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UsersFirst Mobility Map

This knowledge book is designed to help you find answers to common questions about getting a wheelchair. Each chapter guides you step-by-step through the path of getting a wheelchair.

1. Getting Started

1.1. Welcome

Welcome to the UsersFirst Mobility Map.

The UsersFirst Mobility Map is your path to finding the best wheelchair to meet your needs!

The Mobility Map Outline

The Mobility Map is organized in chapters. Each chapter covers one big step in the process of getting a wheelchair.

Using the Mobility Map

The first time you use the Mobility Map you may simply want to move from one page to the next page, like reading a book. For this, scroll to the bottom of each page and click on the number and title for the next page found in the right hand corner. If you want to go back to the last page, click the link in the left hand corner instead.

If you want to read specific pages instead of the Map as a whole. Start at the home page to find the full listing of Mobility Map pages and chapters.

You can also go to any chapter at any time by clicking on one of the boxes at the bottom of each page.

Your Path in the Mobility Map

Everyone's path to mobility is different. You can track your path on paper by downloading 'My Mobility Map,' the printable checklist at the bottom of this page.

Good luck on your journey!

1.2. Getting Started: An Overview

Chapter 1: Getting Started - An Overview

The Mobility Map is a step-by-step guide to getting the best wheelchair for you. This chapter is an overview of that process and introduces you to the first step towards getting a wheelchair.

In this chapter we will answer the following questions:

  • What is the Mobility Map?
  • How do I navigate or use the Mobility Map?
  • Can I print the information I see on pages in the Map?
  • Where do I look to find more information on a page's topic?
  • How do I get back to the home page if I get lost in the Mobility Map?
  • What's my first step towards getting a wheelchair?
  • What is a self-assessment?

1.3. The Overall Process

The Basic Steps to Mobility

  • Step by Step guide to the process of getting your wheelchair
  • Dowloadable checklist of The Basic Steps to Mobility

A pen, notepad, and computer sit on a desk.

The Step-by-Step Process of Getting Your Wheelchair


1) Self-Assessment

2) Gather Your Wheelchair Team

3) Get a Prescription and Complete Your Wheelchair Evaluation and Assessment

4) Finding Funding - How you will pay for your Wheelchair

5) Ordering Your Wheelchair

  • Once payment for your wheelchair is approved (through insurance or another source), your supplier orders your wheelchair from a wheelchair manufacturer. The wheelchair manufacturer is the company that actually makes the chair.


6) Equipment Delivery

These steps will be explained in more detail later in the Map. If you would like to keep track of your path through the Mobility Map on paper, download a printable 'Basic Steps to Mobility Checklist' below.

1.4. Step 1: Self-Assessment

Step 1: Self-Assessment

First things first

Wheelchair users are diverse and so are their needs. A young man, a child, and a woman are pictured smiling and using their manual and power wheelchairs.

You must ask yourself – what do I want to do with my wheelchair?

Answering this question can seem obvious or it may seem complex. But, by doing so it will help you and your wheelchair team match your life activities and physical abilities with specific features of a wheelchair. And, it may make the wheelchair process easier. For example, if you use a manual wheelchair and you have shoulder issues, a possible match for your needs may be a lightweight wheelchair.

The Wheelchair Checklist  was created to make this process a little easier by helping you identify what you want to do with your wheelchair. You can complete the Wheelchair Checklist online here or download and print this checklist below. It may be helpful to refer to your Wheelchair Checklist during your wheelchair evaluation.

 

2. Your Wheelchair Team

2.1. Your Wheelchair Team: An Overview

Chapter 2: Your Wheelchair Team - An Overview

Your wheelchair must match your specific needs. And to get the best chair for you, you need the best team possible. This chapter will introduce you to your team members and help you understand how to build a team that will help you get the best wheelchair for you.

In this chapter we will answer the following questions:

  • Who do I need in my wheelchair team?
  • What do my wheelchair team members do?
  • What types of spcialties or certifications should my team members have?
  • Who gives me a perscription for a wheelchair?
  • How can community organizations and non-profts help me with the process of getting a wheelchair?

2.2. Step 2: Gather your Wheelchair Team

Step 2: Gather Your Wheelchair Team

  • Why you need a wheelchair team
  • Who is in a wheelchair team
  • What wheelchair team members do

A wheelchair team comprised of a doctor, clinician, and supplier, all sit together speaking with a client.

Why do I need a wheelchair team?

Not all wheelchairs are the same, so you need to match your wheelchair to your needs. Getting the right wheelchair requires a good team, because the more minds and eyes helping, the fewer details will be missed.

Note: Once your wheelchair is delivered to you, it is VERY difficult to return it. Make sure it is what you need.

Wheelchair accessories and products are designed to improve movement and independence. Your team will get to know you and help to match the wheelchairs' features with your wants and needs.

Who is in my wheelchair team?


Your team may include the following people:

What will my wheelchair team members do?


Doctor or Physician

  • This doctor may be a general practitioner or may be a specialist
  • Will give you a prescription for a wheelchair and wheelchair assessment (ie your ordering physician)
  • Refer you to a clinician or therapist for your wheelchair assessment (Note: You have the right to choose your clinician)
  • May write your 'letter of medical necessity' for your insurance company

Clinician or Therapist

  • Will most likely be an Occupational Therapist (OT) or Physical Therapist (PT)
  • Completes your wheelchair assessment
  • May write your 'letter of medical necessity' for your insurance company
  • May refer you to a medical equipment supplier (Note: You have the right to choose your supplier)
  • Works closely with your supplier to meet your needs with your wheelchair

Medical Equipment Supplier

  • Oversees the ordering, billing, delivery, and assembly of your wheelchair
  • Will repair your wheelchair when necessary
  • Should be a certified Assistive Technology Professional (ATP) (Note: To find out if a supplier is certified you can visit this website)
  • Works closely with the clinician to meet your needs with the correct wheelchair equipment

Consumer Organizations

  • Can offer additional information about equipment, mobility, funding and more
  • Links to some organizations are listed on the next pages of this document

You will learn more about each other these team members in the following pages of Chapter 2.

2.3. More About Your Team Members: Physician or Doctor

More About Your Team Members: Physician or Doctor

  • The who, when, and what of your doctor's role in your wheelchair team
  • Downloadable version of this overview available below

A group of female and male doctors of different ethnicities stand together in lab coats smiling.

Physician or Doctor Overview


Who

Your first wheelchair team member will be your physician or doctor.

The doctor you schedule your first meeting with about getting a wheelchair may be a general practitioner (example: Primary Care Physician) or a specialist (examples: Physiatrist, Neurologist, or Orthopedist).

When

After you have identified your doctor, you must schedule an appointment with them to get a prescription for a wheelchair assessment. When you visit your physician or doctor to discuss your wheelchair needs with him or her, you will begin Step 3: Prescription and Assessment.

What

Your physician or doctor will:

    • Write a prescription for a Wheelchair Evaluation and Assessment
    • Refer you to a clinician or therapist, usually an occupational therapist (OT) or physical therapist (PT), with who will complete your Wheelchair Evaluation and Assessment (or you may choose your own clinician)
    • It is recommended the therapist be certified as an assistive technology professional (ATP) or a seating and mobility specialist (SMS).
    • Pass the responsibility to YOU to make a Wheelchair Evaluation and Assessment appointment
    • Act as your Ordering Physician and co-sign your Letter of Medical Necessity

2.4. More About Your Team Members: Clinician or Therapist

Clinician or Therapist

  • The who, when, and what of your therapist's role in your wheelchair team
  • Ideas for finding your own clinician
  • Overview of OT and PT assistive technology certifications
  • Downloadable version of this overview available below

Two clinicians conduct a wheelchair assessment with a client. Your Clinician or Therapist: An Overview

Who

Your second wheelchair team member will be a clinician or therapist. This person is usually an occupational therapist (OT) or physical therapist (PT). It is recommended he or she be certified as an assistive technology professional (ATP) or a seating and mobility specialist (SMS). You can search your area for a certified professional (see below).

Your doctor will likely refer you to a clinician who is a seating specialist for your Wheelchair Evaluation. However, you have a right to choose your OT or PT, so you do not have to use your doctor's referral.

To find an OT or PT on your own you can:

When

You will meet with your therapists after you meet with your doctor. Remember, the therapist will need a prescription from your doctor in order to complete the assessment with you. We review this process in greater detail in Chapter 3.

What

The clinician will conduct your Wheelchair Evaluation and Assessment in which they help you match your physical abilities and your lifestyle to specific features of a wheelchair. Usually, the clinician works closely with the medical equipment supplier during the evaluation. The details of a Wheelchair Evaluation and Assessment are in Chapter 3.

This process will include the following:

    • Collecting information from you about your needs
    • Learn about all facets of your life that affect your mobility including your home and work environments
    • Assess you physically
    • Work closely with the supplier to descide what equipment is best for you


2.5. More About Your Team Members: Medical Equipment Supplier

More About Your Team Members: Medical Equipment Supplier Overview

  • The who, when, and what of your medical equipment supplier
  • Important Reminder
  • Downloadable version of this overview available below

A wheelchair supplier takes notes while speaking with a client at a wheelchair assessment.

Medical Equipment Supplier Overview

Who

The medical equipment supplier is the third member added to your wheelchair team and will actually provide your wheelchair.

The supplier is a critical team member, as he or she will ensure that your equipment is ordered accurately, billed to your insurance, and assembled correctly for delivery. The supplier will also oversee any repair issues for your equipment. There are many suppliers to choose from. Some are a part of larger, national companies, and others are local dealerships. It is recommended the supplier be certified as an Assistive Technology Professional (ATP). Another very important certification is CRTS (Certified Rehab Technology Supplier). It is very important you use a wheelchair supplier who is certified. More information about the supplier's certification is below.

You have the right to choose your wheelchair supplier. It is important that you select a supplier that has experience working with people like you, that is close to your home, and who you can trust and feel comfortable with, because all repairs of your equipment will go through your supplier.

You can find a qualified supplier by:

    • Ask your clinician or therapist for recommendations. Ask them why they like this supplier?
    • Search certification websites for local certified suppliers  - www.nrrts.org to find a supplier in your area) 
    • Contact consumer organizations to help locate certified suppliers in your area.
    • You may be told your insurance company only uses one company. You still need to ask the questions below.

When choosing a supplier, here are some recommended questions to ask them:

    • Do you have additional training and experience in my specific area of need (examples: pediatrics, gerontology, ALS, MS, Spinal Cord Injury, CP, Spina Bifida, etc.)?
    • Do you have a location near my home?
    • Do you come to my home for repairs or do I come to your office?
    • How long will the process take to get my wheelchair?
    • What insurance information will you need from me?
    • Do you offer repair service?
    • Is there a warranty on the wheelchair? What does the warranty cover? Just parts? Just labor?
    • Where will the delivery of my wheelchair take place?

When

After you have received your Wheelchair Evaluation and Assessment, your clinician may refer you to a supplier. However, you have the right to choose which supplier provides your equipment, so you may choose to use a different supplier. It is important that you select a supplier that you can trust and feel comfortable with, because your relationship with them will extend beyond your initial wheelchair evaluation and fitting.

What

Your suppler will:

    • Work closely with your clinician or therapist to decide what equipment is most compatible with your specific environment (e.g., home, work, school, vehicle, church, etc.) and will maximize your independence.
    • The supplier may conduct a home evaluation to verify that you will be able to use the prescribed wheelchair in and around your home.
    • Bill your insurance
    • Order your equipment
    • Ensure that your wheelchair is assembled correctly for delivery
    • Deliver your wheelchair the therapist
    • Oversee any future repair issues for your equipment

Suppliers' Certification

Certification is available for suppliers who have specialized knowledge and experience in providing assistive technology, specifically wheelchairs.  

Assistive Technology Professional (ATP)

Certified Rehabilitation Technology Supplier (CRTS)

Rehabilitation Technology Supplier (RTS)

 

Remember, it is important to have good relationships with all members of your team. The wheelchair world is a small one. You need to hold your wheelchair supplier accountable, yet keep in mind, they can choose not to work with you too.

2.6. More About Your Team Members: Consumer Organizations

More About Your Team Members: Consumer Organizations

  • The who, when, what about consumer organizations
  • Downloadable version of listed links available below

A wheelchair user speaks with a UsersFirst representative at a conference information booth.

Consumer Organizations Overview

Who

Consumer Organizations are groups that work with and represent groups of people with a common interest to ensure they are treated fairly or equally. These groups may represent people with a specific type of diagnosis, such as individuals living with Multiple Sclerosis are represented by the National MS Society. Or the organizations may represent people with shared circumstances, such as UsersFirst represents people who use wheelchairs.

When

Consumer Organizations may be helpful to add to your wheelchair team at any point in your wheelchair process. You may want support from like-minded individuals as soon as you begin your process, or you may want to connect with an organization later in the process, for example, when you begin to seek funding sources.

What

Consumer organizations can be excellent resources for information pertaining to equipment, mobility and funding. Each organization offers different resources, so feel free to reach out to as many as you feel necessary.

Links


Consumer Organizations

3. Prescription and Assessment

3.1. Prescription and Assessment: An Overview

Chapter 3: Prescription and Assessment - An Overview

This chapter reviews the next phase of getting your wheelchair in which you will work with your team to find the best equipment to meet your needs. Step 3: Getting a wheelchair prescription, and Step 4: Attending your wheelchair assessment, will be discussed in detail.

In this chapter we will answer the following questions:

  • Who will write my prescription for a wheelchair assessment?
  • Why I need a prescription for a wheelchair assessment?
  • Who makes the appointment for my wheelchair assessment?
  • Who will be at my wheelchair assessment?
  • What can I expect to happen at my assessment?
  • Do I have to do anything at my assessment?
  • What questions should I ask my clinician or therapist and supplier?
  • What is a 'letter of medical necessity' and what does it have to do with my prescription and assessment?

 

3.2. Step 3: Get a Prescription for a Wheelchair Evaluation and Assessment

Step 3: Get a Prescription for a Wheelchair Evaluation

  • How to get a prescription for a wheelchair evaluation and assessment
  • Important reminder for Step 3
  • Step 3 summary available below for download

A seated doctor fills out a prescription form.

Prescription Before Assessment

You need a prescription from your doctor before you get a Wheelchair Evaluation and Assessment.

At your appointment, your doctor will write your prescription, but the Wheelchair Evaluation will be done at another time by a clinician or therapist. Typically the clinician is an Occupational Therapist (OT) or Physical Therapist (PT), so the prescription from your doctor will read, "OT or PT Wheelchair Evaluation." Getting a prescription from your doctor is essential, because it allows a therapist (OT or PT) to conduct an evaluation.

An OT or PT with the certification of ATP or SMS is highly recommended.  This certification is given to therapists who have demonstrated specialized knowledge and skils regarding seating and wheeled mobility.

Your doctor may have recommendations for a local therapist or seating clinic that can provide this assessment. However, you have a right to choose your own clinician instead if you would rather. Read more in Chapter 2 if you need help finding your own clinician.

You Schedule Your Assessment

Once you have the prescription from the doctor, call the wheelchair clinic (it may be a PT department or an OT department) and schedule an appointment. If you have the therapist's direct number go ahead and call. She or he will probably tell you to schedule through the office person.

Remember, whether your doctor makes a referral or not, you must call and set up the appointment for your Wheelchair Evaluation and Assessment. It is your responsibility to call and make an appointment for your Wheelchair Evaluation.

3.3. Step 4: Attend Your Wheelchair Evaluation and Assessment

Step 4: Attend Your Wheelchair Evaluation & Assessment

  • Wheelchair evaluation and assessment overview
  • Downloadable evaluation and assessment overview

A client lays on a mat while two clinicians measure the knees' flexibility with a goniometer.

Your Wheelchair Evaluation and Assessment Overview


Therapists and Supplier May Attend Assessment

A clinician or therapist, typically an OT or PT, will conduct your wheelchair evaluation and assessment. The reason for this evaluation is to help you get the right wheelchair. This assessment could take place in a clinic, in your home, or in both locations to ensure the equipment will work in your living environment.

A medical equipment supplier may also be at this appointment. Suppliers work closely with therapists, so if you already know a supplier you would like to use, let the clinician know before the evaluation appointment.

Time and Content Vary

The length of time needed to perform the assessment of a new wheelchair will vary based on the complexity and diversity of your needs. The wheelchair assessment might be a single occasion or a series of appointments to look at different options and/or provide training about your wheelchair. Ideally, everyone who participated in the original assessment should be present for the delivery of the equipment as well.

Attendees Roles

Role summaries are below, but details are available for download from pages 3.5, 3.6, 3.7 of the Mobility Map's third chapter.


Your Role

Before the Assessment:

  • Schedule your Wheelchair Evaluation and Assessment
  • Tell your Clinician if you have a supplier chosen

 During the Assessment:

  • Ask questions
  • Advocate for your needs
  • Collaborate

 

Clinician's Role

During Assessment:

  • Asks you questions
  • Reviews your medical history
  • Measures you for your wheelchair
  • Conducts a 'mat' evaluation
  • Discusses equipment options

 

Medical Equipment Supplier's Role

During Assessment:

  • Assesses features of manual or power wheelchairs with your clinician
  • Provides options of equipment
  • May discuss the billing process with you 

3.4. Accessibility Needs and Home Assessments

Accessibility Needs and Home Evaluations

  • What are accessibility needs?
  • What if I want and/or need a home evaluation and assessment?
  • Downloadable Home Assessment Form

A woman navigates her home in her wheelchair sitting to use her home computer and moving into a standing position to reach high kitchen cabinets.

Determining Your Accessibility Needs


Working together to meet your needs

The supplier, clinician, and you will work hard to decide what equipment is best for you based on your evaluation. Bringing your Wheelchair Checklist from Chapter 1 could be very helpful in sharing your needs and perspective with your clinician and supplier.

Will your wheelchair work in your physical environment?

Together, the clinician and supplier will look at your accessibility needs to ensure that the recommended equipment will work in your specific physical environment (e.g., home, work, school, vehicle, church, etc.) and will maximize your independence. Sometimes the supplier will conduct a home evaluation to verify that you will be able to use the prescribed wheelchair in and around your home.

During this process, you must ask yourself, does this wheelchair meet my accessibility needs? Or, in other words, will this wheelchair be useable in my physical environments?

Home Evaluations and Assessments

To help you find this out, the therapist or the supplier should take the wheelchair to your vehicle, home, school, etc. to ensure it will work for you. However, you may have to advocate, or speak up for yourself, to get a home evaluation because most insurance companies will not pay for this service. It is important you think about how your equipment will fit into different physical areas of your life.

Want to know how your home's accessibility can be improved? Share with your clinician the downloadable 'Home Assessment Form' below.

Additional information about using your wheelchair in your vehicle and home are available in Chapter 7.

3.5. What to Expect at Your Evaluation and Assessment: Your Role

What to Expect at Your Wheelchair Evaluation: Your Role

  • What you should do before your wheelchair evaluation and assessment
  • What you should do at your wheelchair evaluation and assessment

A wheelchair user seated on a cushioned table is measured by two clinicians while a medical equipment supplier takes notes.

Before the evaluation you will need to:

  • Schedule evaluation
    • Schedule your evaluation with the clinician or therapist after you get a prescription from your doctor
  • Say if you already have a supplier chosen
    • Tell the clinician before your evaluation appointment if you have a supplier you would like to work with.

At the evaluation you will need to:

  • Ask Questions
    • Speak up and ask as many questions as you need during the appointment. Now is the time to mention any needs you have. If you do not speak up, you might end up with a wheelchair that doesn't fit your life, environment, and needs.
    • You'll want to ask about your wheelchair working well in your home and vehicle. To address these environments you might need a home evaluation.
    • You'll want to ask your supplier additional questions as well, such as:
      • How long will the process take to get my chair?
      • What insurance information do you need from me?
      • Is there a warranty on this wheelchair? What does it cover (just parts?, labor?)
      • Where will the delivery of my wheelchair take place?
      • If there are issues with my chair, do I come to your office or do you come out to my home?
      • Can we review the details of my equipment prescription? I want to be sure I understand and agree to all details of my prescription.
  • Advocate for your needs
    • You may have to advocate for a home evaluation, because most insurance companies will not pay for this service. It is important you think about how your equipment will fit into different physical areas of your life and a home evaluation may help with this. For more information, a 'Home Assessment' form is available for download below.
    • You may need to advocate that you receive an evaluation by a therapist with the recommended certification. It is highly recommended that your supplier and your therapist are certified.
  • Collaborate
    • Work with the therapist, and supplier, to complete your evaluation.

3.6. What to Expect at Your Evaluation and Assessment: Your Clinician or Therapist's Role

What to Expect at Your Evaluation: Your Clinician or Therapist's Role

  • What to expect from your clinician or therapist in a wheelchair evaluation and assessment

A woman lays on a soft mat while a clinician guides her arm up and over her head as a part of her wheelchair evaluation and assessment.

At the evaluation the therapist should do the following:

Ask you many questions to help you select the appropriate wheelchair. Examples include:

  • What is your current diagnosis?
  • What are the reasons you need a wheelchair?
  • What do like about your current wheelchair?
  • What do you not like about your current wheelchair?
  • What are your current activities, interests, home environment and the transportation you plan to use?

Review your medical history

  •  They will read and discuss your medical records

Measure you for your chair

  • They will measure your arms, legs, trunk, feet, etc. You want the chair to fit you well and be comfortable.

Conduct a "mat" evaluation

  • Mat evaluations usually take place on a big mat table where you have room to sit and lie down.
  • During this phase of the assessment the clinician will look at how different parts of your body move, identify joint limitations, and try to ensure that the wheelchair is fitted to you correctly and comfortably.
  • The therapist will ask if you have any pain and where.

Discuss equipment options

  • Clinicians and suppliers will share with you various types of equipment (wheelchairs (power or manual), cushions, seatbacks, legrests, wheels) so, as a team, you can choose which type works best for you.

 

3.7. What to Expect at Your Evaluation and Assessment: Your Supplier's Role

What to Expect at Your Evaluation and Assessment: Your Supplier's Role

  • What to expect from your suppler in a wheelchair evaluation and assessment
  • Downloadable checklists (at the bottom of this page)

A woman sits on a mat at her Wheelchair Evaluation and Assessment surrounded by her wheelchair team and speaking with her medical equipment supplier who is taking notes on their conversation.

A Collaboration

The supplier works closely with you and the clinician to decide what equipment is best for you based on the evaluation. Together, the clinician and supplier will also look at your accessibility needs to ensure that the recommended equipment will work in your specific environment (e.g., home, work, school, vehicle, church, etc.) to maximize your independence.

The therapist, supplier and you should assess the following areas together


Features for both Manual and Power Wheelchairs  

(for more information and photos go to page 8.3)  

  • Seat width and depth
    • If the chair is too big or too small it will be difficult to use and uncomfortable.
  • Pelvic (hip) position and support
    • If your hips are not positioned well, it might be hard to use your arms and it could make you tired. Basically, your hips are the base of your support when you are sitting, it is important to know what the best position is for you to be as independent as possible. 

  • Cushion
    • A VERY important part of the wheelchair! You need to feel stable and have a cushion that will decrease the possibility of a pressure sore. Ideally, the clinic will pressure map you sitting on the cushion.
  • Leg support
    • Footrest angle, leg rest length, foot support (strap?) – it is important your feet are aligned well so you have support to sit up as well as possible. You can what feels most supportive.
  • Appropriate trunk support
    • The back support of the wheelchair will help you stay upright and increase your endurance. Just like a good seat in a car, if it is comfortable and you are able to move as freely as possible and have the support you need, you can drive longer and be more alert.
  • Back support
    • You might want a low back or a high back. A low back will give you more room to move your arms, but has less back support. A high back will provide more support, but might limit your arm movement.
  • Chest support
    • Lateral supports (supports the side of your chest) or chest strap (a strap on your chest if you are worried you will fall forward). These features help you keep your balance when leaning forward, or to the side.
  • Headrest
    • You might want a head support if you feel it gives you the necessary support while driving your chair or if your wheelchair seat is able to tilt back.
  • Hip Guides
    • These pads, located on the outside of your legs to provide support by keeping your knees from widening.


Specific Considerations for Manual Wheelchairs

(for more information and photos go to page 8.2)

  • Wheel position
    • Like a car, a wheelchair with a shorter wheelbase might be more maneuverable, but might also be less stable (tippy). And, if you sit lower to the ground, like a sports car, you are more stable, but you are also shorter.
  • Weight of the actual wheelchair
    • A lightweight wheelchair is easier to push and can be easier to put in a car.
  • Seat back
    • A shorter back allows you to have more movement, but does not provide as much support. A low back will give you more room to move your arms, but has less back support. A high back will provide more support, but might limit your arm movement.
  • Pressure Relief
    • Be sure you have a Pressure Relief plan, or the ability to achieve pressure relief using a method planned in advance. For example: leaning forward, lifting yourself up with your arms, standing, leaning to one side.


Specific Considerations for Power Wheelchairs

(for more information and photos go to page 9.1)

  • Joystick or specialty controls
    • Be sure you can control the chair with your hand using a Joystick or with specialty controls that can be located anywhere you have consistent body movement (head, mouth, foot)
  • Operate the chair in any position
    • Be sure you can operate the chair in any position (tilt, recline, standing)
  • Know power options
    • Be sure you know how to use the different power options (tilt, recline, seat elevation, elevating leg-rests, standing)
  • Have a pressure relief plan
    • Be sure you have a Pressure Relief plan (ability to achieve pressure relief using planned method). For example: leaning forward, tilting the seat back, lifting yourself up with your arms, standing, leaning to one side.

Does this seem like too much to remember?

If you're feeling a little overwhelmed, download the information on all pages of chapter three. And don't worry, you're not alone! Below is a document called 'Wheelchair Assessment Checklist: Steps to remember and questions to ask' for you to print and track the details of your prescription and assessment process. Download this checklist below.

 

3.8. Letter of Medical Necessity

Letter of Medical Necessity

  • The what, who, and when of a 'Letter of Medical Necessity'
  • What is in an effective 'Letter of Medical Necessity'
  • Downloadable 'Letter of Medical Necessity' Overview

Letter of Medical Necessity Overview

What

The 'Letter of Medical Necessity' is a letter written after your wheelchair assessment to the insurance company paying for your wheelchair that justifies your need for the specific chair requested.  This letter is very descriptive and tells all about what equipment is recommended for you and why. Very often this letter must also include specialists' support and research to back up the medical need for a particular type of wheelchair. 

Who

The clinician or therapist who did your wheelchair evaluation will write the letter of medical necessity, which is addressed to the third party payer or insurance company. Typically, your doctor who wrote your prescription for an assessment co-signs the letter as the 'ordering physician' to support the assessment's findings. 

In addition to the ordering physician, supporting documentation may come from several other specialists who are involved in your care. For example, if you are being treated for a wound or pressure sore, it is good to have documentation from your wound care specialist. This specialist can support your need for pressure relieving features on your wheelchair such as particular seat cushions, power tilt, custom armrests or a standing feature. 

When

This letter will be written after your wheelchair assessment and submitted to the third party, usually your insurance company, who is paying for the wheelchair. 


The Letter of Medical Necessity's Important Details


What is in a Great and Effective 'Letter of Medical Necessity'?


Clear

  • Explains clearly why you need the type of wheelchair you are asking for (power, manual, lightweight, power standing, etc.)

Justified

  • Each feature of the wheelchair must be justified as "medically necessary" (insurance companies define "medically necessary", so you want to find out what words they use to define "medical necessity.")
  • Examples of justifications:
    • Tilt feature on a power wheelchair:  "needed to relieve pressure and decrease the risk of pressure sores" 
    • Lightweight manual wheelchair:  "needed to increase endurance due to limited arm strength or arm injury."
    • Cushion to "reduce the risk of pressure sores"

Medically Detailed

  • Describes clearly your diagnosis (spinal cord injury, cerebral palsy, multiple sclerosis, ALS) and how the equipment will help you functionally and medically (breathing, endurance, transfers, independent mobility, etc.). It gets quite medical, but that is what the reviewers are looking for. It is important your therapist and supplier understand why this is important.

Focused 

  • Includes only information about you that is related to your wheelchair. The letter does not need to talk about your children, your supportive wife or husband - the insurance company might find a reason to deny the wheelchair based on unrelated facts.


4. Finding Funding

4.1. Finding Funding: An Overview

Chapter 4: Finding Funding - An Overview

Now you are entering one of the more complicated parts of getting the right wheelchair. It is important to stay calm during this process and ask for help from consumer organizations, your wheelchiar team and friends, and family members if the process gets overwhelming. There are many ways to fund your wheelchair, from traditional funding options, such as private (ex: Blue Cross) and public (ex: Medicare and Medicaid), to alternative funding sources, such as community organizations. So, try to remain calm focus and get creative.

In this chapter we will answer the following questions:

  • What are traditional funding sources?
  • What do I do if I can't get my wheelchair fully paid for by my insurance?
  • What paperwork do I need?
  • How long will it take to get funding and my wheelchair?

 

4.2. Step 5: Explore Traditional Funding Sources

Step 5: Start to Find Funding

  • Traditional vs Alternative Funding Sources
  • The first step to finding funding to pay for your wheelchair
  • Downloadable summary of where to start looking for funding

A stethoscope lays on a pile of money.

Where to Start Looking for Funding?

Traditional Vs Alternative Funding Sources

There are many ways to fund your wheelchair. There are traditional funding options, such as Medicare, Medicaid and private insurance. And, if traditional funding will not work for you, there are also alternative funding sources, such as community organizations. Alternatives are discussed further later in this chapter.

The first step to discovering how you will pay for your wheelchair is to explore your current coverage.

You may have coverage from any of the following traditional sources:

  • Private Insurance
  • Medicare
  • State Medicaid
  • Department of Veterans Affairs (VA)
  • Secondary Insurance
  • Cash

Explore Your Coverage


Follow the steps below to become aware of what your insurance company's benefits are:

  1. Find your insurance company's benefit handbook.
  2. If you have misplaced your handbook you may be able to view it online through your insurer's website or call and request a new handbook.
  3. Call the insurance company with your member ID in hand. Your member number is on your insurance card and may be listed on past bills. They need this information to answer specific questions about your policy.
  4. Find out what your insurance company says about wheelchairs by asking lots of questions such as the ones below.
    • What is their DME coverage? (durable medical equipment) (is there a certain amount only they will pay for DME)
    • Will they pay for some equipment and not others?
  5. Don't hesitate to ask for more information or to speak with someone else if you do not understand the information you are getting.
You can always contact us and we will help you go through this process www.usersfirst.org.  
 

Private Insurance

Private insurance companies are typically for-profit organizations. Each company develops their own policies and regulations regarding durable medical equipment (DME) coverage. That is what can make the funding process so confusing. It is essential you find out what your insurance company has stated in writing regarding coverage of wheelchairs. It is up to you to know about your insurance plan. Remember, knowledge is power.

Some common private insurance companies are:

-Anthem BlueCross BlueShield - Aetna - Cigna - Human -United Healthcare

 

Medicare

Medicare is a federal program administered by the Centers for Medicare and Medicaid Services (CMS). CMS dictates the guidelines by which a wheelchair or any other durable medical equipment (DME) is funded under the Medicare program.

Medicare Paperwork Requirements:

The "proof" of eligibility for any mobility device must be addressed in the documentation that is submitted to Medicare for reimbursement. The required documents are as follows:

  • Physician's written order
  • Chart notes from the physician's face-to-face examination with you (see below)
  • Home assessment (performed on-site)
  • Specialty evaluation by the therapist (OT or PT), if needed
  • Attestation that the supplier and therapist have no financial relationship
  • The supplier's (ATP's) documentation, if applicable
  • Detailed product description (from the supplier)
  • First month purchase option letter, if applicable
  • Delivery ticket
  • Additional documents as needed, such as an Advanced Beneficiary Notice 

 

State Medicaid

Medicaid is a state run program, which is subsidized, or partially paid for, with federal funds. Individual state Medicaid programs must follow a basic foundation of federally mandated DME coverage rules, but beyond this the states have some freedom to develop their own programs, policies and coverage criteria. You can find out information about your state's Medicaid program, including enrollment data and link's to individual state's sites, at the Medicaid website (http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/By-State.html).

 

Department of Veterans Affairs (VA)

The Veteran's Administration (VA) Hospitals offer excellent service and benefits for those who qualify to be in the system. The qualification requirements are specific and can be found at VetsFirst, a program of United Spinal Association.

 To enroll in the VA system, simply do one of the following:

  • Contact the Enrollment Coordinator for your local VA Health Care Facility
    • Contact a National or State Veteran's Service Organization (examples: DAV, AMVETS, PVA) Go to www.va.gov and complete the 10-10EZ form online 


Secondary Insurance

Secondary insurance gives you more insurance coverage on top of your main or 'primary' coverage. This secondary insurance is usually through a different company than your primary insurance coverage.

Secondary insurance coverage supplements your existing policies and can cover gaps in your main insurance. In some case the secondary insurance will pay for your primary insurance company's deductible or co-payment.  For example, you may have Medicare and AARP or United Healthcare as a secondary. If you have secondary insurance, don't forget to check with that company regarding their policies as a secondary insurer as well as your primary insurer.

4.3. Private Insurance

Private Insurance

  • What is private insurance?
  • What should you know about your priviate insurance coverage?
  • Important reminder 

 An older man reviews his personal insurance plan's paperwork while calling his insurer.Private Insurance Overview

Private insurance companies are typically for-profit organizations. Each company develops their own policies and regulations regarding durable medical equipment (DME) coverage. That is what can make the funding process so confusing. Despite the autonomy, more and more insurance plans are using Medicare policies as the standard to follow in development of their own programs.

It is very important you get your insurance handbook. If you do not have it anymore, you can follow the links below for more information.  Also, this is where it is essential you find out what your insurance company has stated in writing regarding coverage of wheelchairs. It is up to you to know about your insurance plan.  Remember, knowledge is power.

Steps to learn about your insurance coverage:

  1. Find your insurance card, so you have your policy number near by
  2. Find your insurance handbook, read the information about wheelchairs
  3. Search your insurance company's website for more information about your policy
  4. Call member services with questions or to order a new copy of your insurance handbook

Some common private insurance companies are:

What Should I Know About my Private Insurance Coverage? 

What paperwork is required and how long is the process?

Each insurance company has its own policies and procedures. Check to see if pre-approval is necessary and what the covered benefits are regarding Durable Medical Equipment (DME), wheelchairs specifically. You can find this out from your insurance handbook, searching your insurance company's website or by calling member services. NOTE: There may be different policies within the same company – so it is best to look at your individual policy in your insurance handbook or on the website provided to you by member services.

Is there a cap on your coverage?

It is important to know what the insurance company says about wheelchairs for yourself. You may have great benefits or you might have a "cap" on the dollar amount that can be used towards your wheelchair. Find out what your insurance company and personal plan pays for and to what amount.

What is your co-pay? 

A co-payment is a flat dollar amount or a percentage paid for a medical service. If you are required to pay a percentage co-payment, that number is based off of the allowable for your insurance company and supplier agree upon, not the actual equipment retail cost. For example, if your wheelchair retails for $7,000.00 but your insurance allowable, is set at $5,342.00, the allowable is the largest amount that can be billed. That billed amount is then used to calculate your co-payment. Meaning, if you had a 20% co-payment, the amount you owed would be calculated from the $5342.00 resulting in $1068.40 that you owned. No matter what the retail cost is, the allowable determines your cost.

If you are unsure what your co-pay is or your percentage check your insurance handbook, insurance card or call member services to see if a co-payment will be required for your wheelchair.

What is your insurance company's definition of 'Medical Necessity'? 

Each insurance company has its own definition of medical necessity. It is imperative for you to know your insurance company's definition and qualifiers for you to be eligible for a wheelchair. There are many ways to find out your insurance companies definition, check your insurance handbook, search their website or call your member services.   

4.4. Medicare Coverage

Medicare Coverage

  • Medicare Overview
  • Paperwork Requirements
  • Documentation Requirements
  • Using Equipment in your Home  
  • Helpful Definitions

A medical insurance claim form sits on a desk with a pair of glasses and a pen waiting to be completed.

Medicare Overview

Medicare is a federal program administered by the Centers for Medicare and Medicaid Services (CMS). CMS dictates the guidelines by which a wheelchair or any other durable medical equipment (DME) is funded under the Medicare program.

Paperwork Requirements

The "proof" of eligibility for any mobility device must be addressed in the documentation that is submitted to Medicare for reimbursement. Generally this information is included in the chart notes from the doctor, along with the report completed by the clinician (occupational or physical therapist) who performed your wheelchair evaluation together with the supplier. The combined documentation must paint a picture of why the device you want is needed to resolve your mobility limitation. 

Therefore, it must include a detailed medical history and physical assessment to support the need for the recommended equipment. Further, it must include why less costly types of items will not suffice. As noted above, the coverage criteria for some types of wheelchairs and seating equipment are based on whether you have a certain medical diagnosis, so it is critical that this is included as well. Unfortunately, sometimes "painting the picture" is not enough; you must also have the right diagnosis from a pre-determined list.

Documentation Requirements for Mobility Devices 

Medicare has specific documentation requirements for all mobility devices, however, these requirements are the most stringent for power mobility devices (power wheelchairs and scooters). The documentation must come from several different sources (physician, therapist, other clinicians, etc.) and is collected by the equipment supplier for submission to Medicare as appropriate. There are times when the supplier may run into difficulty obtaining the necessary documents and may, at that time, request your assistance in communicating the importance of this documentation to the involved parties, such as your physician. In other words, you need to be part of the process.

The required documents are as follows:

  • Physician's written order
  • Chart notes from the physician's face-to-face examination with you (see below)
  • Home assessment (performed on-site)
  • Specialty evaluation by the therapist (OT or PT), if needed
  • Attestation that the supplier and therapist have no financial relationship
  • The supplier's (ATP's) documentation, if applicable
  • Detailed product description (from the supplier)
  • First month purchase option letter, if applicable
  • Delivery ticket
  • Additional documents as needed, such as an Advanced Beneficiary Notice 

Medicare Details

Definitions

Based on the Medicare National Coverage Determination (NCD)

Durable Medical Equipment (DME)

The equipment can withstand repeated use; i.e., could normally be rented and used by successive patients; is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of illness or injury; and, is appropriate for use in a patient's home.

280.1 – Durable Medical Equipment Reference List (Effective May 5, 2005)

Mobility Assistive Equipment (MAE)

"Determination of the presence of a mobility deficit will be made by an algorithmic process, Clinical Criteria for MAE Coverage, to provide the appropriate MAE to correct the mobility deficit."

"the evidence is adequate to determine that MAE is reasonable and necessary for beneficiaries who have a personal mobility deficit sufficient to impair their participation in mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations within the home."

Guidelines

Medicare Process for Obtaining Equipment

280.3 – Mobility Assistive Equipment (MAE) (Effective May 5, 2005)

  • Your equipment does not get a "prior authorization" through Medicare.
  • There is an option to seek 'Advanced Determination of Medicare Coverage' or 'ADMC'
  • ADMC does not guarantee that Medicare will cover the equipment, but it does help indicate that the equipment being requested appears to meet the coverage criteria defined by CMS.
  • ADMC is a waste of time if the item being requested is a known "Non-Covered" item (i.e. seat elevation systems, standing systems, etc.)
  • For these items, the consumer has a choice to sign an 'Advanced Beneficiary Notice of Non-Coverage' or 'ABN' – agreeing to pay anything that Medicare ultimately denies.

If the item is denied by Medicare – there is an appeals process that the consumer can and should take advantage of. In the cases of "non-covered" items – the appeal often needs to be taken through the 'Administrative Law Judge' or 'ALJ' hearing. A sample appeal is available below for download. 

Policy HotSpot
Using Your Wheelchair Outside
Have you been told that Medicare will not pay for your wheelchair if you go outside with it?

Share your story and connect with UsersFirst to take action!

Use of Equipment in Your Home

Medicare has very strict guidelines for coverage of DME and in particular for the subset of DME that they term "mobility assistive equipment" or "MAE". This includes cane, walkers manual and power wheelchairs and scooters (also called power operated vehicles or POVs).

Central to these guidelines is the policy that the MAE must be medically necessary for use in the home and not solely for use outside the home. In other words, the device must be needed in order for you to get around your home and carry out the daily activities that Medicare has termed "mobility related activities of daily living" or MRADLs. Without the device you must be unable to carry out one or more of these activities. Medicare defines MRADLs as those daily activities that include, but are not limited to, toileting, feeding, dressing, grooming, and bathing.

Medicare does not cover an MAE device if it is only needed for use outside of the home. For example, let's say that you are able to walk about your house and carry out all your daily activities in your home without a walker or wheelchair, however you need the mobility device when you go to the doctor's office or the grocery store or the mall. In this situation Medicare will not pay for the walker or wheelchair, since it is not needed within the home. This does not mean that you cannot use your walker or wheelchair outside of your home as well, but use outside the home cannot be your only need.

4.5. State Medicaid Coverage

State Medicaid Coverage

  • State Medicaid Overview
  • Required Medicaid Paperwork
  • Want to Know More? Details about Unified Medicaid Policies

A medical insurance claim form sits on a messy desk waiting to be completed.

State Medicaid Overview

Medicaid is a state run program, which is subsidized, or partially paid for, with federal funds. Individual state Medicaid programs must follow a basic foundation of federally mandated DME coverage rules, but beyond this the states have some freedom to develop their own programs, policies and coverage criteria. You can find out information about your state's Medicaid program, including enrollment data and link's to individual state's sites, at the Medicaid website.

Required Medicaid Paperwork

State-by-State Inidividual Paperwork

Each State has varying requirements for specific paperwork required and fluctuating time frames to obtain prior authorization for mobility equipment. To find information about your state's  Medicaid paperwork requirements, you can visit their website (a listing can be found at the Medicaid website) or call them directly.

Want to Know More?

Details about the Unified Medicaid Policies

Though the paperwork varries, the laws surrounding State Medicaid programs are consistent across the country.  

Policy HotSpot
Medicaid Discrimination
Do you feel you have experienced discrimination within the Medicaid program regarding your wheelchair?

Share your story with UsersFirst and get support

Medicaid's Statutory Purpose:

Medicaid's purpose is clearly stated and backed up

  • "To furnish rehabilitation and other services to help such families and individuals attain or retain capability for independence or self care." 42 U.S.C. § 1396 (2)
  • The primary goal of Medicaid is to provide medical assistance to persons in need and to furnish them with rehabilitation and other services to help them "attain or retain capability for independence or self-care." Meyers v. Reagan, 776 F.2d 241, 243 (8th Cir. 1985)
  • The Medicaid Act requires that each state medical assistance program be administered in the "best interest of the recipients." 42 U.S.C.§1396a(a)(19).
  • Given the remedial nature of this legislation, both the Act and its implementing regulations must be liberally construed in favor of Medicaid beneficiaries seeking medically necessary health careCristy v. Ibarra, 826 P.2d. 361 (Court of Appeals, Co. 1991).

Equal Protection – Age:

  • Estaban v Cook, 77 F. Supp. 2d 1256 (S.D.Fla. 1999). Florida Medicaid's cost cap of $582 for wheelchairs effectively denied both motorized and customized mobility devices to Medicaid recipients over age 21 and thus failed to comply with HCF's policy on DME coverage as the cap was absolute and there were no procedures for requesting an exception. The exclusion was unreasonable because it was based solely on age (over 21) rather then medical necessity, and did not comport with the purpose of the Medicaid "ct which is to help individuals "attain or retain capacity for independence and self-care."
  • Fred C. v Texas, 988 F. Supp. 1032 (W.D. Tex. 1997), aff'd 167 F.3d 537 (5th Cir. 1998). Denial of coverage for ACDs for beneficiaries over the age of 21 is irrational in light of purpose of the Medicaid Act, which is to help individuals attain the capability for independence and self-sufficiency. State may not deny treatment solely based upon age as there is no rational basis for distinguishing between those over and under 21.
  • Hunter v Chiles, 944 F. Supp. 914 (S.D.Fla.1996). Adults sought ACDs which state conceded it would cover for child if unavailable from other sources. Citing Salgado, court held that "Medicaid funding cannot be denied on the basis of age." Age as sole criterion is wholly unrelated to medical necessity and is unreasonable.

Equal Access to Care:

Found in Title XIX of the Social Security Act, 42 U.S.C. § 1396a:

  • 1396a(a)(2) – requires that the state plan ensure that there is an equalization of services provided and that the lack of adequate funds from local sources will not result in lowering the amount, duration, scope or quality of care and services available under the plan.
  • 1396a(a)(30) – requires that the state medical assistance plan enlist enough resources and providers so that the care and services provided under the plan are at least equal to the care and services available to the general population in the geographic area.

Amount, Duration, and Scope Rule:

  • Each Service Must Be Sufficient in Amount, Duration and Scope to Reasonably Achieve Its Purpose. 42 C.F.R. § 440.230(b)
  • The Medicaid Agency May Not Arbitrarily Deny or Reduce the Amount, Duration, or Scope of a Required Service To an Otherwise Eligible Beneficiary Solely Because of the Diagnosis, Type of Illness, or Condition. 42 C.F.R. § 440.230 (c)

Reasonable Promptness Revision:

The Medicaid Act requires that a state plan for medical assistance:

  • "must . . . provide that all individuals wishing to make application for medical assistance under the plan shall have opportunity to do so, and that such assistance shall be furnished with reasonable promptness to all eligible individuals." 42 U.S.C. § 1396a(a)(8).
  • Federal regulations implementing this provision require that a state Medicaid agency must "furnish Medicaid promptly to recipients without delay caused by the agency's administrative procedures" and "continue to furnish Medicaid regularly to all eligible individuals until they are found to be ineligible." 42 C.F.R. § 435.930

4.6. Department of Veterans Affairs (VA)

Department of Veterans Affairs (VA)

  • Department of Veterans Affairs (VA) Overview
  • What are the VA's benefits
  • Applying for VA benefits
  • Benefits Hot Spot 

A military veteran navigates a crowded park in his manual wheelchair.

Department of Veterans Affairs (VA) Overview

The Veteran's Administration (VA) Hospitals offer excellent service and benefits for those who qualify to be in the system. The qualification requirements are specific and can be found at the US Department of Veterans Affairs.  If you need more information or run into a roadblck you can contact VetsFirst.

When you are enrolled in the VA health care system, you will be assigned to a primary care physician (PCP). That PCP is associated with a clinic which also includes nursing, pharmacy, and social work services. When you need a wheelchair, your PCP will refer you to rehab. An occupational therapist (OT) or physical therapist (PT) will assess your need for a wheelchair and make appropriate recommendations. The therapist documents your need for the specific equipment and then the prosthetics department places the order for the wheelchair.

VA benefits

Some VA Benefits Include:

  • Home modifications
  • Vehicle lifts to transport equipment
  • Home improvement structural alteration (HISA)

Applying for VA benefits

To enroll in the VA system, simply do one of the following:

  1. Contact the Enrollment Coordinator for your local VA Health Care Facility
  2. Contact a National or State Veteran's Service Organization (examples: DAV, AMVETS, PVA)
  3. Go to www.va.gov and complete the 10-10EZ form online
Benefit Hot Spot
ALS is a Service-Connected Condition
ALS (Amyotrophic Lateral Sclerosis or Lou Gehrig's disease) is a service-connected condition for all affected veterans with more than 90 consecutive days of service, even if you were diagnosed after being discharged.

Ask VetsFirst to find out more about this benefit.

Home               Share Your Thoughts

4.7. Secondary Insurance

Secondary Insurance

  • Secondary Insurance Overview

Secondary Insurance Overview

Secondary insurance gives you more insurance coverage on top of your main or 'primary' coverage. This secondary insurance is usually through a different company than your primary insurance coverage.

Secondary insurance coverage supplements your existing policies and can cover gaps in your main insurance. In some case the secondary insurance will pay for your primary insurance company's deductible or co-payment.  For example, you may have Medicare and AARP or United Healthcare as a secondary.

If you have secondary insurance please check with that company regarding their policies as a secondary insurer.

4.8. Step 6: Responding to Roadblocks

Respond to Roadblocks

  • What to do if your first source of funding doesn't pay for your wheelchair
  • Responding to an insurance denial 

A warning sign and cement barrier block traffic from traveling down a road.

Traditional Funding Sources are Just the Beginning

Don't worry! If at first traditional funding sources don't give you with all the coverage you need, there are other options. 

Possible Funding Roadblocks

You may...

  • Receive a denial,
  • Only have a portion of your needs paid for, or
  • Need to find alternative funding sources.

What's next?

This is where you must strengthen your resolve to get your needs met, become your own best advocate, and get creative! The next few pages will give you the tools to deal with the common roadblocks to coverage listed above.

4.9. Dealing with Denial

Dealing with an Insurance Denial

  • The Steps to Dealing with a Denial
  • Details about reasons for denials

An insurance claim form is stamped with the word 'rejected.'

The Steps for Dealing with a Denial

  1. First, use your wheelchair team. The clinician and the supplier are usually working hard to get the best chair for you.
  2. Get the Denial in Writing
  3. Figure out why you were denied. Non-covered benefit? Least costly alternative? Not considered medically necessary? Discrimination?
  4. Review the details about your policy to find errors or issues with the denial decision.
  5. File an appeal.
  6. Reach out for extra help. Talk to consumer organizations, an attorney, your clinician and therapist, and/or your supplier for help and feedback.

1) Get the Denial in Writing

Get the Denial in Writing to see what the reasoning is for denying the equipment. Many times, funding sources will contact your supplier's office on the phone to say that they are denying your equipment request. This is an unacceptable form of notifying you and the supplier of the denial. It is your right to get any denial for your equipment in writing.

If you do not have the actual denial in writing, it will be difficult, if not impossible, to proceed through the appeals process. This is especially important if your claim ends up going to a fair hearing.

2) Figure out why you were denied

  1. Non-Covered Benefit
  2. Least Costly Alternative
  3. Not Medically Necessary
  4. Other Discriminatory Reasons

1. Non-Covered Benefit

It is worth at least one level of appeal if you get a denial based on an item that's "non-covered." Know your policy well! If you can prove the item qualifies as DME under the policy definition or qualifies under the definition of 'medical necessity' for your specific needs – then it should NOT be considered excluded.

Private Insurance Companies

May have excluded items because they fall outside of their:

    • Definition of Durable Medical Equipment (DME)
    • Definition of Medical Necessity, or
    • Definition of Excluded Items – typically this states, "anything not determined to be medically necessary, for example . . ."

Medicare

Policies may exclude some items such as:

    • Group 4 power wheelchairs,
    • Seat elevation (E2300) Note: this is a Medicare code.  Medicare attaches a code to every product and procedure. , and
    • Wheelchair standers (E2301/E2230)

Medicaid

May not deny any item because it's 'not covered.' All decisions in Medicaid must be made based on individual medical necessity.

2. Least Costly Alternative

If your receive a denial that offers you instead a 'least costly alternative' to the equipment requested, you should take the following into account when filing your appeal:

    • To be a true alternative – the item must be EQUALLY EFFECTIVE!
    • Know how the recommended product differs from other products in the same category. Contact the manufacturer's representative for help with comparing similar products from other manufacturers.
    • 'Least costly' doesn't necessarily mean 'cheapest' – Consider your holistic needs of equipment and cost savings across the entire medical spectrum.
    • For example – the feature on your wheelchair might allow you to reduce the amount of paid caregiver time, medications required, or other interventions that cost money.
    • Is there a true alternative? There may not be if the alternative is not eqally effective.

3. Not Medically Necessary

If your receive a denial stating that the equipment requested is 'not medically necessary,' you should take the following into account when filing your appeal:

    • Know your insurer's definition of medical necessity in your individual policy
    • You should be able to show how the equipment meets the definition of medical necessity in your individual case and use research if it is available.
    • Work with the manufacturer of the equipment being requested to provide additional support during this appeal process.

Each insurance company has its own definition of medical necessity. It is imperative for you to know how your insurance company defines medical necessity and what criterion you need to meet in order to qualify for a wheelchair.

There are many ways to find your insurer's definition of medical necessity:

    • Check your insurance handbook,
    • Search the insurer's website, or
    • Call your member services.

4. Discrimination

If you receive a denial for reasons such as age, diagnosis, or life expectancy, then your appeal will cite federal law pertaining to discrimination.

 

Policy HotSpot 
Medicaid Discrimination
Do you feel you have experienced discrimination within the Medicaid program regarding your wheelchair?

Share your story with UsersFirst and get support

 

3) Review the details about your policy

 It is very important you review your insurance handbook for details to combat the denial in an appeal. If you do not have your handbook anymore, you can go to your insurer's website for information or call customer service to request a new handbook.


4) File an appeal

 There are many different policies for each insurance company. The best way to find out the appeal policy for your particular insurance plan is to check your member handbook. Look under appeals or grievances for more information or contact your insurance company. Listed below are some general appeals processes for each company listed.

 

If you do not see your insurer listed above, go to your insurer's website or call their customer service line to learn the process for appeal.


5) Reach out for help 

Contact UsersFirst.

4.10. Alternative Funding Sources

Alternative Funding Sources

  • National Resources
  • State Resources
  • Other Ideas

The process of seeking alternative funding sources is depicted by arrows navigating a brick wall by going over, under, and through this barrier.

You Deserve the Correct Equipment

UsersFirst believes you should receive the correct equipment that works for you through your insurance company. However, if your insurance does not fund a portion of your wheelchair, there may be other sources that can help you with payment of those items. Here are some resources.

National Resources (Listed Alphabetically)

State Resources

Other ideas

  • Fundraisers: raise money through churches and school
  • Contributions: people can seek contributions from large sports teams, or businesses/local businesses

5. Ordering Your Wheelchair

5.1. Ordering Your Wheelchair: An Overview

Chapter 5: Ordering Your Wheelchair - An Overview

Finally - You have gotten funding and your supplier can order your wheelchair!

In this chapter we will answer the following questions:

  • Who will order my wheelchair?
  • When will my chair be ordered?
  • What's next - when do I get my wheelchair?

5.2. Step 7: Ordering Your Wheelchair

Step 7: Ordering Your Wheelchair

  • The who, when, and where of ordering your wheelchair

A young man smiles while sitting with his arm over the shoulder of his clinician.

The Next Big Step


Who

Your supplier will order your wheelchair.

How

The wheelchair supplier will fill out an order form (usually during the evaluation with you and the therapist) from the wheelchair manufacturer (ex: Quickie, Invacare, Pride Mobility, Permobil, Colours, TiLite). There are boxes to check on that form that relate to each part of your wheelchair.

When

Once payment for your wheelchair is approved, your order can be placed.

Where

Your wheelchair will be ordered directly from the manufacturer, the company that actually makes the chair. The manufacturer ships the chair to your supplier.  Your wheelchair may have parts on it from other companies (like a headrest, cushion or seatbelt). Your supplier will put the chair together per the specifications you and your wheelchair team agreed upon. 

6. Equipment Delivery

6.1. Equipment Delivery: An Overview

Chapter 6: Equipment Delivery - An Overview

The arrival of your wheelchair marks the end of one journey and the beginning of another. In this chapter we will cover the first steps of this new phase including the actual equipment delivery process and will touch on management and maintenance issues.

In this chapter we will answer the following questions:

  • What can I expect at my equipment delivery? 
  • Who will assess my wheelchair's fit? 
  • What do I do if my chair makes me uncomfortable?
  • What do I do if my wheelchair breaks?

6.2. Step 8: Equipment Delivery

Step 8: Equipment Delivery

  • Equipment Delivery Overview
  • What to Expect at your Equipment Delivery 
  • Downloadable Overview of What to Expect

Two people are introduced to their new wheelchairs. A young man in shown how to work the touch screen attached to his wheelchair. A woman is shown how to bring her wheelchair into a standing position.

Equipment Delivery Overview 

Your clinic will contact you for an appointment to deliver your equipment. However, you have every right to call the supplier to ask them what the status is on your wheelchair approval and delivery before they contact you. 

Basic process:

  1. Once the wheelchair is received by the supplier they will let the clinic know
  2. The clinic should call you to schedule an appointment for delivery
  3. Attend your equipment delivery

What to Expect at your Equipment Delivery 

At your equipment delivery you will not simply receive your wheelchair, but you also attend a scheduled appointment with your prescribing clinician where he or she will ensure that your wheelchair is a good fit and will work for you. And this is also an opportunity to learn more about living as a wheelchair user and to ask your clinician and supplier questions about your new chair.

Equipment delivery should include:

  • Meeting with your prescribing clinician to assess fit, positioning, and equipment set up
  • Receiving information and education about pressure management, operational skills, safety, and more
  • Learning how you should deal with clinical or equipment issues in the future

6.3. Clinic Appointment with Prescribing Clinician

Clinic Appointment with Prescribing Clinician

  • Clinic Appointment with Prescribing Clinician Overview
  • Details of a Fit Assessment
  • Additional Information and Education to Expect at the Appointment
  • Downloadable Overview Available Below

A woman meets with her clinician and supplier to assess the fit of her new wheelchair.

Clinic Appointment with Prescribing Clinician Overview

The length of time needed to perform the Fit Assessment of a new wheelchair will vary based on the complexity of the wheelchair. It could an hour to several hours, depending on the complexity of your wheelchair and seaing equipment. Ideally, everyone who participated in the original assessment should be present for delivery of complicated equipment.

Fit Assessment


During the appointment the clinician and supplier should assess the following areas together:

  • Seat width and depth
  • Pelvic position/Support
  • Cushion: Appropriate support. Pressure map when necessary
  • Leg support (footrest angle, legrest length, foot strapping)
  • Appropriate trunk support
  • Back support (height, contact area)
  • Lateral supports, chest harness (appropriate location and support)
  • Other positioning devices
  • Headrest (appropriate height and location, provides appropriate amount of support)
  • Hip Guides/Adductor Pads (appropriate location and support)
  • Specific considerations for Manual Wheelchairs
  • Wheel position (Forward, Backward, Vertical position)
  • Specific considerations for Power Wheelchairs
  • Joystick or specialty control position for access
  • Ability to access controls when tilted or reclined
  • Ability to manage pressure, edema, and other medical issues with power features
  • Pressure Relief (ability to achieve pressure relief using planned method)

Operational Information

Both the clinician and the supplier will assist you in how to use your equipment within your individual environments and circumstances to get the maximum benefit from your mobility device. Your supplier should instruct you on the proper care and maintenance required for your equipment based on the manufacturer's recommendations. 

Additional Education and Information

During your appointment you should receive education about pressure management when using your wheelchair, maintenance, safety information and more. Your clinician and supplier should also let you know what to do if you have a problem with your wheelchair. The general responses to issues faced with your wheelchair are listed below, however, be sure to ask questions specific to your wheelchair and needs at this time as well.

What to do if I develop a problem with my wheelchair?

When problems occur with a wheelchair, the first call should be to the supplier. 

Equipment Issues

If the problem is mechanical, it should be able to be addressed by the supplier. Many payer sources require a prescription from a physician prior to providing the repairs or adjustments. 

Clinical Issues

If new equipment needs to be ordered, because the equipment is not working, a clinician or therapist should be consulted to work with you and the supplier to decide the most appropriate equipment to be ordered.

7. Living as a Wheelchair User

7.1. Living as a Wheelchair User: An Overview

Chapter 7: Living as a Wheelchair User - An Overview

This chapter will introduce you to living your life as a wheelchair users by touching on topics from using your wheelchair in your vehicle to integrating into your community.

In this chapter we will answer the following questions:

  • Is there maintenance required for my wheelchair?
  • Who will do my wheelchair maintenance?
  • How can I learn to use my wheelchair with my vehicle?
  • Are there rules about where I can and cannot use my wheelchair?
  • I'm unsure about integrating into my community, what can I do?

7.2. Wheelchair Maintenance

Wheelchair Maintenance

Maintenance Required

Contact your supplier and the manufacturer of your equipment to determine the appropriate maintenance to keep your mobility device in good working order. It is also a good idea to make an appointment with your supplier for an annual "tune-up" where all bolts/screws can be tightened up, growth options will be explored, and overall functioning of the device can be assessed.

Wheelchair Tech Guide

You can get connected with other wheelchair users to discuss and ask questions about your equipment at United Spinal Wheelchair & Assistive Technology Program.


7.3. Use of Equipment in Your Home

Use of Equipment in Your Home

  • Medicare Guidelines Informaton 
  • Important note
  • Policy Hot Spot: Learn More & Act Now!

A woman enters her front door in her wheelchair with her guide dog.

Safety

The Home Assessment Form is a great tool to identify any accessibility issues. This tool can also help prioritize repairs. You can download the checklist below.

You May Not Know...

Medicare has very strict guidelines for coverage of DME and in particular for the subset of DME that they term "mobility assistive equipment" or "MAE". This includes canes, walkers manual and power wheelchairs and scooters (also called power operated vehicles or POVs).

Central to these guidelines is the policy that the MAE must be 'medically necessary' for use in the home and not solely for use outside the home. In other words, the device must be needed in order for you to get around your home and carry out the daily activities that Medicare has termed "mobility related activities of daily living" or MRADLs. And without the device you would be unable to carry out one or more of these activities. Medicare defines MRADLs as those daily activities that include, but are not limited to, toileting, feeding, dressing, grooming, and bathing.

Medicare does not cover an MAE device if it is needed only for use outside of the home.

For example:

You may be able to walk a litle around your home and carry out all your daily activities in your home without a walker or wheelchair, but you need the mobility device when you go out, say to the doctor's office or the grocery store or the mall. In this situation Medicare will not pay for the walker or wheelchair, since it is not needed within the home. This does not mean that you cannot use your walker or wheelchair outside of your home as well, but use outside the home cannot be your only need.

 

7.4. Use of Equipment in Your Vehicle

Use of Equipment in Your Vehicle 

  • Use of Equipment in Your Vehicle Overview
  • NMEDA Information

A woman exits her van by lowering herself on her electronic wheelchair lift.

Use of Equipment in Your Vehicle Overview

As NMEDA says, "Transportation is the key to freedom." Learn more about using your wheelchair with a vehicle through NMEDA. 

NMEDA Information

 

NMEDA stands for 'National Mobility Equipment Dealers Association.' 

According to the association's website:

"NMEDA is a non-profit trade association of mobility equipment manufacturers, dealers, driver rehabilitation specialists, and other professionals dedicated to improving the lives of people with disabilities and assisting with driving independence using wheelchair accessible vans, truck and cars."

To find a certified NMEDA provider in your area, go to:
www.nmeda.com

7.5. Community Integration

Community Integration

Men and women with greatly diverse backgrounds and interests comprise the wheelchair community.

Community Integration Resources

Adjusting to Life After Sustaining a Spinal Cord Injury or Disease (SCI/D)

Living with Multiple Sclerosis (MS)

ALS Care

Living with Cerebral Palsy

Living with a Brain Injury


Links to Organization's with Community Integration Information

United Spinal Association - Spinal Cord Central

UsersFirst

More Consumer Orgaizations

8. Wheelchair Seating and Mobility Basics

8.1. Power Wheelchair Information

Click on the PDF below for a slideshow that will cover the following topics along with photos.


Specific Considerations for Power Wheelchairs

  • There are different kinds of power bases that maneuver according to their type:  
    • Front-wheel drive, mid-wheel drive and rear-wheel drive
    • They each have benefits and drawbacks
    • It is up to you and your team to decide which type works best for you 
  • Joystick or specialty controls
    • Be sure you can control the chair with your hand using a Joystick or with specialty controls that can be located anywhere you have consistent body movement (head, mouth, foot)
  • Operate the chair in any position
    • Be sure you can operate the chair in any position (tilt, recline, standing)
  • Know power options
    • Be sure you know how to use the different power options (tilt, recline, seat elevation, elevating leg-rests, standing)
  • Have a pressure relief plan
    • Be sure you have a Pressure Relief plan (ability to achieve pressure relief using planned method). For example: leaning forward, tilting the seat back, lifting yourself up with your arms, standing, leaning to one side.

8.2. Manual Wheelchair Information

Click on the PDF below for a slideshow that will cover the following topics along with photos.

 

The slideshow will discuss the basics of manual wheelchair function and set-up.  The following subjects will be provided:

  • Description of the different types of manual wheelchairs
  • The Medicare codes are mentioned for use when you work with the therapist and wheelchair supplier.  For more information about Medicare click here.
  • Different types of components will be discussed
  • The set-up of a manual wheelchair or configuration will be discussed.  This is how you set your wheelchair up to fit your lifestyle and physical abilities.
  • The recommended way to push your manual wheelchair will be shown.  This is important so you don't injure your shoulders or arms.

8.3. Basic Wheelchair Information

Basic Wheelchair Information

Click on the file below to view basic information about wheelchairs.

 

The following basic information will be covered in the slideshow below:

  • Seat width and depth
    • If the chair is too big or too small it will be difficult to use and uncomfortable.
  • Pelvic (hip) position and support
    • If your hips are not positioned well, it might be hard to use your arms and it could make you tired. Basically, your hips are the base of your support when you are sitting, it is important to know if they are straight or if one side is higher than the other.
  • Cushion
    • A VERY important part of the wheelchair! You need to feel stable and have a cushion that will decrease the possibility of a pressure sore. Ideally, the clinic will pressure map you sitting on the cushion.
  • Leg support
    • Footrest angle, leg rest length, foot support (strap?) – it is important your feet are aligned well so you have as much support to sit up as well as possible. You can what feels most supportive.
  • Appropriate trunk support
    • The back support of the wheelchair will help you stay upright and increase your endurance. Just like a good seat in a car, if it is comfortable and you are able to move as freely as possible and have the support you need, you can drive longer and be more alert.
  • Back support
    • You might want a low back or a high back. A low back will give you more room to move your arms, but has less back support. A high back will provide more support, but might limit your arm movement.
  • Chest support
    • Lateral supports (supports the side of your chest) or chest strap (a strap on your chest if you are worried you will fall forward). These features help you keep your balance when leaning forward, or to the side.
  • Headrest
    • You might want a head support if you feel it gives you the necessary support while driving your chair or if your wheelchair seat is able to tilt back.

9. Wheelchair Glossary

9.1. Assistive Technology Certification

Assistive Technology Certification

In the wheelchair world, an ATP is usually a physical therapist, occupational therapist or supplier who has met the ATP standards for knowledge about wheelchairs and seating products along with other assistive technologies.


Assistive Technology Professional (ATP)


Basic certification is available for providers who have extra knowledge and experience in providing assistive technology (AT) including wheelchairs. This Assistive Technology Professional (ATP) certification is through the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA).  An occupational therapist, physical therapist or a wheelchair supplier is eligible for this certification.

An Assistive Technology Professional (ATP) is a certified "service provider who analyzes the needs of consumers with disabilities, assists in the selection of appropriate assistive technology for the consumer's needs, and provides training in the use of the selected devices." Source: Rehab Engineering and Assistive Technology Society of North America.

Seating and Mobility Specialist (SMS)

In 2010, RESNA introduced an additional advanced certification in seating and mobility. This certification is called the Seating and Mobility Specialist (SMS) certification. This certification is available for providers who have extra knowledge and experience in providing assistive technology such as wheelchairs. This certification is also through the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA).

To search a list of certified AT professional you can go to the RESNA website.

 

RRTS or CRTS:

NRRTS Registrants are dedicated professionals in the field of Complex Rehab Technology service delivery. A NRRTS Registrant possesses the experience and knowledge to work with the clinician and client to determine the most appropriate enabling technology for people with disabilities. These professionals know the range of the products available  that includes wheeled mobility, seating and positioning, ambulation assistance, environmental controls and/or products for daily living.

An extensive application and pre-qualification process must be completed before Registration is attained.

Only NRRTS Registrants may use the credential of RRTS® - Registered Rehabilitation Technology Supplier, or CRTS® - Certified Rehabilitation Technology Supplier®. A CRTS® is a RRTS® in good standing for at least two years who has passed the Assistive Technology Professional, ATP, exam administered by RESNA and continues to maintain the ATP credential with RESNA.

 

9.2. Physician

Physician

Your physician determines the medical necessity of providing you with a wheelchair, as evidenced by a prescription.  In addition, your physician determines the medical necessity of providing you with a seating evaluation, also evidenced by the provision of a prescription.

The doctor you schedule your first meeting with about getting a wheelchair may be a general practitioner (example: Primary Care Physician) or a specialist (examples: Physiatrist, Neurologist, or Orthopedist).

A physiatrist, or rehabilitation physician, is a nerve, muscle, and bone expert who treats injuries or illnesses that affect how you move

Physical medicine and rehabilitation involves the management of disorders that alter the function and performance of the patient. Emphasis is placed on the optimization of function through the combined use of medications, physical modalities, physical training with therapeutic exercise, movement & activities modification, adaptive equipment and assistive device, orthotics (braces), prosthesis, and experiential training approaches.

Rehabilitation physicians are medical doctors who have completed training in the medical specialty of physical medicine and rehabilitation (PM&R). Specifically, rehabilitation physicians:

  • Diagnose and treat pain
  • Restore maximum function lost through injury, illness or disabling conditions
  • Treat the whole person, not just the problem area
  • Lead a team of medical professionals
  • Provide non-surgical treatments
  • Explain your medical problems and treatment/prevention plan
 

A neurologist is a medical doctor with specialized training in diagnosing, treating, and managing disorders of the brain and nervous system. Neurologists do not perform surgery.

A neurologist's training includes an undergraduate degree, four years of medical school, a one-year internship, and at least three years of specialized training. Many neurologists also have additional training in other areas—or subspecialties—of neurology such as stroke, epilepsy, neuromuscular disease, and movement disorders. These are some of the more common subspecialties within the field of neurology.

What Does a Neurologist Treat?

Common neurologic disorders include:

  • Amyotrophic lateral sclerosis (ALS, also called Lou Gehrig's disease)
  • Alzheimer's disease
  • Brain and spinal cord injuries
  • Brain tumors
  • Epilepsy
  • Headache
  • Pain
  • Multiple Sclerosis
  • Parkinson's disease
  • Stroke
  • Tremor


Orthopedics is a branch of medicine focused on injuries to the musculoskeletal system, including spine and joint injuries or deformities. There are multiple branches of orthopedics, including orthopedic surgeons, rheumatologists, and orthopedic pediatricians. They work in small, specialized practices, in larger, less specialized practices, or in hospitals.

Orthopedic doctors treat broken bones, joint problems, like arthritis, and degenerative conditions, like osteoporosis. They also treat sports injuries, infections, congenital conditions, and tumors in the bones. The work depends on what specialty a doctor chooses, or by where they choose to practice medicine. A doctor in a small, specialized clinic may only treat sports injuries, for example, while orthopedic doctors in a large hospital may work with everything from sprained ankles to a patient receiving a hip transplant.

The education and training to become an orthopedic doctor lasts about 13 years, with eight years of schooling (both undergraduate and postgraduate), and five years of residency. During this time, an orthopedic doctor chooses a specialty to study. This could be a focus the bones of a particular body part, such as the hand, musculoskeletal oncology, joint replacement, or any of the other numerous branches of orthopedics.

9.3. Supplier

Wheelchair Supplier

The wheelchair supplier is a critical team member, as he or she will work closely with your therapist throughout the entire process to ensure that your equipment is ordered accurately, billed to your insurance, and assembled correctly for delivery. The supplier will also oversee any repair issues for your equipment. There are many suppliers to choose from. Some are a part of larger, national companies, and others are local dealerships. It is highly recommended your supplier is certified as an Assistive Technology Professional (ATP).

You have the right to choose which supplier provides your equipment. It is important that you select a supplier that you can trust and feel comfortable with. You want to develop and sustain a long-term relationship with the supplier.  The supplier will be your first call if you need repairs for your equipment.  Another point to consider when choosing a supplier is if they have a location close to your home.  

The supplier works closely with the clinician to determine what equipment would be most appropriate for you based on the evaluation findings. Together, the clinician and supplier will also look at your accessibility needs to ensure that the recommended equipment is compatible in your specific environment (e.g., home, work, school, vehicle, church, etc.) and will maximize your independence. The supplier may conduct a home evaluation to verify that you will be able to use the prescribed wheelchair in and around your home.

Some suppliers hold one or more of the following certifications:

RRTS or CRTS:

NRRTS Registrants are dedicated professionals in the field of Complex Rehab Technology service delivery. A NRRTS Registrant possesses the experience and knowledge to work with the clinician and client to determine the most appropriate enabling technology for people with disabilities. These professionals know the range of the products available  that includes wheeled mobility, seating and positioning, ambulation assistance, environmental controls and/or products for daily living.

An extensive application and pre-qualification process must be completed before Registration is attained.

Only NRRTS Registrants may use the credential of RRTS® - Registered Rehabilitation Technology Supplier, or CRTS® - Certified Rehabilitation Technology Supplier®. A CRTS® is a RRTS® in good standing for at least two years who has passed the Assistive Technology Professional, ATP, exam administered by RESNA and continues to maintain the ATP credential with RESNA.