Power Wheelchair or Mobility Scooter Insurance Information

 Power Wheelchair or Mobility Scooter Insurance Information

Power wheelchairs and scooters are considered medical devices and may be covered by insurance.

Are you considering purchasing a power wheelchair but are asking yourself “Does insurance pay for power wheelchairs?” you’re at the right place. In this blog post I’ll explain what the process is for buying an electric wheelchair with insurance by going over the pros and cons. Like most things, the tips and information in this blog post may not apply to certain insurance policies and coverage so its best that you contact your insurance provider to get exact answers to your questions about your specific policy as there are thousands of insurance companies and policy types available with a variety of options. In this blog post we’ll cover what it’s like using insurance for most policies (i.e. Humana, Bluecross, Medicare/Medicaid etc).

Steps thru the process

  • 1. Funding for Wheelchairs in General

The process of getting a wheelchair usually starts with getting a prescription for a wheelchair from a physician. Most of the time this prescription comes from your family doctor or internist. You are familiar with a prescription for a medication that you take to the drug store. These prescriptions are precisely written instructions about the quantity, the dose and the brand that your doctor wants you to take. You take this prescription to the drug store and you get exactly what the doctor ordered.

The prescription for a wheelchair is usually very different. Instead of getting very specific, the doctor usually writes a prescription for "A wheelchair." Since there are many options and characteristics of wheelchairs and since most physicians don't know much about wheelchairs, this leaves the process wide open for other people get involved and, possibly, for you to be less than satisfied with the outcome.

  • 2. The Wheelchair Prescription

A wheelchair and seating team is usually comprised of:

  • A consumer and maybe someone from their family or an advocate.
  • An Occupational Therapist or a Physical Therapist
  • A Rehabilitation Technology Supplier
  • Sometimes, a Rehabilitation Engineer

  • 3. The Wheelchair Evaluation Process

A wheelchair evaluation can be a good solution to this problem. An evaluation should start with the consumer and their needs, as well as some questions about their daily routines and lifestyle. It should involve the consumer all the way through the process. I should conclude with a recommended wheelchair and seating system. Evaluations may be required by a reimbursement source, whether that is Medicare or private health insurance, as a condition for payment. Because the outcome can be so much better, many funders are starting to require them.

Occasionally, physicians who are specialists in physical medicine and rehabilitation (often called "physiatrists"), actually know quite a bit about wheelchairs and can write a more detailed prescription or may get more involved in the selection process. Otherwise, if the service is available, many physicians refer their patient to a rehabilitation professional (like an OT or a PT). This professional takes the lead in helping to determine exactly what kind of wheelchair is right for you. They are skilled at assessing your strengths and limitations and finding out about your lifestyle and your expectations for activities. They are also familiar with the brands and categories of wheelchairs that match your needs.

If you will be spending long periods of time in your wheelchair or if you have specific posture needs, then your prescription may need to include some additional information. If you are working with a rehabilitation professional, then they can request that the physician be more explicit in writing your prescription. If special features are needed are needed in a wheelchair then most funding sources require that the prescription describe them explicitly. Some examples of additional things that may need to be written into a prescription are: a pressure relieving cushion, a solid seat or back, brake extensions, special push rims, a one-arm drive, or low to the floor to enable pushing with the feet.

  • 4. The Evaluation Team

A wheelchair and seating team is usually comprised of:

  • A consumer and maybe someone from their family or an advocate.
  • An Occupational Therapist or a Physical Therapist
  • A Rehabilitation Technology Supplier
  • Sometimes, a Rehabilitation Engineer
  • 5. The Consumer as the Focus

You, the consumer, should be the person who guides the direction of the evaluation team. The whole point of the evaluation process is to get the right or the best wheelchair into the hands of the person who will use it everyday. It is something that must function in many environments: the house, the grocery store, the neighborhood, at church, and out in the community. A wheelchair however is not a car or a bicycle that will be parked somewhere and used only to move beyond the house. It must be appropriate for full time use because it must either substitute for or augment moving around on legs. It needs to just right for you. I needs to be easy to maneuver, well fitting, comfortable, durable, safe and it must not contribute to future problems like shoulder injuries.

The wheelchair that is chosen at the end of the process should be something that allows you to do the things you want to do in your every day life. For that reason it is good to think of a few things ahead of time. It is the consumer's job to be as clear as possible about what they want from a wheelchair.

  1. Where will I use my wheelchair most?
  2. What will I use my wheelchair occasionally?
  3. What kinds of activities that I do (or did) everyday are most important to me to get back to doing?
  4. How will I get my wheelchair (and myself) from place to place?
  5. How much of the day will I be spending in this wheelchair?
  6. How will I transfer from the wheelchair to other surfaces?
  7. If I will need help with my wheelchair who will that come from and what features about my wheelchair are important to them?
  8. How will I get my wheelchair around my neighborhood or yard? What kind of surfaces or slopes are involved?

The next member of the wheelchair team would be the Occupational Therapist (OT) or the Physical Therapist (PT). These members should be registered in their profession or licensed by your state government. You can find out more about registration and licensure at the American Occupational Therapy Association or the American Physical Therapy Association.

If your clinician is certified as an Assistive Technology Provider (ATP) this is an excellent credential and means that they have complete additional training and passed a certifying examination from RESNA. (You can even use their WWW page at http://www.resna.org/PracInAT/CertifiedPractice/Directory/Practitioners.html to possibly find a credentialed provider in your area.) Years of experience and the "word or mouth" reputation of a therapist among people who use wheelchairs can also be helpful indicators about expertise. It is their job to help determine exactly what type of wheelchair is right for you, to assess your strengths and limitations and to find out about your lifestyle and your expectations for activities. It is also their job to write the letter of justification that makes the insurance company understand the relationship between your mobility needs and the equipment that is recommended for you.

(Note: If you would like to read more about the ATP Certification process read an article written by Jim Lenker for OT Practice Magazine entitled: "Certification in Assistive Technology")

The other important team members is the Rehabilitation Technology Supplier. This person is sometimes called a "vendor" or a "durable medical equipment" dealer. These names don't give credit to the high level of professionalism and knowledge of some rehabilitation technology suppliers (RTS) professionals. Like therapists it is possible and desirable for an RTS to be credentialed by RESNA or by NRRTS. This means that they have gotten additional training and are committed to a code of ethics. It is their job to know all about specific kinds of wheelchairs, to know the equipment features and manufacturers and to be able to compare the characteristics of wheelchairs or cushions.

Occasionally, a Rehabilitation Engineer is on the team, especially in an evaluation center that works with clients with more complex physical disabilities. Rehabilitation engineers are professionals are experts at customizing equipment that is commercially available or at fabricating something completely unique. It is their job to know about loads, forces, torques, moments, and the interaction of those things with your body and your wheelchair. These are all of the things that affect how your wheelchair will perform for you over the long run.

  • 6. The Evaluation Summary

The end product of the team's evaluation should be some kind of an evaluation report. It summarizes the findings and the recommendations from the evaluation team. It is probably sent to your physician with a copy to stay in the evaluation teams files as well. After that one of two things can happen the doctor can write a letter of Medical Necessity or the therapist can write a Letter of Justification.

  • 7. Letter of Medical Necessity or Justification

A letter of medical necessity is usually written by a physician and is addressed to the third-party payer. It tells them that a piece of equipment (usually some kind of medical equipment) is needed because of an authentic or verifiable medical condition or impairment.

A letter of justification is usually written by a person very familiar with the consumer/client and the product recommended.Usually it is a therapist but in some cases experienced rehabilitation technology suppliers write them.

This kind of letter takes the recommendations that come out of the evaluation and correlates them to the features of a recommended wheelchair or seating system to "paint a picture" for the payer. It is a letter that helps the third-party payer understand why certain features or characteristics of the recommended equipment are important.

  • It describes the relationship between product features and the anticipated functional outcome for the individual or the consumer. It should tell what the consumer will be able to do as a result of having the equipment.
  • It is important that the items being requested really are medically necessary. This might sound obvious but the letter writer would be abusing the funding system or third-party payer if they requested equipment that a client just wanted to have, but did not actually need.
  • A letter of justification also helps third-party payers realize why it might be better to spend a little more money for a certain feature on a wheelchair now in order to avoid a more costly expense later.

A letter of justification is an expert opinion about what is best for a particular consumer! If a therapist or supplier is good at writing this kind of a letter that makes them a very valuable resource for helping you get the kind of equipment that you really need.

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