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Public Policy

The goal of the Disability Policy Collaboration is to impact national public policy for people with developmental disabilities, including those with cerebral palsy and intellectual disability, and their friends, families and loved ones.

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Volume 2 (2004):

CMS Restricts Access to Medicare Wheelchair Coverage

In December the Centers for Medicare and Medicaid Services (CMS) issued a policy "clarification" that restricts Medicare eligibility for manual and power wheelchairs and scooters. This clarification will adversely impact Medicare beneficiaries with mobility disabilities of all ages.

Original Medicare law states that, Medicare Part B (which covers out-patient services) will pay for a mobility device "for use in the home." Congress wanted to draw a distinction between home and hospital use since Durable Medical Equipment (DME) costs associated with hospitalization are already included under Medicare Part A. CMS regulations and policy directives have narrowly interpreted "in the home" and will only purchase these mobility devices when the individual needs them to move about within the four walls of the home.

In practice, prior to the new policy clarification, CMS allowed Durable Medical Equipment Regional Carriers (DMERCs)—the entities it contracts with to administer the benefit—to use local medical review policies to evaluate an individual’s disability in its totality, taking all factors into consideration. For example, the DMERC would consider not only whether a beneficiary with cerebral palsy could take a step, or had the upper body strength to operate a manual wheelchair, but also whether s/he had the fine motor skills to manipulate a manual wheelchair.

Under the new policy clarification, DMERCs are instructed to determine eligibility for mobility devices solely by assessing whether a person is ambulatory or non-ambulatory by determining if the person can take a step, and the strength and function of a person’s arms and legs. The policy requires that if a patient "is able to walk either without any assistance or with the assistance of an ambulatory aid, such as a walker, the wheelchair is denied as not medically necessary." This implies that if a beneficiary is able to take one step with the aid of a walker, cane, or brace, they are not eligible for any mobility device.

To qualify for a power wheelchair, the policy clarification requires that a person must be "unable to operate" a manual wheelchair. This limitation fails to consider whether the use of a power wheelchair would prevent secondary disability (e.g. injuries to shoulders as manual wheelchair users age). It is also unclear whether lack of fine motor skills (which as noted above, many people with cerebral palsy and other disabilities experience) would constitute "inability to operate" a manual wheelchair.

CMS issued this policy clarification to address the increased utilization of mobility devices, which the agency believes is due to fraud and abuse. In the fall of 2003, CMS announced "Operation Wheeler Dealer"—a 10-point plan to address alleged fraud and abuse by some DME vendors.

Wheelchair users, physicians and advocates believe that this new policy clarification will result in inappropriate denials of legitimate claims or significant delays in obtaining necessary equipment, even in cases where ample documentation supporting the need for a mobility device exists.

UCP and The Arc are working with the Independence Through the Enhancement of Medicare and Medicaid (ITEM) coalition (a broad based disability, aging, and non-profit provider coalition) to convince CMS to rescind this policy clarification. To complement the ITEM coalition’s efforts, the DME industry came together recently and formed the Restore Access to Mobility Partnership (RAMP) coalition.