Does Insurance Pay for Wheelchairs and Other Mobility Devices?

Insurance coverage for wheelchairs and other mobility devices can be a lifesaver for individuals with disabilities. Many insurance policies cover the cost of wheelchairs, but the specifics vary widely.

Most health insurance plans, including Medicare and Medicaid, cover the cost of wheelchairs as durable medical equipment (DME). This means that if you have a prescription from a doctor for a wheelchair, your insurance should cover it.

However, the type of wheelchair covered by insurance can be limited. For example, some insurance plans may only cover manual wheelchairs, while others may not cover power wheelchairs at all.

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Insurance coverage for wheelchairs is a case-by-case basis, with approval decisions based on thorough documentation of the equipment that meets the member's medical and functional needs.

Eligible members can receive one new manual wheelchair base (MWB) to be used as their primary mode of mobility or as a secondary mobility device to a power mobility device (PMD). If you own a PMD, you may be approved for a secondary MWB if your provider demonstrates medical necessity and you need it to complete activities of daily living at home and in the community.

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Here are the eligible MWB categories:

In addition to MWBs, Health First Colorado may also approve the purchase of a stroller or Transport Chair if your provider demonstrates medical necessity and you need it to complete activities of daily living at home and in the community.

Insurance coverage is a vital aspect of financial planning, and understanding the different types of insurance can help you make informed decisions. There are several types of insurance, each designed to protect against specific risks.

Life insurance, for example, provides financial support to loved ones in the event of the policyholder's passing. It can also be used to pay off outstanding debts or cover funeral expenses.

Health insurance, on the other hand, helps cover medical expenses, including doctor visits, hospital stays, and prescriptions. Some policies also offer additional benefits, such as dental or vision coverage.

Disability insurance replaces a portion of the policyholder's income if they become unable to work due to illness or injury. This can be especially important for those with high incomes or careers that require specialized skills.

Homeowners and renters insurance protect against damage to property and belongings, whether caused by accidents, theft, or natural disasters.

Manual Wheelchair Bases are a covered benefit for Health First Colorado members who have a condition that affects their ability to sit or ambulate safely and functionally.

To qualify for a Manual Wheelchair Base, a member's condition or diagnosis must be such that they would be unable to sit or ambulate safely, timely, or functionally without one. This is reviewed on a case-by-case basis, based on documentation submitted by the provider.

Approval for a Manual Wheelchair Base is based on the most appropriate and least costly option available to meet the member's medical and basic functional needs.

Members may receive one new Manual Wheelchair Base to be used as their primary mode of mobility or as a Secondary Mobility Device to a Power Mobility Device. If a member owns a Power Mobility Device, Health First Colorado may approve the purchase of a secondary Manual Wheelchair Base if it is required to enable the member to meet their activities of daily living at home and in the community.

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Eligible members may also receive a stroller or Transport Chair if it is medically necessary, and cannot be completed with the use of their Power Mobility Device or Manual Wheelchair Base.

Here are the requirements for eligible members to receive a Manual Wheelchair Base:

Note that members are only eligible for one Primary Mobility Device and one Secondary Mobility Device when medically necessary, and requests for additional wheelchairs to be used solely as a backup will be denied as not medically necessary.

Insurance coverage for wheelchairs can be a complex topic, but let's break it down. Standard equipment includes nonstandard options or accessories, which may be covered depending on the provider's documentation.

Providers must be prepared to submit additional documentation of medical necessity, beyond what is typically required. This means having all the necessary paperwork and records in order to ensure coverage.

Nonstandard options or accessories may include features that are tailored to an individual's specific needs, such as custom wheelchairs or specialized seating systems.

Powered wheelchairs and scooters are a great option for people who need assistance with mobility. They can be medically necessary, but a doctor's order, certificate, or prescription is required to obtain one.

If a doctor determines that an electric wheelchair or scooter is medically necessary, they may request prior authorization for Original Medicare to cover certain types of powered wheelchairs and scooters.

A doctor must state that the person cannot use a manual wheelchair or another mobility device and requires an electric one. This should be done in an in-person meeting with the doctor, which should occur no more than 45 days before they write the order.

The person's condition will determine whether they require a powered wheelchair, powered scooter, or another mobility device.

Nonstandard options or accessories may include specialized seating systems for mobility devices. These can be medically necessary to enable individuals to perform daily activities at home and in the community.

Standard equipment is just the beginning, and there are many other options available to enhance mobility and independence. These may include customized controls, specialized cushions, or other adaptive equipment.

Duplicate services will not be approved, so if you already have a wheelchair seating system for one mobility device, you won't be able to get another one for a different device. This is to ensure that members get the most value from their equipment.

In some cases, Health First Colorado may pay for repairs or modifications to existing equipment, but this is only after medical necessity has been evaluated and well-documented by a provider. This is to ensure that the equipment is truly necessary and not just a convenience.

Transport and rollabout chairs are designed for people who need assistance with mobility. They have casters at least five inches in diameter and are intended for intermittent transport of non-ambulatory individuals.

These chairs have limited adjustability and don't accept specialized seating supports, so they're not meant for long-term use. They're often used in homes, offices, and institutions for general purposes.

To qualify for coverage, you'll need to meet certain criteria. If you'll spend less than two hours per day in the mobility device, you may be eligible.

You'll also qualify if you're unable to self-propel a mobility aid and have a caregiver who can operate the transport chair or rollabout chair. Or, if you have an impairment that makes you a non-functional ambulator due to pain or fatigue.

In some cases, you may need a transport chair or rollabout chair for safety reasons or to access routine transportation and accessibility needs. If you require dependent mobility in the home and/or community, you may be eligible for coverage.

Here are the specific criteria for transport and rollabout chairs:

If you're considering a wheelchair or scooter, you're likely wondering how much it will cost and whether insurance will cover it. First, it's essential to note that Medicare Part B covers wheelchairs when medically necessary, but you'll need to meet specific requirements.

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Medicare will cover 80% of the cost, but you'll be responsible for the remaining 20% after paying your Part B deductible. In 2025, the deductible is $257. This means that if a power wheelchair costs $2,500, your out-of-pocket cost would be $500 (20% of the total).

The cost of wheelchairs and scooters can vary widely, depending on the specific model, features, and supplier. A basic, manual wheelchair can cost a few hundred dollars, while a high-end, power wheelchair with advanced features can cost several thousand dollars.

If you live in an area where Medicare's competitive bidding program applies, you'll need to get your scooter from a vendor contracted with Medicare under the program, which can help lower costs. It's also essential to ensure that your supplier and doctor are participating in the Medicare program.

Here are some estimated costs for wheelchairs and scooters:

Keep in mind that these are just estimates, and the actual cost may vary depending on your specific needs and the supplier you choose.

To get insurance to cover a wheelchair, you'll need to meet specific documentation requirements. Prior Authorization is required for purchase of all wheelchairs and wheelchair-related items as outlined in the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Billing Manual.

A Prior Authorization Request (PAR) must be accompanied by documentation, including a letter of medical necessity that includes the member's name, date of birth, residence address, height and weight, and all relevant medical diagnoses. The letter must also summarize the member's current medical condition, prognosis, and previous and current treatments.

The PAR must include the manufacturer, make, and model of the equipment, and a quoted amount must be submitted with the PAR for all purchases or repairs.

Here are the basic documentation requirements:

Note that some items, such as CRT wheelchairs, require Specialty Evaluation documentation, which provides further details to establish medical necessity.

Documentation Requirements can seem overwhelming, but understanding the basics can make a big difference.

There are two levels of documentation requirements for Prior Authorization Requests (PARs) for wheelchairs and wheelchair-related items.

Basic documentation requirements apply to all wheelchairs and wheelchair-related items that require a PAR, as indicated in each of the subparts of this Benefit Coverage Standard. This level of documentation does not require a Specialty Evaluation.

Some Complex Rehabilitation Technology (CRT) items require Specialty Evaluation documentation, which provides further details in order to establish medical necessity.

The following documentation is required for Basic PARs:

It's essential to note that all PARs must be accompanied by a letter of medical necessity that includes all of the required information.

Documentation and requirements are crucial for maintaining clarity and consistency in our processes. A clear revision log can help ensure that everyone is on the same page.

The Wheelchair Benefit Coverage Policy Revision Log is a great example of this. It keeps track of changes made to the policy over time.

The log shows that the manual was revised for interChange implementation on December 1, 2022. This change was made by HCPF.

The log also notes that the manual was converted to a web format on April 18, 2023. This change was also made by HCPF.

Here is a breakdown of the revisions made to the policy:

Power mobility devices come in different types, and understanding these options can help you make an informed decision.

Power Operated Vehicles (POVs), also known as scooters, are three or four-wheeled motorized transportation systems designed for individuals with impaired ambulation. They're operated by a tiller with a professionally manufactured basic seating system.

Power Wheelchairs (PWCs) are professionally manufactured devices that provide motorized wheeled mobility and body support for individuals with impaired mobility. There are five groups of PWCs, each with different features such as range, speed, durability, and obstacle-climb capabilities.

Here's a brief overview of the features used to differentiate the five groups of PWCs:

Power mobility devices, such as scooters and wheelchairs, are crucial for individuals with impaired mobility. There are two main types of power mobility devices: Power Operated Vehicles (POVs) and Power Wheelchairs (PWCs). POVs are three or four-wheeled, non-highway motorized transportation systems, while PWCs are four or six-wheeled motorized vehicles with electronic steering and body support.

POVs, also known as "scooters", are designed for persons with impaired ambulation, providing basic seating systems and tiller operation. PWCs, on the other hand, offer motorized wheeled mobility and body support specifically for individuals with impaired mobility.

Here are the five groups of PWCs, differentiated by features such as range, speed, durability, and obstacle-climb capabilities:

Custom molded seating systems are fabricated from an impression or digital image of the member using created-for- or molded-to-patient techniques. This type of seating provides positioning or pressure relief that cannot be met with a standard, mass-produced cushion or seating system.

Custom fabricated seating systems can be entirely created by the provider or purchased from a manufacturer. To be considered custom fabricated, the seating system must have been coded E2609 or E2617 by Medicare’s Pricing, Data Analysis and Coding.

Seating systems purchased from a manufacturer must have been coded E2609 or E2617 to be considered custom fabricated. This coding is crucial for billing and authorization purposes.

Custom fabricated seating systems (E2609 or E2617) require authorization when the submitted charge is over $1,200. The provider must submit an invoice from the manufacturer to show the cost of the seating system.

Bill labor and material costs associated with fabricating an individually made seating system to MHCP using one of the following HCPCS codes. This includes the cost of parts and labor for custom fabricated seating created by the provider.

When requesting authorization or billing for custom fabricated seating, backs, or customized wheelchair equipment, submit an invoice from the provider showing the provider’s cost for parts and labor. This is a crucial step in the billing process.

Handicap scooters are a type of mobility device that can be covered by Medicare if your healthcare provider certifies that you have a medical condition that limits your mobility.

Medicare will pay 80% of the allowable charges for your equipment, and you'll pay the remaining 20% plus any applicable deductible. On average, the price of a motor-powered scooter can range between $700-$2500+.

To qualify for coverage, you'll need to go through the same steps as seniors over 65, including receiving a doctor's certification that your device is medically necessary and that you're capable of safely operating it.

If you receive Social Security Disability Insurance (SSDI) benefits, you can become eligible for Medicare benefits as well, which can include coverage for handicap scooters.

You'll still need to have a doctor determine that your device is medically necessary to obtain coverage, regardless of your age or disability status.

Medicare-approved handicap scooters can help provide beneficiaries with viable solutions for improved mobility and quality of life, but it's essential to understand the costs involved and how to navigate the process.

Manual wheelchairs, power-operated vehicles, and power wheelchairs can greatly enhance independence and mobility for individuals with mobility-related disabilities.

These devices help people complete activities of daily living in their homes and communities.

Many people rely on these wheelchairs to navigate their daily routines, and they can be a game-changer for those who struggle with mobility issues.