Home Health & Hospice Week

Forthcoming coverage policy should use functional standard of 'non-ambulatory,' lawmakers say.

The pressure is on the Centers for Medicare & Medicaid Services, and suppliers are hoping the agency will formulate a reasonable wheelchair coverage policy as a result.

CMS recently received the strongest message yet - instructions in the House and Senate reports that accompany the appropriations bills passed on Sept. 10 and Sept. 15, respectively.

The House Appropriations Committee says it was "disturbed" earlier this year by examples of durable medical equipment regional carriers denying wheelchair claims "based on an excessively narrow interpretation of what constitutes 'nonambulatory,'" according to House Report 108-636.

And both the House committee and Senate Appropriations Committee urge CMS to develop "a coverage policy firmly based on a functional standard of nonambulatory." That means making sure beneficiaries who can't perform "basic acts of daily living" - toileting, food preparation and emergency egress - fall under the nonambulatory definition and have access to mobility products, the committees instruct.

Ensuring wheelchair access for these types of beneficiaries would actually save Medicare money because it would prevent expensive institutional care and hospitalizations, the committees say.

CMS' interagency workgroup on wheelchair coverage plans to have the new policy out by year's end (see Eli's HCW, Vol. XIII, No. 22, p. 171).

Industry Cheers Report Language

"This language is very positive," says Seth Johnson, director of government affairs for Exeter, PA-based Pride Mobility Products Corp. "It's an indirect way for Congress to tell CMS what to do without having to pass a law." That's especially handy because Congress isn't expected to pass any legislation making changes to Medicare in this election year.

The appropriations language carries a lot of weight because those committees fund CMS' budget, notes Erik Sokol with the Power Mobility Coalition. These are the committees "that pay [CMS] decision-makers' salaries," Sokol points out.

Giving instructions via report language has been effective in the past, Johnson tells Eli. And the timing is perfect because CMS' interagency work group will be wrapping up its policy in the next month or two.

These instructions are the latest in a string of events, including court cases and letters from individual members of Congress, that have been putting pressure on CMS to make its wheelchair coverage policy reasonable. But a favorable outcome for wheelchair dealers and users is far from assured.

"CMS still seems to be entrenched" in the narrower definition of nonambulatory, Sokol admits. That's why the industry continues to build the pressure, he says. Sokol praises suppliers for communicating their concerns loud and clear to their congressional representatives.

Wheelchair suppliers have seen some relief from claims denials based on the non-ambulatory definition CMS issued in its now-retracted December memo (see Eli's HCW, Vol. XIII, No. 12, p. 92). "There has been a dramatic improvement since June" in most DMERC regions, Johnson reports. 

Editor's Note: House Report 108-636 and Senate Report 108-345 are available at
http://thomas.loc.gov/cp108/cp108query.html.