Medicare Coverage Determination: Providing Wheelchairs through Federal Regulations

Palaestra, Winter 2005 | Go to article overview

Medicare Coverage Determination: Providing Wheelchairs through Federal Regulations


Last year, Medicare spent more than $1.2 billion providing power wheelchairs and power scooters for people applying for this service. The Centers for Medicare and Medicaid Services (CMS) are opening a National Coverage Determination (NCD) to review criteria for wheelchair coverage under Medicare to make sure patients get the care and equipment they need, and providers are properly reimbursed while curbing abuse. During a recent forum, CMS received a number of public comments asking the agency to adopt a function-based interpretation of need for wheelchairs. According to CMS, "A function-based interpretation might consider the beneficiary's inability to safely accomplish activities of daily living such as toileting, grooming, and eating with and without the use of a mobility device, such as a wheelchair." This concept can be carried another step in the community. Without access to a proper wheelchair, individuals may not be able to access community resources such as recreation facilities, gymnasiums, or fitness centers.

The function-based model is being addressed by CMS. According to Sean Tunis, CMS' Chief Medical Officer, "Our goal is to focus on a set of clinical and functional characteristics that are evidence-based and will better predict who would benefit from a power wheelchair or scooter."

How These Federal Regulations Actually Work

One of the aspects of legislative advocacy for physical activity at the federal level is oversight of the development of regulations for recently passed laws. Bills are signed into law by the President, then Congress decides how much money to appropriate to fund the law. Next, regulations are developed. Regulations are the interpretations of what the law intends. A public comment period is opened and recommendations taken about the law for a period of 30 days. We are currently in the public comment period with regard to the Medicaid National Coverage Determination process for wheelchair support. After the public comment period, regulations or rules are drafted which then implement the law.

Regulations Enabling Access to Wheelchairs

Many persons with physical disabilities need wheelchairs to participate in a wide range of physical activity (i.e., wheelchair sports and physical recreation). Wheelchairs are expensive and not always affordable to persons with disabilities due to fixed incomes, lack of opportunities to work full-time, etc. These regulations provide opportunities for individuals to access the Medicaid and Medicare system (i.e., through Social Security Disability Income) in order to acquire wheelchairs.

As previously mentioned, a major component of the Medicaid National Coverage Determination is to curb abuse. The Consolidation Appropriations Act of 2005 included an initiative to control fraud and abuse through proper substantiation of need for wheelchairs without narrowing the definition of non-ambulatory to exclude beneficiaries who have a medical need for a wheelchair. The CMS were required to examine the modification of access to wheelchairs for persons with disabilities of all ages. The rule was to examine the medical need for a wheelchair. Modification of the regulations could impact on access issues for wheelchairs and participation in leisure physical activity in wheelchair sports, for example, for persons who are physically disabled.

Process for Modification of the Regulations

The process for modification of this regulation involved: a) review of the science associated with the issue, b) development of functional criteria to assess the need for a wheelchair, c) appropriate prescription of the wheelchairs for persons with disabilities, d) safe use of the wheelchair, and e) assessment of ambulation of function to determine need.

The Interagency Wheelchair Workgroup (IWWG)--The IWWG was assembled to study modification of the regulation in light of the best science available. Groups of scientists were assembled from manufacturers, consumers, engineering, technologists, physicians, and advocates. …

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Medicare Coverage Determination: Providing Wheelchairs through Federal Regulations
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