ITEM Coalition Members and Friends:

Medicare has issued modifications to recent changes in power wheelchair reimbursement levels. Many stakeholders, including many ITEM Coalition members, had raised concerns with their Members of Congress and CMS that the new reimbursement levels were too low and could negatively impact consumer access. The recent modifications increase reimbursement levels for many of the high-functioning, Group 3 wheelchairs that are commonly prescribed for individuals with long-term, severe disabilities. Although it remains too early to fully assess the impact of these modifications, they are clearly a step in the right direction.

However, a major problem with the Medicare wheelchair benefit remains – the perpetuation of the discriminatory “in the home” restriction – which continues to confine beneficiaries with mobility impairments to the four walls of their homes, and in some instances, to one level of their homes.

Below is a summary of the new Medicare wheelchair policies that went into effect on November 15, 2006, as well as a request for action with regard to the “in the home” restriction.

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Background:

In August, Medicare issued a final LCD for power mobility devices. The new LCD will implement a series of new payment codes for power wheelchairs and scooters, and create coverage standards for devices with functional capabilities that place them into 6 “groups.” (Only Group 1 (lowest functioning), Group 2, Group 3 (higher functioning) and Group 5 (pediatric) power wheelchairs will be covered by Medicare.)

The original LCD policy had three major problems:

• First, the policy would have significantly "downcoded" the Medicare wheelchair benefit placing many individuals into inadequate and often unsafe power wheelchairs;
  
  
• Second, the new policy required that a beneficiary be unable to "stand and pivot" in order to qualify for the highest functioning chair (Group 3) - a standard that failed to take into account the functional needs of individuals, especially those who may be able to stand and pivot but need a Group 3 device to participate in their daily activities; and
  
  
• Third, the policy implemented a more restrictive definition of the "in the home" restriction by denying access to wheelchairs that have capabilities which are deemed unnecessary for indoor use.

Additionally, in early October, CMS issued new reimbursement levels for power wheelchairs that seriously cut payments to suppliers of many of the high functioning power wheelchairs. Because many suppliers indicated they would not be able to continue supplying such devices to Medicare beneficiaries, these reimbursement cuts would have created significant access problems for beneficiaries requiring high functioning mobility devices.

Changes to Policies:

• On September 20, 2006, the Centers for Medicare and Medicaid Services (CMS) released “clarifications” to the LCD alleviating some of the access concerns associated with downcoding from Group 2 to Group 1 wheelchairs. This downcoding was of great concern because many individuals with disabilities could have been placed in inadequate and often unsafe mobility devices.
  
  
• On November 1, 2006, CMS made additional changes to the LCD that removed the requirement that an individual must be unable to “stand and pivot” in order to qualify for a higher functioning power wheelchair (Group 3). The revised criterion now states that in order to qualify for a Group 3 wheelchair “the patient’s mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity.”
  
  
• On November 9, 2006, CMS issued modifications to the new reimbursement levels that appear to increase reimbursement for many of the high-functioning mobility devices. Although these changes are positive, it is still too early to assess whether they will alleviate the access concerns associated with the original reimbursement changes.

Problems that Remain:

Although CMS has made positive changes to the recent LCD and reimbursement levels, the policy continues to be misguided in important ways. This is primarily due to the fact Medicare’s long-standing and discriminatory “in the home” policy remains in place and is even more prominent in coverage standards than ever before! As long as this harmful restriction remains in place, Medicare will continue to deny individuals with mobility impairments the devices necessary to meet their functional needs – both inside and outside of their homes.

ACTION REQUESTED:

Although the recent changes to the LCD and reimbursement levels are important changes, we must continue to advocate for a reasonable Medicare wheelchair policy. This policy must reflect the true functional needs of individuals with mobility impairments and recognize the important role of wheelchairs and other assistive devices in the goal of independent living for people with disabilities.

Please call your Members of Congress toll-free at 1-877-224-0041 and ask them to:

1. Support legislation to eliminate Medicare’s “in the home” restriction on mobility devices (S. 3677/H.R. 5983). Without enactment of this important legislation, Medicare may continue to utilize this discriminatory coverage restriction which prevents access to appropriate mobility devices for people with disabilities.
   
   
2. Contact Health and Human Services (HHS) Secretary Leavitt and ask him to take action on the “in the home” restriction. The agency has the authority to determine how Medicare interprets this language and we need to continue asking the HHS Secretary to modify this policy to reflect beneficiaries’ true mobility needs, both inside and outside of their homes.

Please contact Emily Niederman at the ITEM Coalition (202) 349-4260 with any questions.

Thank you for your advocacy!