From obtaining a doctor’s prescription to understanding the types of wheelchairs and associated costs, navigating Medicare can be complex, especially when it comes to durable medical equipment like wheelchairs.
For those who are still unsure about their coverage or need personalized advice, The Medicare Family is here to help. With over 40 years of experience and access to 30+ top insurance companies, they can guide you through finding the best Medicare plan for your needs—all at no cost. Schedule your FREE call today to get expert advice and access to the top choices in your area. Let The Medicare Family take the stress out of understanding your Medicare options, so you can focus on what matters most: your health and mobility.
Frequently Asked Questions
What assistive devices does Medicare cover?
Medicare covers a variety of assistive devices under its Durable Medical Equipment (DME) benefit, including wheelchairs, walkers, canes, crutches, hospital beds, and oxygen equipment. These items must be prescribed by a Medicare-enrolled doctor for use at home and be deemed medically necessary. Medicare typically covers 80% of the cost after you meet the Part B deductible.
What diagnosis will cover a wheelchair?
Medicare covers a wheelchair if diagnosed with a medical condition that impairs mobility, necessitating its use for daily activities, and if you are unable to use a cane or walker safely.
