Current through Register Vol. 43, No. 02, November 27, 2024
(1) Wheelchairs are
a covered benefit for patients who meet full Medicaid eligibility criteria and
medical necessity. The patient must meet criteria applicable to wheelchairs
pursuant to this chapter, and Chapter 14, DME, of the Medicaid Provider
Manual.
(2) All requests for
wheelchairs are subject to the Medicaid prior approval provisions in accordance
with Rule No.
560-X-13-.03 and any additional
requirements in Chapter 14, DME, of the Medicaid Provider Manual.
(3) Limitations and Exclusions
(a) Patients may be approved for one manual
or power/motorized wheelchair every five years for children ages 0-20 and every
seven years for adults ages 21-99 based on medical necessity.
(b) Home, environmental and vehicle
adaptations, equipment and modifications are not covered.
(c) Repairs or replacement of parts require
prior authorization unless otherwise specified by Medicaid.
(d) Within the five year period for children
ages 0-20 and seven year period for adults ages 21-99, Medicaid will not repair
or replace equipment that is lost, destroyed, or damaged as a result of misuse,
neglect, loss or wrongful disposition or equipment by the recipient, the
recipient's caregiver(s), or the provider. At a minimum, examples of equipment
misuse, neglect, loss or wrongful disposition by the recipient, recipient's
caregiver, or the provider include, but are not limited to the following:
1. Loss of wheelchair or parts.
2. Selling or loaning wheelchair or
parts.
3. Damage due to
weather.
4. Failure to store the
wheelchair in a secure and covered area when not in use.
5. Use on public roadways where the speed
limit is greater than 25 miles per hour.
6. Loss, destruction or damage caused by the
malicious, intentional or negligent acts.
(4) Patient Education
(a) Providers are responsible for patient
education and documentation of appropriate usage of wheelchair. Patient
education shall include, but not be limited to, proper storage, usage on or off
public roadways, battery life, cleaning, warranty, etc.
(b) Documentation of patient education and
understanding by both the servicing provider and the recipient or caregiver
shall be kept in the patient file for the life of the wheelchair.
(5) Reimbursement for wheelchair,
except as outlined in this section for EPSDT-referred wheelchairs, will be made
in accordance with the DME Fee Schedule located on the Medicaid
website.
(6) Reimbursement for
EPSDT-referred Wheelchair Systems
(a) All
requests for EPSDT-referred wheelchairs are subject to the Medicaid prior
approval provisions in accordance with Rule No.
560-X-13-.03 and the following
additional provisions:
1. If no Medicare
price is available for EPSDT-referred wheelchair systems, the reimbursement
rate is established based on a discount from Manufacturers Suggested Retail
Price (MSRP) instead of a "cost-plus" basis.
2. Providers are required to submit MSRPs
from three manufacturers for wheelchair systems (excluding seating system and
add-on products) appropriate for the individual's medical needs.
3. Requests submitted with less than three
prices from different manufacturers must contain documentation supporting the
appropriateness and reasonableness of equipment requested for a follow-up
review by Medicaid staff or designee. Provider must document non-availability
of required MSRPs to justify not sending in three prices.
(b) The established rate will be based on the
MSRP minus the following discounts:
1. Manual
wheelchair systems - 20% discount from MSRP
2. Power wheelchair system - 15% discount
from MSRP
3. Ancillary (add-on)
products:
(i) Electronic ancillary products -
15% discount from MSRP
(ii)
Non-electronic ancillary products - 20% discount from MSRP
Author: Keisha Howard, PDL Administrator,
Clinical Services and Support
Statutory Authority: State Plan Attachment
4.19-A;
42 CFR, Section
440.70; Title XIX, Social Security
Act.
