Current through September 24, 2024
A. The Division of
Medicaid defines a wheelchair as a seating system that is designed to increase
the mobility of residents who would otherwise be restricted by inability to
ambulate or transfer from one place to another.
B. The Division of Medicaid defines an
individualized, resident specific custom manual and/or custom motorized/power
wheelchair as one that has been uniquely constructed or substantially modified
for a specific resident referred to in this Rule as "custom manual wheelchair"
and/or "custom motorized/power wheelchair".
C. The Division of Medicaid does not classify
the following wheelchairs as custom manual and/or custom motorized/power
wheelchairs:
1. Standard manual
wheelchairs,
2. Standard manual
wheelchairs with added accessories,
3. Standard motorized/power wheelchairs,
and/or
4. Standard motorized/power
wheelchairs with added accessories.
D. The Division of Medicaid covers custom
manual and/or custom motorized/power wheelchairs and accessories for rental up
to the purchase price or purchase when:
1.
Medically necessary with comprehensive documentation that a standard wheelchair
cannot meet the resident's needs and the resident requires the custom manual
and/or custom motorized/power wheelchair for six (6) months or
longer,
2. Ordered by a
pediatrician, orthopedist, neurosurgeon, neurologist, or a
physiatrist,
3. Not primarily used
as a restraint, and
4. Prior
authorized by the Utilization Management/Quality Improvement Organization
(UM/QIO).
E. The
Division of Medicaid requires the following documentation for a custom manual
and/or custom motorized/power wheelchair.
1. A
face-to-face evaluation by a pediatrician, orthopedist, neurosurgeon,
neurologist, or a physiatrist who is prescribing the custom manual and/or
custom motorized/power wheelchair which includes, but is not limited to:
a) The reason for the evaluation visit was a
mobility examination.
b) If the
resident currently possesses a custom manual and/or custom motorized/power
wheelchair not previously purchased by the Medicaid program.
c) A certificate of medical necessity with
comprehensive documentation that describes the medical reason(s) why a custom
manual and/or custom motorized/power wheelchair is medically necessary such
that no other type of wheelchair can meet the needs of the resident including,
but not limited to:
1) The
diagnosis/co-morbidities and conditions relating to the need for a custom
manual and/or custom motorized/power wheelchair.
2) Description and history of
limitation/functional deficits.
3)
Description of physical and cognitive abilities to utilize equipment.
4) History of previous interventions/past use
of mobility devices.
5) Description
of existing equipment, age of equipment, and specifically why it is not meeting
the resident's needs.
6)
Explanation as to why a less costly mobility device is unable to meet the
resident's needs.
7) Description of
the resident's ability to safely tolerate/utilize the prescribed custom manual
and/or custom motorized/power wheelchair.
8) The type of custom wheelchair and each
individual attachment and/or accessory required by the resident.
2. An initial
evaluation by a physical therapist (PT) or occupational therapist (OT), not
employed by the Durable Medical Equipment (DME) provider or the manufacturer,
within three (3) months of the date of the written prescription to determine
the individualized needs of the resident which includes whether the resident
currently possesses a custom manual and/or custom motorized/power wheelchair,
not previously purchased by the Medicaid program.
3. An agreement by both the prescribing
physician and the PT or OT performing the initial evaluation that the
individualized equipment being ordered is appropriate to meet the needs of the
resident.
4. A subsequent
evaluation after the delivery of the custom manual and/or custom
motorized/power wheelchair by a PT or OT, not employed by the DME provider or
the manufacturer, to determine if the custom manual and/or custom
motorized/power wheelchair is appropriate for the resident's needs. The DME
provider cannot bill the Division of Medicaid until the PT/OT documentation
verifies on the subsequent evaluation that the custom manual and/or custom
motorized/power wheelchair is appropriate for the resident's needs.
5. The PT/OT initial and subsequent
evaluations must include the appropriate seating accommodation for the
resident's height and weight, specifically addressing anticipated growth and
weight gain or loss.
F.
The Division of Medicaid covers a custom motorized/power wheelchair only when a
custom manual wheelchair cannot meet the needs of the resident and the resident
must:
1. Be bed/chair confined with
documented severe abnormal upper extremity dysfunction or weakness,
2. Expect to have physical improvements or
the reduction of the possibility of further physical deterioration from the use
of a custom motorized/power wheelchair,
3. Be for the necessary treatment of a
medical condition,
4. Have a poor
prognosis for being able to self-propel a functional distance,
5. Not exceed the weight capacity of the
custom motorized/power wheelchair prescribed,
6. Have sufficient eye and/or hand perceptual
capabilities to operate the custom motorized/power wheelchair safely,
7. Have sufficient cognitive skills to
understand directions, such as left, right, front, and back, and be able to
maneuver the motorized/power wheelchair in these directions
independently,
8. Be independently
able to move away from potentially dangerous or harmful situations when seated
in the custom motorized/power wheelchair,
9. Demonstrate the ability to start, stop,
and guide the custom motorized/power wheelchair within a reasonably confined
area,
10. Be in an environment
conducive to the use of the custom motorized/power wheelchair.
a) The environment must have sufficient floor
surfaces and sufficient door, hallway, and room dimensions for the custom
motorized/power wheelchair to turn and enter and exit, as well as necessary
ramps to enter and exit the nursing facility.
b) The environmental evaluation must be
documented and signed by the resident/caregiver and DME provider for the custom
motorized/power wheelchair.
G. The Division of Medicaid covers a
customized electronic interphase device, specialty and/or alternative controls
if the resident is unable to manage a custom motorized/power wheelchair without
the assistance of said device. The Division of Medicaid requires documentation
of an extensive evaluation of each customized feature required for physical
status and specification of the medical benefit of each customized feature.
1. For a joystick, the resident must
demonstrate safe operation of the custom motorized/power wheelchair with an
extremity, such as the hand or foot, using a joystick hand or foot operated
device. The resident can manipulate the joystick with fingers, hand, arm, or
foot.
2. For a chin control device,
the resident must demonstrate safe operation of the custom motorized/power
wheelchair with manipulation of the chin control device. The resident must have
a medical condition which prevents the use of their hands/arms but is able to
move their chin and safely operate the chair in all circumstances.
3. For a head control device, the resident
must demonstrate safe operation of the custom motorized/power wheelchair with
manipulation of the head control device. The resident must have a medical
condition which prevents the use of their hands/arms but is able to move their
head freely with control of their head and can safely operate the chair in all
circumstances.
4. For an extremity
control device, the resident must demonstrate safe operation of the custom
motorized/power wheelchair with manipulation of the extremity control device.
The resident must have a medical condition which prevents or limits fine motor
skills during the use of their extremities but is able to move their
hands/arms/legs to safely operate the chair in all circumstances.
5. For a sip and puff feature, the resident
must demonstrate safe operation of the custom motorized/power wheelchair with
manipulation of the sip and puff control. The resident cannot move their body
at all and cannot operate any other driver except this one.
H. Custom manual and custom
motorized/power wheelchairs are limited to one (1) per resident every five (5)
years based on medical necessity. Reimbursement:
1. Is made for only one (1) custom manual and
custom motorized/power wheelchair at a time.
2. Includes all labor charges involved in the
assembly of the wheelchair and all covered additions, accessories and
modifications.
3. Includes support
services such as emergency services, delivery, setup, education and ongoing
assistance with use of the wheelchair.
4. Is made only after the PT or OT subsequent
evaluation is completed.
I. The DME providers must ensure the
prescribed custom manual and/or custom motorized/power wheelchair and
accessories are adequate to meet the resident's needs, must ensure the proper
height and width, and must provide an automatic or special locking mechanism
for residents unable to apply manual brakes.
J. The DME provider providing custom
motorized/power wheelchairs to residents must:
1. Have at least one (1) employee with
Assistive Technology Professional (ATP) certification from Rehabilitation
Engineering and Assistive Technology Society of North America (RESNA) who
specializes in wheelchairs and who must be registered with the National
Registry of Rehab Technology Suppliers (NRRTS).
a) The NRRTS and RESNA certified personnel
must have direct, in-person, face-to-face interaction and involvement in the
custom motorized/power wheelchair selection for the resident.
b) RESNA certifications must be updated every
two (2) years.
c) NRRTS
certifications must be updated annually.
d) If the certifications are found not to be
current, the prior authorization request for the motorized/power wheelchair
will be denied.
2.
Provide a lifetime warranty on the powered mobility base frame against defects
in material and workmanship for the lifetime of the resident.
3. Provide a two (2) year warranty of the
major components, beginning on the date of delivery to the resident.
a) The main electronic controller, motors,
gear boxes and remote joystick must have a two (2) year warranty from the date
of delivery.
b) Cushions and
seating systems must have a two (2) year warranty or full replacement for
manufacturer defects or if the surface does not remain intact due to normal
wear.
4. If the DME
provider supplies a custom motorized/power wheelchair that is not covered under
a warranty, the DME provider is responsible for any repairs, replacement or
maintenance that may be required within the two (2) years.
K. DME providers providing custom
motorized/power wheelchairs, customized electronic interphase devices,
specialty and/or alternative controls for wheelchairs, extensive modifications
and seating and positioning systems must have a designated repair and service
department, with a technician available during normal business hours, between
eight (8:00) a.m. and five (5:00) p.m. Monday through Friday. Each technician
must keep on file records of attending continuing education courses or seminars
to establish, maintain and upgrade their knowledge base.
L. The Division of Medicaid covers repairs,
including labor and delivery, of a custom manual and/or custom motorized/power
wheelchair owned by the resident not to exceed fifty percent (50%) of the
maximum allowable reimbursement for the cost of replacement.
1. The nursing facility is responsible for
the repairs, including labor and delivery, of custom manual and/or custom
motorized/power wheelchairs delivered to the resident prior to January 2,
2015.
2. Major repairs and/or
replacement of parts require prior authorization from the UM/QIO and must
include an estimated cost of the necessary repairs, including labor, and
documentation from the practitioner that there is a continued need for the
custom manual and/or custom motorized/power wheelchair.
3. An explanation of time involved for
repairs and/or replacement of parts must be submitted to the UM/QIO.
4. Manufacturer time guides must be followed
for repairs and/or replacement of parts.
5. The Division of Medicaid defines repair
time as point of service and does not include travel time to point of
service.
6. No payment is made for
repairs or replacement if it is determined that intentional abuse, or misuse,
of the wheelchair or components has occurred, which includes damage incurred
due to inappropriate covered transportation for the prescribed custom manual
and/or custom motorized/power wheelchair.
7. Reimbursement will be made for up to one
(1) month for a rental of a wheelchair while the resident's wheelchair is being
repaired.
8. The Division of
Medicaid does not cover the repair of a rented custom manual and/or custom
motorized/power wheelchair.
Social Security Act
§ 1834; Miss. Code Ann. §§
43-13-117;
43-13-121.
