Definitions and explanations.
"Basic equipment package" is the
following standard set of parts and accessories that come with a wheelchair at
the time of purchase:
(a) A sling or solid
seat with back, a captain's chair, or a stadium-style seat;
(b) Standard casters or wheels with
non-elevating legrests with footrests
Wheel locks or brakes;
(f) With a
power mobility device, motors;
With a power mobility device, a non-expandable controller;
(h) With a power mobility device, a battery
(i) With a power
wheelchair, a standard proportional joystick; and
(j) With a power-operated vehicle,
rehabilitation technology (CRT)" is a categorization of wheelchair equipment
individual evaluation, fitting,
configuration, adjustment, or programming is
to meet the specific medical and functional needs of the user, as
well as services related to those products. CRT includes, for example,
customized seating systems, adaptive positioning devices, and alternative drive
systems (directional interfaces other than a standard joystick).
(3) "Custom wheelchair" is a wheelchair that
has a customized seating system. A custom wheelchair, therefore, cannot be
easily used or adapted for use by another individual.
(4) "Customized seating system" is a
wheelchair seat, wheelchair back, or combination of wheelchair seat and back
that has been tailored specifically to the particular body shape and
positioning needs of an individual user. Customization may be achieved by means
of molding, contouring, carving, or other forms of fabrication or by the
integration of prefabricated components into the wheelchair frame. Items such
as seat cushions and other removable positioning aids do not by themselves
constitute a customized seating system.
"DMEPOS Fee Schedule" is a list of
payment amounts for durable medical equipment, prostheses, orthoses, and
supplies published by the centers for medicare and medicaid services (CMS); it
is available at http://www.cms.gov
January 2015 revision is the basis for the medicaid payment amounts described
in paragraph (E) of this rule.
"Individualized seating system" is a wheelchair seat, wheelchair back, or
combination of wheelchair seat and back that has been tailored to the body
shape and positioning needs of an individual user by means of installing and
configuring prefabricated cushions or other removable positioning
"Medical necessity" is
defined in rule
of the Administrative Code. Wheelchairs and wheelchair parts and accessories
meet additional criteria in order to be considered medically necessary:
Wheelchairs and wheelchair parts and
accessories are generally not necessary nor even useful in the absence of
illness, injury, impairment, disability, or other condition that limits
provide mobility to an individual
for whom ambulation is not possible, takes inordinate physical effort, or
causes considerable physical discomfort.
also needs to
suited to the purposes and daily routines of the individual using it.
A manual wheelchair
provide a level of needed functionality that cannot be achieved with an
assistive device such as a cane, a crutch or crutches, or a walker.
A power mobility device (PMD)
provide a level of needed functionality that cannot be achieved with a manual
be functional in the environment in which it is used. The individual (or
someone assisting the individual)
have the ability to take proper care of
the PMD, the individual's place of residence
accessible and have adequate electrical service, transportation of the PMD
be available as necessary, and there
be sufficient protection for the PMD
from the elements. The place of residence is considered to be accessible only
if the individual will be able to use the PMD without assistance to enter and
leave the residence and to move easily about the main living space (which is
used for purposes such as food preparation, eating, sleeping, personal hygiene,
enable an individual to sit (or recline, as
appropriate) for long periods of time, provide postural support to permit
functional activities, or reduce pressure on the body to a degree that cannot
be achieved with items such as a standard wheelchair seat, an individualized
seating system (e.g., a prefabricated seat cushion or other removable
positioning aid or combination of positioning aids), or a spinal orthotic
verification" is a process, similar to prior authorization, by which the
department determines whether to make payment for the repair of a wheelchair
part or accessory that exceeds the established frequency guideline. One purpose
of need verification is to enable the department to consider whether the
purchase of a new piece of equipment might be more cost-effective than
mobility device (PMD)" is a collective term for a power wheelchair or a
power-operated vehicle (POV, commonly referred to as a "scooter"). Each PMD is
classified on the basis of performance into one of eight groups developed under
the auspices of CMS:
(a) Group one
two power-operated vehicles;
Group one power wheelchairs;
Group two power wheelchairs;
Group three power wheelchairs;
Group four power wheelchairs;
Group five power wheelchairs; and
(h) Power mobility devices not otherwise
maintenance" of a wheelchair is any upkeep that is necessary to maintain
optimum functioning of the equipment and that does not
a skilled or trained technician to perform.
(11) "Wheelchair" is a collective term for a
manual wheelchair or a power mobility device.
Prescribing providers. Eligible medicaid
providers of the following types, acting within their scope of practice, may
certify the medical necessity of a wheelchair:
(a) A physician;
(b) An advanced practice registered nurse
with a relevant specialty
(e.g., clinical nurse
specialist, nurse practitioner);
(c) A physician assistant; or
(d) A podiatrist.
Evaluators. The following professionals
may evaluate an individual's particular needs:
(a) For wheelchairs incorporating CRT, a
physiatrist, orthopedic surgeon, neurologist, physical therapist, or
occupational therapist; or
wheelchairs not incorporating CRT, a physician, physical therapist, or
Rendering providers. The following
eligible providers may furnish a wheelchair, part, or accessory or may render a
(a) For manual wheelchairs
without CRT, a provider enrolled as a basic durable medical equipment (DME)
For PMDs and CRT,
a provider enrolled as a specialized
with appropriate certification or licensure from the
Ohio respiratory care board (ORCB) to engage in business involving
Billing providers. The following eligible providers may receive medicaid
payment for submitting a claim for a wheelchair, part, accessory, or related
(a) For manual wheelchairs without
CRT, a provider enrolled as a basic DME supplier; or
For PMDs and CRT, a provider enrolled as
with appropriate certification or licensure from the
ORCB to engage in business involving wheelchairs
must be determined to be medically necessary
The medical necessity of a wheelchair needs to be
before the department will make payment. For a wheelchair
purchased by the department, this necessity is documented on form ODM 03411,
"Certificate of Medical Necessity: Wheelchairs" (rev.
). The medical necessity of a wheelchair that
has not been purchased by the department is documented either on this
certificate of medical necessity (CMN) or on an equivalent form.
(b) If more than one type of wheelchair will
meet an individual's needs and satisfy the criteria of medical necessity, then
the maximum payment amount is the lowest of the respective costs, regardless of
which wheelchair is supplied.
The provision of or payment for the purchase, repair, or rental of a medically
necessary non-custom wheelchair for a resident of a longterm care facility
(LTCF) is the responsibility of the LTCF. This responsibility holds even if the
wheelchair incorporates CRT other than a customized seating system. In turn,
the LTCF receives medicaid payment in accordance with Chapter 5160-3 of the
Administrative Code. Therefore, claims submitted to the department by
wheelchair suppliers for the purchase, repair, or rental of non-custom
wheelchairs furnished to LTCF residents will be denied.
Custom wheelchairs for individuals living
in a LTCF and wheelchairs for individuals not living in a LTCF. Prior
authorization (PA) is
, and a face-to-face evaluation of need
be performed by a prescribing provider not earlier than one hundred eighty days
before the submission of the PA request.
The purchase of a wheelchair
includes the basic equipment package, delivery, setup, instruction and training
in use, and adjustments or minor modifications. No separate payment is made for
these items. Payment for other parts or accessories, either parts or
accessories that are substituted for individual items in the basic equipment
package or parts or accessories outside the basic equipment package that are
added after a wheelchair is purchased,
will not be given for the purchase of more than one wheelchair for concurrent
use by an individual. An exception to this restriction may be made if it can be
satisfactorily demonstrated that having a second wheelchair, such as
manual wheelchair in addition to a
significantly improves an individual's
mobility and is cost-effective.
Repair, including replacement of existing
parts or accessories.
for individuals living in a LTCF and wheelchairs for individuals not living in
a LTCF. The repair of a component such as a frame, seating system, motor, drive
system, or battery is subject to need verification. No verification is
for the repair of a wear item, such as a
caster bearing, tire, arm pad).
For a wheelchair not purchased by the
department, submission of documentation of the medical necessity of the
wheelchair itself is
for the initial repair but not for
subsequent repairs. The determination that a wheelchair not purchased by the
department is medically necessary does not indicate that the wheelchair itself
would be authorized for purchase.
Payment is not permitted for temporary
replacement equipment (a "loaner wheelchair")
provided while an individual's wheelchair is being repaired
(e.g., a "loaner wheelchair")
(iii) No payment is made for routine
Custom manual wheelchairs. PA is
Non-custom manual wheelchairs for
individuals not living in a LTCF. No PA is
the first three months. PA is
for rental periods after the first three
PMDs. PA is
(i) Payment will not be made for
the rental of more than one wheelchair per month for an individual.
(ii) Payment for rental is all-inclusive; no
separate payment is made for any other wheelchair-related items.
During a rental period and for ninety
days afterward, all rental amounts paid are applied toward purchase. The total
of the rental amounts
exceed the purchase amount.
(a) An evaluator may receive
payment for determining an individual's needs for a wheelchair. Not more than
one payment will be made per wheelchair per individual.
(b) Payment includes all services rendered by
the evaluator, including evaluation, product selection, confirmation at
delivery, and follow-up.
After delivery, the supplier
maintain documentary evidence that the following statements are true concerning
a wheelchair and any related accessories:
They were delivered to the individual for whom they were prescribed;
(b) They are consistent with the items
described in the CMN; and
correspond exactly to the items listed on the submitted claim.
(2) Claim payments for which there
is insufficient documentation are subject to recovery.
A PA request
all relevant information (e.g., HCPCS code, manufacturer, model). A PA request
include the serial number of the equipment
and a complete itemization of parts and estimated labor needed.
(4) When an authorization specifies a
manufacturer, model, part number, or other information identifying a particular
item, then a supplier may provide and subsequently submit claims only for the
not be authorized for a wheelchair to be used by an individual younger than one
year. For a child one year of age or older whose needs are not met by an
adult-sized wheelchair, consideration for authorization will be given only to
wheelchairs that accommodate growth, unless there is a more appropriate,
cost-effective, medically necessary alternative available. Payment may be made
for additional parts
to "grow" a wheelchair if the combined
cost of the parts and related labor is less than the cost of a new
(6) Payment will not be
authorized for wheelchairs, parts, accessories, or modifications whose primary
application is leisure or recreational activities.
(7) Payment will not be authorized for a PMD
intended exclusively for outdoor use.
(8) A wheelchair purchased by medicaid is the
property of the individual for whom it was prescribed.
As of the effective date of this rule,
the payment amount is established as the lesser of the submitted charge or the
applicable medicaid maximum from the following list:
(a) For purchase of a covered new wheelchair,
part, or accessory, ninety per cent of the allowed amount listed for Ohio on
the "DMEPOS Fee Schedule";
purchase of a covered group four power wheelchair for which there is no
medicare allowed amount, one hundred ten per cent of the medicaid maximum
payment amount allowed for purchase of the most closely corresponding covered
group three power wheelchair;
For purchase of any other covered wheelchair, new part, or new accessory for
which there is no medicare allowed amount, payment by report;
(d) For purchase of a covered wheelchair,
part, or accessory that has been previously used but remains in good working
order, fifty per cent of the medicaid maximum payment amount allowed for
purchase of a comparable new wheelchair, part, or accessory;
(e) For monthly rental of a covered
wheelchair to which rental applies, ten per cent of the medicaid maximum
payment amount allowed for purchase;
(f) For performance of an evaluation and
related services, eighty per cent of the amount established by the medicare
physician fee schedule; or
labor provided for a covered repair or covered maintenance, the result L
obtained by the formula L = ([W + B] × P + M) × A × 0.25.
(i) L is the medicaid maximum payment amount
for labor, reported in fifteen-minute units.
W is the hourly median wage for medical
equipment repairers in Ohio reported by the United States bureau of labor
statistics (available at http://www.bls.gov/oes/
). (The initial
wage figure used was from May 2014.)
(iii) B is hourly employee-related expenses
such as benefits, calculated as thirty-five per cent of wages.
(iv) P is a productivity adjustment factor,
defined as the ratio of the number of total work hours per day (specified as
eight) to the number of available productive work hours per day (specified as
six and a half).
M is an hourly
mileage allowance, defined as the ratio of the daily mileage allowance to the
number of available productive work hours per day. The daily mileage allowance
is the product of the average travel speed (specified as thirty-five miles per
hour), the average total travel time (specified as one hour and fifteen
minutes), and the federal standard mileage rate for business (available at
). (The initial
standard mileage rate used was for 2015.)
(vi) A is an administrative cost factor,
specified as one hundred ten per cent.
(2) After the effective date of this rule, if
the medicare amount for an item or service becomes less than the current
medicaid maximum payment amount, then the medicaid maximum payment amounts
related to that item or service are reestablished on the basis of the new
(3) After the
effective date of this rule, if updates to the median hourly wage or the
federal standard mileage rate would cause a variance of at least five per cent
in the maximum payment amount for labor, then the maximum payment amount is
reestablished on the basis of the updated figures.
The payment provisions of this rule
supersede entries in appendix DD to rule
Administrative Code that pertain to wheelchairs, parts, accessories, or related