I would like to go deeper into the explanation of what Medicare covers regarding wheelchairs. There are two popular types of chairs used for daily activity of more than two-hours/day. These would be what I call my full-time patients who have MS, had a stroke, dementia, etc.:
K0004—high strength, lightweight (I recommend the Insignia from Invacare or Stylus from Pride and is 33 pounds). http://www.pridemobility.com/quantum/manualwheelchairs/stylusls.asp Medicare pays for this at $142/month (if no co-insurance, only $113). If we were to go this route, Howard’s accepts what Medicare pays and the patient would only have an out-of-pocket expense if Medicare didn’t pay because of lack of doctor documentation or if the patient had a copay.
K0005—ultra-lightweight wheelchair (this is the Prospin 4 I recommend from Invacare or Lifestream from Pride, base weight of 15-17 pounds, actual weight of about 27 pounds). http://www.pridemobility.com/quantum/manualwheelchairs/LiteStreamXF.asp Medicare typically does not cover these chairs but you do have the option of using your K0004 credit toward these chairs if you would like to upgrade. Think of car shopping and if you decide to get power windows and locks or a sunroof, it is a upcharge. For example, if you buy the chair for $2200, over the next 13 months you would be reimbursed $142/month from Medicare which is what you would have received had the patient received a K0004 wheelchair so the actual price on the wheelchair is closer to about $400-600. Howard’s expects the patient to pay the full amount up-front (in Medicare terminology this is called non-assignment). Last, some people do not like the risk because if the patient goes to the hospital, nursing home, or if the doctor does not get back the right paperwork to Medicare, Medicare does not pay the full amount of the wheelchair.
Accessories—No matter what direction you decide to go on a wheelchair, I usually recommend billing accessories to Medicare. You just need a standard prescription for these and they will pay for them minus the 20% copay if the patient doesn’t have co-insurance. I personally are bugged to see certain people sit in wheelchairs without a standard cushion and anti-tippers. One is for comfort, the second is for safety for going over thresholds and up ramps
As always, let me know if you have any questions. Howard’s offers free quotes and in-home evaluations. Many people can’t track with this discussion but a lot of other people really enjoy getting technical understanding the ins/outs of insurance rules and regulations.
Regards, Erik Mickelson ATP
Assistive Technology Professional
Manager of Howard’s Medical LLC