Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers
Section 5160-10-16 - DMEPOS: wheelchairs

(a) A sling or solid seat with back, a captain's chair, or a stadium-style seat;

(b) Standard casters or wheels with tires;

(c) Standard armrests;

(d) Standard front rigging , such as non-elevating legrests with footrestsor a footplate;

(e) Wheel locks or brakes;

(f) With a power mobility device, motors;

(g) With a power mobility device, a non-expandable controller;

(h) With a power mobility device, a battery charger;

(i) With a power wheelchair, a standard proportional joystick; and

(j) With a power-operated vehicle, batteries.

(a) Wheelchairs and wheelchair parts and accessories are generally not necessary nor even useful in the absence of illness, injury, impairment, disability, or other condition that limits ambulation. Therefore, a wheelchair needs to provide mobility to an individual for whom ambulation is not possible, takes inordinate physical effort, or causes considerable physical discomfort.

(b) A wheelchair also needs to be suited to the purposes and daily routines of the individual using it.

(c) A manual wheelchair needs to provide a level of needed functionality that cannot be achieved with an assistive device such as a cane, a crutch or crutches, or a walker.

(d) A power mobility device (PMD) needs to provide a level of needed functionality that cannot be achieved with a manual wheelchair.

(e) A PMD needs to be functional in the environment in which it is used. The individual (or someone assisting the individual) needs to have the ability to take proper care of the PMD, the individual's place of residence needs to be accessible and have adequate electrical service, transportation of the PMD needs to be available as necessary, and there needs to be sufficient protection for the PMD from the elements. The place of residence is considered to be accessible only if the individual will be able to use the PMD without assistance to enter and leave the residence and to move easily about the main living space (which is used for purposes such as food preparation, eating, sleeping, personal hygiene, and relaxation).

(f) A customized seating system needs to enable an individual to sit (or recline, as appropriate) for long periods of time, provide postural support to permit functional activities, or reduce pressure on the body to a degree that cannot be achieved with items such as a standard wheelchair seat, an individualized seating system (e.g., a prefabricated seat cushion or other removable positioning aid or combination of positioning aids), or a spinal orthotic device.

(a) Group one power-operated vehicles;

(b) Group two power-operated vehicles;

(c) Group one power wheelchairs;

(d) Group two power wheelchairs;

(e) Group three power wheelchairs;

(f) Group four power wheelchairs;

(g) Group five power wheelchairs; and

(h) Power mobility devices not otherwise classified.

(a) A physician;

(b) An advanced practice registered nurse with a relevant specialty ;

(c) A physician assistant; or

(d) A podiatrist.

(a) For wheelchairs incorporating CRT, a physiatrist, orthopedic surgeon, neurologist, physical therapist, or occupational therapist; or

(b) For wheelchairs not incorporating CRT, a physician, physical therapist, or occupational therapist.

(a) For manual wheelchairs without CRT, a provider enrolled as a basic durable medical equipment (DME) supplier; or

(b) For PMDs and CRT, a provider enrolled as a specialized DME supplier .

(a) For manual wheelchairs without CRT, a provider enrolled as a basic DME supplier; or

(b) For PMDs and CRT, a provider enrolled as a specialized DME supplier .

(a) The medical necessity of a wheelchair needs to be determined before the department will make payment. For a wheelchair purchased by the department, this necessity is documented on form ODM 03411, "Certificate of Medical Necessity: Wheelchairs" (rev. 7/2021). The medical necessity of a wheelchair that has not been purchased by the department is documented either on this certificate of medical necessity (CMN) or on an equivalent form.

(b) If more than one type of wheelchair will meet an individual's needs and satisfy the criteria of medical necessity, then the maximum payment amount is the lowest of the respective costs, regardless of which wheelchair is supplied.

(c) The provision of or payment for the purchase, repair, or rental of a medically necessary non-custom wheelchair for a resident of a longterm care facility (LTCF) is the responsibility of the LTCF. This responsibility holds even if the wheelchair incorporates CRT other than a customized seating system. In turn, the LTCF receives medicaid payment in accordance with Chapter 5160-3 of the Administrative Code. Therefore, claims submitted to the department by wheelchair suppliers for the purchase, repair, or rental of non-custom wheelchairs furnished to LTCF residents will be denied.

(a) Custom wheelchairs for individuals living in a LTCF and wheelchairs for individuals not living in a LTCF. Prior authorization (PA) is needed, and a face-to-face evaluation of need has to be performed by a prescribing provider not earlier than one hundred eighty days before the submission of the PA request.

(b) Constraints and limitations.

(a) Custom wheelchairs for individuals living in a LTCF and wheelchairs for individuals not living in a LTCF. The repair of a component such as a frame, seating system, motor, drive system, or battery is subject to need verification. No verification is needed for the repair of a wear item, such as a caster bearing, tire, arm pad).

(b) Constraints and limitations.

(a) Custom manual wheelchairs. PA is needed.

(b) Non-custom manual wheelchairs for individuals not living in a LTCF. No PA is needed for the first three months. PA is needed for rental periods after the first three months.

(c) PMDs. PA is needed.

(d) Constraints and limitations.

(a) An evaluator may receive payment for determining an individual's needs for a wheelchair. Not more than one payment will be made per wheelchair per individual.

(b) Payment includes all services rendered by the evaluator, including evaluation, product selection, confirmation at delivery, and follow-up.

(a) They were delivered to the individual for whom they were prescribed;

(b) They are consistent with the items described in the CMN; and

(c) They correspond exactly to the items listed on the submitted claim.

(a) For purchase of a covered new wheelchair, part, or accessory, ninety per cent of the allowed amount listed for Ohio on the "DMEPOS Fee Schedule";

(b) For purchase of a covered group four power wheelchair for which there is no medicare allowed amount, one hundred ten per cent of the medicaid maximum payment amount allowed for purchase of the most closely corresponding covered group three power wheelchair;

(c) For purchase of any other covered wheelchair, new part, or new accessory for which there is no medicare allowed amount, payment by report;

(d) For purchase of a covered wheelchair, part, or accessory that has been previously used but remains in good working order, fifty per cent of the medicaid maximum payment amount allowed for purchase of a comparable new wheelchair, part, or accessory;

(e) For monthly rental of a covered wheelchair to which rental applies, ten per cent of the medicaid maximum payment amount allowed for purchase;

(f) For performance of an evaluation and related services, eighty per cent of the amount established by the medicare physician fee schedule; or

(g) For labor provided for a covered repair or covered maintenance, the result L obtained by the formula L = ([W + B] × P + M) × A × 0.25.