Bill Would Clear ‘Major Issue' For High-Tech Wheelchairs

Published in Complex Rehab on October 16, 2023

Bill Would Clear ‘Major Issue' For High-Tech Wheelchairs This post was originally featured in HME News.

A new bill in the U.S. House of Representatives would allow Medicare beneficiaries to pay the difference to upgrade to a titanium or carbon fiber manual wheelchair.

Right now, if a consumer wants a titanium or carbon fiber manual wheelchair, they must pay for the full cost of the wheelchair out of pocket, have their provider file a non-assigned claim on their behalf and, if approved, wait to receive 80% of the Medicare allowable.

“These numbers aren’t reflective of the allowable, but it means if the allowable is $3,000 and the chair’s selling price is $4,000, the beneficiary can’t pay just the $1,000 difference,” said Dan Fedor, director of reimbursement and education for U.S. Rehab, a division of VGM & Associates. “They must pay $4,000 and that prohibits most people from doing it.”

The bill, H.R. 5371, was introduced in mid-September by Rep. John Joyce, R-Pa., with Rep. Michelle Steel, R-Calif., joining as an original co-sponsor.

The need for the bill stems from an interpretation by the DME MACs in 2016 that prohibits using an advanced beneficiary notice (ABN) “to shift liability for an item or service that is described as ‘better’ or ‘higher quality’ but does not exceed the HCPCS code description.”

“We disagree with the interpretation that you can’t upgrade within a code,” Fedor said. “As long as the base product meets the code description and meets the medical necessity features for that code, if there’s a better product and they pay extra, why can’t that happen?”

As a result of the interpretation, providers that want to accept assignment and beneficiaries who don’t want to pay the full amount for a titanium or carbon fiber wheelchair must go with a standard ultra lightweight wheelchair made of aluminum.

“This is really a consumer choice bill,” said Wayne Grau, executive director of NCART. “It gives them the choice to upgrade to a better piece of equipment. We don’t understand why this is a major issue.”

Stakeholders believe the bill is well positioned to move – its champions have positions on key committees like Energy & Commerce and, because beneficiaries would pay for the upgrade, it’s budget neutral.

“It’s a common sense item that’s not going to cost Medicare anything,” Grau said.

TAGS