Action Alert: Important Changes to Wheelchair Coverage Policy
- Access Concerns Remain

Dear ITEM Coalition Members and Friends:

As a result of incredible advocacy on the part of many stakeholders, Medicare has again made changes to the new local coverage determination (LCD) for power mobility devices (PMD) that will alleviate additional consumer access concerns. Specifically, the recent changes eliminate a requirement that an individual be "unable to independently stand and pivot" in order to qualify for access to high functioning mobility devices. You should all be proud of winning this significant battle - but the war is far from over.

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 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 fails 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.

Changes to Policy:

* 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 the 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." The final policy is posted at
http://www.trustsolutionsllc.com/
MedPolicies/PMD%20R2%20Final%20Draft.htm

Problems that Remain:

* Although CMS has made positive changes to the recent LCD, the policy continues to be misguided in important ways. This is primarily due to the fact the 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 remain 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.

* Medicare has recently issued new reimbursement levels for power wheelchairs that seriously cut payments to providers for many of the high functioning power wheelchairs. The reimbursement cuts are scheduled to take effect on November 15, 2006 and many providers indicate they will not be able to continue supplying such devices to Medicare beneficiaries. Therefore, these reimbursement cuts will create significant access problems for beneficiaries requiring high functioning mobility devices.

ACTION REQUESTED:

Although the recent changes to the LCD are important improvements, 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 change this policy.

3. Press Medicare to seriously examine the impact of the new reimbursement cuts on individuals requiring high-functioning wheelchairs.

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

Thank you for your advocacy!

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