Provider Notice issued 03/16/04

Custom Power Wheelchairs

The Department is reiterating its policy concerning coverage of custom power wheelchairs. The Department evaluates requests for custom power wheelchairs for Medicaid-eligible clients strictly according to medical necessity, regardless of residency. Reimbursement for customized power wheelchairs is available from the Department for beneficiaries when determined medically necessary. A need to add standard components or accessories to a wheelchair is not considered customization.

Pursuant to 89 Illinois Administrative Code 140.476, long term care facilities continue to be responsible for standard power and manual wheelchairs used by Medicaid-eligible residents. The Department is only responsible for power wheelchairs that are customized to fit a specific resident's condition. Some conditions that may qualify a resident would include Muscular Dystrophy, Multiple Sclerosis, severe osteoarthritis, quadriplegia and severe obesity with pulmonary problems. Residents of long term care facilities have a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident, including assisting that resident in obtaining needed services.

Only a durable medical equipment (DME) provider enrolled under the Medical Assistance Program is authorized to, and responsible for, submitting a prior approval request to the Department for consideration of a custom power wheelchair. A request made to a DME provider by a facility for a custom power wheelchair must include, at a minimum, the following:

• a physical or occupational therapy evaluation, which clearly identifies the resident's physical limitations and abilities related to the wheelchair;

• medical history;

• current medical status;

• documentation of other, less expensive options that were considered and the reason why those options will not meet the patient's medical needs; and

• a physician certification of medical necessity. Medical necessity must be documented for each component, accessory or modification as it relates to the resident's medical needs.

A custom power wheelchair ordered on behalf of a resident in a long term care facility becomes the property of that resident.

In the event that a request for a custom power wheelchair is denied, the denial may be appealed by the resident any time within 60 days following the date of the denial notice and a fair hearing will be scheduled. A resident may ask for a fair hearing by calling 1-800-435-0774 or by writing to the Illinois Department of Public Aid, Bureau of Administrative Hearings, 401 South Clinton Street, 6th Floor, Chicago, IL 60607. The Department of Human Services local office will provide the resident, upon request, with an appeal form and will help the resident complete the appeal form. The resident may represent him or herself at the hearing or may be represented by anyone else such as a lawyer, relative or friend.

If you have any questions, please contact the Bureau of Long Term Care at 217-524-7244.

Anne Marie Murphy, Ph.D.

Administrator

Division of Medical Programs