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Provider Notice issued 03/28/07
Right of Nursing Facility Residents to Motorized Wheelchairs
| To: | Providers of Nursing Facility Services and Durable Medical Equipment and Physicians and Hospital Discharge Planners |
| Date: | March 28, 2007 |
| Re: | Right of Nursing Facility Residents to Motorized Wheelchairs |
As required by the United States District Court in Jackson v. Maram, No. 04-C-174 (N.D.III), nursing facility residents who are eligible for Medicaid must be evaluated and assessed for motorized wheelchairs, and be provided with motorized wheelchairs when medically necessary.
Nursing facilities are responsible for ensuring that residents are evaluated and assessed for motorized wheelchairs and assisting the resident in obtaining medically necessary motorized wheelchairs. These evaluations must occur upon admission to the nursing home and annually as part of the resident’s Plan of Care.
The Department will pay for medically-necessary custom motorized wheelchairs. A custom motorized wheelchair is one that is built, in whole or in part, for a specific individual.
Nursing facilities must pay for medically-necessary non-custom motorized wheelchairs. A non-custom motorized wheelchair is one that is not constructed for a specific individual.
Nursing facility residents have the right to appeal denials of motorized wheelchairs either by the Department or by the nursing facility. Additionally, nursing facilities that fail to evaluate, assess or provide medically-necessary non-custom motorized wheelchairs are subject to appropriate enforcement action by the Department, including fines and decertification.
TO NURSING FACILITY ONLY: Attached is a notice to nursing facility residents. As required by the U.S District Court, this notice must be prominently displayed within the nursing facility, including on all bulletin boards. |
Theresa Eagleson Wyatt
Acting Administrator
Division of Medical Programs
To: All Medicaid-eligible Nursing Facility Residents:
Under Medicaid, and under a consent Order of the U.S. District Court in Jackson v. Maram, No. 04-C-174, you may qualify for a motorized wheelchair. This notice is being sent to help you understand whether you qualify and, if so, how to request a motorized wheelchair.
• Do I qualify for a motorized wheelchair?
You qualify if:
• You are eligible for Medicaid, and
• A motorized wheelchair is medically necessary for you to move around independently.
• How do I find out whether a motorized wheelchair is “medically necessary”?
• Your nursing facility has to arrange for an evaluation and then, if appropriate, a full wheelchair assessment by an independent assessor who is experienced in rehabilitation seating and positioning. Then, the nursing facility must submit the assessment to a physician.
• The physician may prescribe a motorized wheelchair or explain to you, in writing, why the physician is not recommending a motorized wheelchair.
• Who pays for the motorized wheelchair?
It depends on whether you need a custom or non-custom motorized wheelchair and who your primary payor is.Your assessment and physician should determine which type of wheelchair you need.
• A custom motorized wheelchair is built specifically for you, in whole or in part. The Department of Healthcare and Family Services pays for custom motorized wheelchairs if you are Medicaid eligible and have no other insurance.
• A non-custom motorized wheelchair is one that is not built specifically for you. Your nursing facility pays for a non-custom motorized wheelchair.
• If I need a custom motorized wheelchair, how do I apply?
• You, your nursing facility, or anyone else on your behalf should send the assessment and physician’s prescription to the Durable Medical Equipment Supplier of the resident’s choice who is a provider enrolled under the Medical Assistance Program, who in turn will send a prior approval to the Illinois Department of Healthcare and Family Services.
• If the Department doesn’t approve my custom motorized wheelchair, what can I do?
• The denial notice the Department sends you will contain information on how to request a hearing.
Within 60 days of the denial, ask for a Fair Hearing in either of the following ways:
• Call the Department at 1-800-435-0774, or
• Complete a form provided by your caseworker with the Department of Human Services local office.
• What if the nursing facility won’t evaluate me for a motorized wheelchair, or won’t pay for a non-custom motorized wheelchair?
• Contact the Department of Healthcare and Family Services Healthcare Benefit Hotline at 1-800-226-0768, and let them know what happened.
• File a complaint with the Illinois Department of Public Health by calling 1-800-252-4343.