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 a
Utilization Management/Quality Improvement Organization (UM/QIO), the Division
of Medicaid or designated entity.
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 is 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 Division of Medicaid at the time of the initial evaluation.
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.
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. The resident
must meet the following criteria:
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 ICF/IID.
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 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/or 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 provider 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 ICF/IID 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 a UM/QIO, the Division of
Medicaid, or designated entity 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 a UM/QIO, the Division of Medicaid, or designated entity.
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. This 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 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.
42 U.S.C.
§
1395m; Miss. Code Ann. §§
43-13-117,
43-13-121.
