Ala. Admin. Code r. 560-X-13-.17

Current through Register Vol. 42, No. 11, August 30, 2024

Section 560-X-13-.17 - Wheelchairs

(1) Wheelchairs are a covered benefit for patients who meet full Medicaid eligibility criteria and medical necessity. The patient must meet criteria applicable to wheelchairs pursuant to this chapter, and Chapter 14, DME, of the Medicaid Provider Manual.

(2) All requests for wheelchairs are subject to the Medicaid prior approval provisions in accordance with Rule No. 560-X-13-.03 and any additional requirements in Chapter 14, DME, of the Medicaid Provider Manual.

(3) Limitations and Exclusions

(a) Patients may be approved for one manual or power/motorized wheelchair every five years for children ages 0-20 and every seven years for adults ages 21-99 based on medical necessity.

(b) Home, environmental and vehicle adaptations, equipment and modifications are not covered.

(c) Repairs or replacement of parts require prior authorization unless otherwise specified by Medicaid.

(d) Within the five year period for children ages 0-20 and seven year period for adults ages 21-99, Medicaid will not repair or replace equipment that is lost, destroyed, or damaged as a result of misuse, neglect, loss or wrongful disposition or equipment by the recipient, the recipient's caregiver(s), or the provider. At a minimum, examples of equipment misuse, neglect, loss or wrongful disposition by the recipient, recipient's caregiver, or the provider include, but are not limited to the following:

1. Loss of wheelchair or parts.

2. Selling or loaning wheelchair or parts.

3. Damage due to weather.

4. Failure to store the wheelchair in a secure and covered area when not in use.

5. Use on public roadways where the speed limit is greater than 25 miles per hour.

6. Loss, destruction or damage caused by the malicious, intentional or negligent acts.

(4) Patient Education

(a) Providers are responsible for patient education and documentation of appropriate usage of wheelchair. Patient education shall include, but not be limited to, proper storage, usage on or off public roadways, battery life, cleaning, warranty, etc.

(b) Documentation of patient education and understanding by both the servicing provider and the recipient or caregiver shall be kept in the patient file for the life of the wheelchair.

(5) Reimbursement for wheelchair, except as outlined in this section for EPSDT-referred wheelchairs, will be made in accordance with the DME Fee Schedule located on the Medicaid website.

(6) Reimbursement for EPSDT-referred Wheelchair Systems

(a) All requests for EPSDT-referred wheelchairs are subject to the Medicaid prior approval provisions in accordance with Rule No. 560-X-13-.03 and the following additional provisions:

1. If no Medicare price is available for EPSDT-referred wheelchair systems, the reimbursement rate is established based on a discount from Manufacturers Suggested Retail Price (MSRP) instead of a "cost-plus" basis.

2. Providers are required to submit MSRPs from three manufacturers for wheelchair systems (excluding seating system and add-on products) appropriate for the individual's medical needs.

3. Requests submitted with less than three prices from different manufacturers must contain documentation supporting the appropriateness and reasonableness of equipment requested for a follow-up review by Medicaid staff or designee. Provider must document non-availability of required MSRPs to justify not sending in three prices.

(b) The established rate will be based on the MSRP minus the following discounts:

1. Manual wheelchair systems - 20% discount from MSRP

2. Power wheelchair system - 15% discount from MSRP

3. Ancillary (add-on) products:

(i) Electronic ancillary products - 15% discount from MSRP

(ii) Non-electronic ancillary products - 20% discount from MSRP

Ala. Admin. Code r. 560-X-13-.17

New Rule: Filed September 19, 2003; effective October 24, 2003. Amended: Filed August 11, 2004; effective September 15, 2004. Amended: Filed September 9, 2005; effective October 14, 2005. Amended: Filed December 12, 2008; effective January 16, 2009. Amended: Filed March 13, 2009; effective April 17, 2009. Amended: Filed November 9, 2012; effective December 14, 2012.

Amended by Alabama Administrative Monthly Volume XXXIV, Issue No. 04, January 29, 2016, eff. 2/25/2016.

Amended by Alabama Administrative Monthly Volume XXXV, Issue No. 09, June 30, 2017, eff. 7/24/2017.

Author: Keisha Howard, PDL Administrator, Clinical Services and Support

Statutory Authority: State Plan Attachment 4.19-A; 42 CFR, Section 440.70; Title XIX, Social Security Act.