You might think that if you’re 65 or older and need a wheelchair or electric scooter to get around, Medicare would automatically cover it. But, as with so many areas of Medicare, things aren’t quite that simple.
Whether Medicare will pay for the cost of a mobility device like a manual wheelchair, power wheelchair or electric scooter depends on whether you meet all its requirements.
“It’s not the easiest thing in the world,” says Diane Omdahl, author of Medicare for You and cofounder of the Medicare advisory firm, 65 Incorporated.
To clear up any confusion about terminology: a manual wheelchair is one you propel or your caregiver does; a power wheelchair (also called an electric wheelchair or power chair) is for people lacking the motor function or cardiovascular strength to operate a manual wheelchair and an electric or power scooter helps users who can’t operate a manual wheelchair and can’t use canes or walkers.
Even if you qualify for Medicare reimbursement for a mobility device, you’ll be on the hook for 20% of the approved amount — your coinsurance — after paying your Part B deductible, which is $240 in 2024.
The first rule for Medicare coverage of a wheelchair or scooters is that you must have a medical need for one in your home.
“That doesn’t mean you have to use it exclusively in your home, but that you need it in your home,” says Casey Schwarz, senior counsel for education and federal policy at the Medicare Rights Center.
Medicare won’t cover the wheelchair or scooter if you only want the device for convenience or when traveling. Traditional Medicare also won’t pay for a home wheelchair ramp.
The second rule for reimbursement is what Medicare calls “limited mobility.”
That means having all of these:
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A health condition causing significant difficulty moving around at home
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An inability to do daily living activities like bathing, dressing or using the bathroom with help from a cane, crutch or walker
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The ability to safely operate a wheelchair or scooter or someone always available to help you do it
Pass those tests and you’ll need a face-to-face examination from a doctor (who must participate in Medicare). The physician will then submit to Medicare a Certificate of Necessity saying you have the medical need and that they are treating you for the condition.
You may need prior authorization from Medicare to get reimbursement for a power wheelchair, That’s true whether you’re in traditional Medicare or a health insurer’s Medicare Advantage plan. Medicare’s site has a list of more than 40 power wheelchairs requiring prior authorization.
“The supplier and your health provider will submit the prior authorization,” says Schwarz. “If it’s denied or you need to provide more information, you can submit a new request.
You can either buy or rent wheelchairs and scooters. Manual wheelchairs tend to cost between $1,000 and $2,000; power wheelchairs can run well over $10,000. Electric scooters go for about $600 to $4,000. Rentals are often $100 to $400 a month.
Typically, if you rent a mobility device, ownership will transfer to you after 13 months.
Medicare won’t replace a wheelchair or scooter you recently bought or began renting because you’re not happy with it.
“If you have a chair that doesn’t fit you well and you’re not comfortable in it but Medicare already paid for it, they’re not going to give you another one for five years,” says Paul Lane, the accessibility specialist and tech access lead for United Spinal Association’s Tech Access Initiative.
Last year, Medicare expanded its coverage of power wheelchairs to include power seat elevation. That feature helps users reach countertops and cabinets more easily.
“This landmark Medicare decision to cover seat elevation is a major milestone that will improve the quality of life for so many who rely on this technology,” says Chiquita Brooks-LaSure, the Centers for Medicare and Medicaid Services (CMS) Administrator in a statement.
You’ll need an evaluation from a trained medical professional to qualify for the seat-lift benefit.
The Independence Through Enhancement of Medicare and Medicaid (ITEM) Coalition of groups such as the Medicare Rights Center and the United Spinal Association wants Medicare to also cover power-standing features for wheelchairs.
“Standing wheelchairs can cut down on pressure sores and increase bowel and bladder function,” says Lane.
CMS has said it plans to consider covering them in the future.
To buy or rent a wheelchair or scooter and get reimbursed by Medicare, you need to go to a durable medical equipment supplier that takes Medicare assignment. You can find ones near you on the Medicare.gov site.
Don’t purchase a wheelchair at a drugstore or department store just because it’s convenient and you assume the store has Medicare certification. “If you go to a corner pharmacy in a remote area, I doubt they’re certified,” says Omdahl.
Be careful with nomenclature: A supplier that’s Medicare-approved but doesn’t take assignment might charge you more for a wheelchair or scooter than Medicare’s approved amount.
Medicare Advantage plans from private health insurers (the alternative to traditional Medicare) have their own networks of wheelchair and scooter suppliers as well as their own mobility-device coverage rules.
“I found one Medicare Advantage insurer that will transfer ownership of a wheelchair to the user after 13 months, a second that will transfer certain items and one that never transfers no matter how many co-payments you make,” says Omdahl.
Before you buy or rent a wheelchair or scooter, your doctor or the equipment supplier must visit your home to verify that you can actually use it there.
The durable medical equipment supplier may send a certified Assisted Technology Professional (ATP) to make the assessment and to determine the chair or scooter features you need and that Medicare will approve.
“They’re pretty well versed. They’ll say, ‘Medicare won’t pay for that. Medicare won’t pay for this.’ They guide you along the way,” says Lane.
A home assessment is critically important before getting a wheelchair since some models are too wide to fit through doorways.
“I had a chair five or six years ago and it was just huge and hard for me to get into different doorways in my home,” says Lane. “I would scrape up a lot of walls.”
Omdahl recalls when she was a home care nurse helping a woman with a broken hip who got a wheelchair that didn’t fit through her bedroom door. “I moved the bed into the doorway and taught the woman how to stand up and hop on her bed,” Omdahl says.
The United Spinal Association site has user reviews of thousands of wheelchairs. You can search by model, manufacturer or type.
This story was originally featured on Fortune.com
