Your Medicare Coverage
Is my test, item, or service covered?
Manual wheelchairs & power mobility devices
How often is it covered?
Medicare Part B (Medical Insurance) covers power-operated vehicles (scooters) and manual wheelchairs as durable medical equipment (DME) that your doctor prescribes for use in your home. You must have a face-to-face examination and a written prescription from a doctor or other treating provider before Medicare helps pay for a power wheelchair. Power wheelchairs are covered only when they're medically necessary.
You may have to get prior approval (known as “prior authorization”) for certain types of power wheelchairs. Under this program, only 2 types of power wheelchairs require “prior authorization” before Medicare will pay for them:
- K0856: Power wheelchair, group 3 std., single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
- K0861: Power wheelchair, group 3 std., multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
Your DME supplier will need to:
- Request “prior authorization”
- Send the request and required documents to Medicare
You don’t need to do anything. If your physician prescribes one of these wheelchairs to you, your DME supplier will, in most cases, submit a prior authorization request and all documentation to Medicare on your behalf. Medicare will review the information to make sure that you’re eligible and meet all requirements for the power wheelchair. Your Medicare coverage and benefits will stay the same, and you shouldn’t experience delays getting the items you need.
Your prior authorization request may be denied if:
- Medicare finds you don’t medically require a power wheelchair
- Medicare doesn’t get all the information needed to make a decision
If additional information is needed, your DME supplier may resubmit your prior authorization request.
For more information, call 1-800-MEDICARE.
All people with Part B are covered.
Your costs in Original Medicare
If your supplier accepts assignment, you pay 20% of the Medicare-approved amount, and the Part B deductible applies. Medicare pays for different kinds of DME in different ways. Depending on the type of equipment:
- You may need to rent the equipment.
- You may need to buy the equipment.
- You may be able to choose whether to rent or buy the equipment.
Medicare will only cover your DME if your doctors and DME suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If your doctors or suppliers aren’t enrolled, Medicare won’t pay the claims submitted by them.
It’s also important to ask your suppliers if they participate in Medicare before you get DME. If suppliers are participating suppliers, they must accept assignment. If suppliers are enrolled in Medicare but aren’t “participating,” they may choose not to accept assignment. If suppliers don't accept assignment, there’s no limit on the amount they can charge you.
Competitive Bidding Program
If you live in or visit certain areas, you may be affected by Medicare's Competitive Bidding Program. In most cases, Medicare will only help pay for these equipment and supplies if they're provided by contract suppliers when both of these apply:
- You have Original Medicare.
- You get competitively bid equipment and supplies in competitive bidding areas.
Contract suppliers can't charge you more than the 20% coinsurance and any unmet yearly deductible for any equipment or supplies included in the Competitive Bidding Program.
If your current supplier isn't a Medicare contract supplier, you may still be able to stay with that supplier if they decide to participate in the program as a "grandfathered" supplier. Suppliers that don't get Medicare contracts can decide to become "grandfathered" suppliers. This means a supplier may continue to rent equipment to you if you were renting the equipment when the program started. This rule applies to oxygen, oxygen equipment, and certain rented equipment. You may continue using the "grandfathered" supplier until the rental period for your equipment ends.
If you start renting additional equipment from a "grandfathered" supplier after the program starts, Medicare won't pay for the new equipment.
If you're renting equipment that's eligible for grandfathering, your supplier will let you know in writing 30 business days before the program begins whether it will or won't become a "grandfathered" supplier.
What happens if my supplier decides not to become a grandfathered supplier?
You need to decide whether to continue to rent from your current supplier and pay all the costs, or switch to a Medicare contract supplier.
A supplier that doesn’t have a contract and decides not to become a grandfathered supplier is required to notify you and pick up the item from your home after the program starts. Your supplier must notify you these 3 ways before it can pick up the item:
- The supplier must send you a letter at least 30 business days before the program starts telling you that it will no longer provide rental items to you after a certain date. This letter will tell you the date that a Medicare contract supplier must start to provide you with the rented item.
- The supplier must call you 10 days before picking up the item to make arrangements for pick up at an agreed upon time.
- The supplier must call you again 2 business days before picking up the item.
A supplier that isn’t grandfathered can't pick up a medically necessary item before the end of the last rental month for which the supplier is eligible to get a rental payment.
If you change to a Medicare contract supplier, your old supplier should work with the contract supplier so there isn’t a break in service. Keep the pickup slip or other documentation from the old supplier that shows you no longer have the item.
Under current Medicare rules, you own these types of equipment after renting for 13 months. When you switch to a Medicare contract supplier instead of using a "grandfathered" supplier or other non-contract supplier, your 13-month rental period will start over. So, you won't own the equipment until after the new rental period ends. This will extend your rental period and result in additional months of coinsurance. However, the amount you pay may be lower because the amount you'll pay will be based on the new payment rates under the new program.
- Once you own the equipment, you must get replacement supplies and accessories for the equipment from a contract supplier in order for Medicare to help you pay for these items. You may get repairs for the equipment you own from any Medicare-approved supplier (even a non-contract supplier), including replacement parts needed for the repair.
- If you already own your equipment, you must use a Medicare contract supplier for your replacement supplies and accessories.
To find out how much your test, item, or service will cost, talk to your doctor or health care provider. The specific amount you’ll owe may depend on several things, like:
- Other insurance you may have
- How much your doctor charges
- Whether your doctor accepts assignment
- The type of facility
- Where you get your test, item, or service