In October 1, 2014, special rules changed if you live in AZ, CA, FL, GA, IL, IN, KY, LA, MD, MI, MO, NJ, NY, NC, OH, PA, TN, TX or WA and have Original Medicare. Your provider or supplier now needs to ask Medicare for permission before you can get a power wheelchair or scooter. This process is called prior authorization. Your doctor or supplier must send the request to the Durable Medical Equipment Medicare Administrative Contractor (DME MAC).
The DME MAC will let you, your provider and supplier know whether the purchase of a power wheelchair or scooter has been approved or denied. The request will be answered within 10 business days (sooner if going without the equipment could harm your health). If the DME MAC approves coverage, your Medicare-participating supplier will provide you with the equipment and charge you for coinsurance and deductibles.
If the DME MAC denies prior authorization for your equipment, your provider or supplier can request it one more time. Your provider or supplier should give more reasons you are in need or require a power wheelchair or scooter.
If prior authorization is denied again, it is very unlikely that Medicare will end up paying for your wheelchair or scooter. However, if you and your doctor truly believe you should qualify for a power wheelchair or scooter, you have another chance to get Medicare to pay. In the end, you must be prepared to end up paying the full cost of the equipment yourself.
Here’s how this might work:
- Before providing you the equipment, the supplier should give you an Advance Beneficiary Notice (ABN).
- On the ABN, select the box asking your supplier to submit the bill to Medicare and agreeing to pay if Medicare denies it.
- The supplier can charge you for the full cost of the equipment in the meantime.
- If Medicare denies the claim, you can appeal the denial through the Original Medicare appeals process.
- If you win the appeal, Medicare will either pay the provider or send you a check as reimbursement.
- The supplier must refund you any amount that Medicare pays it for the equipment.
For more information on your benefits or if you would like to review your Medicare Health Plan, please contact Medicare Pathways for more information. You may speak to a licensed insurance agent by calling 866-466-9118. During a free no obligation benefit review and/or quote, you may find a plan available in your area that better fits your financial and medical needs. Don’t wait! Learn more now and call 866-466-9118.