Section 5160-10-16 - DMEPOS: wheelchairs(A) Definitions and explanations. (1) "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 tires;(d) Standard front rigging , such as non-elevating legrests with footrestsor a footplate;(e) Wheel locks or brakes;(f) With a power mobility device, motors;(g) With a power mobility device, a non-expandable controller;(h) With a power mobility device, a battery charger;(i) With a power wheelchair, a standard proportional joystick; and(j) With a power-operated vehicle, batteries.(2) "Complex rehabilitation technology (CRT)" is a categorization of wheelchair equipment items for which individual evaluation, fitting, configuration, adjustment, or programming is needed 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.(5) "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. The January 2015 revision is the basis for the medicaid payment amounts described in paragraph (E) of this rule.(6) "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 aids.(7) "Medical necessity" is defined in rule 5160-1-01 of the Administrative Code. Wheelchairs and wheelchair parts and accessories need to meet additional criteria in order to be considered medically necessary: (a) 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 ambulation. Therefore, a wheelchair needs to provide mobility to an individual for whom ambulation is not possible, takes inordinate physical effort, or causes considerable physical discomfort.(b) A wheelchair also needs to be suited to the purposes and daily routines of the individual using it.(c) A manual wheelchair needs to 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.(d) A power mobility device (PMD) needs to provide a level of needed functionality that cannot be achieved with a manual wheelchair.(e) A PMD needs to be functional in the environment in which it is used. The individual (or someone assisting the individual) needs to have the ability to take proper care of the PMD, the individual's place of residence needs to be accessible and have adequate electrical service, transportation of the PMD needs to be available as necessary, and there needs to 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, and relaxation).(f) A customized seating system needs to 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 device.(8) "Need 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 continued repair.(9) "Power 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 power-operated vehicles;(b) Group two power-operated vehicles;(c) Group one power wheelchairs;(d) Group two power wheelchairs;(e) Group three power wheelchairs;(f) Group four power wheelchairs;(g) Group five power wheelchairs; and(h) Power mobility devices not otherwise classified.(10) "Routine maintenance" of a wheelchair is any upkeep that is necessary to maintain optimum functioning of the equipment and that does not need a skilled or trained technician to perform.(11) "Wheelchair" is a collective term for a manual wheelchair or a power mobility device.(B) Providers. (1) Prescribing providers. Eligible medicaid providers of the following types, acting within their scope of practice, may certify the medical necessity of a wheelchair: (b) An advanced practice registered nurse with a relevant specialty ;(c) A physician assistant; or(2) 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(b) For wheelchairs not incorporating CRT, a physician, physical therapist, or occupational therapist.(3) Rendering providers. The following eligible providers may furnish a wheelchair, part, or accessory or may render a related service:(a) For manual wheelchairs without CRT, a provider enrolled as a basic durable medical equipment (DME) supplier; or(b) For PMDs and CRT, a provider enrolled as a specialized DME supplier .(4) Billing providers. The following eligible providers may receive medicaid payment for submitting a claim for a wheelchair, part, accessory, or related service:(a) For manual wheelchairs without CRT, a provider enrolled as a basic DME supplier; or(b) For PMDs and CRT, a provider enrolled as a specialized DME supplier .(C) Coverage. (1) Principles. (a) The medical necessity of a wheelchair needs to be determined 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. 7/2021). 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.(c) 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.(2) Purchase. (a) Custom wheelchairs for individuals living in a LTCF and wheelchairs for individuals not living in a LTCF. Prior authorization (PA) is needed, and a face-to-face evaluation of need has to be performed by a prescribing provider not earlier than one hundred eighty days before the submission of the PA request.(b) Constraints and limitations.(i) 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, is subject to PA.(ii) Authorization 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 a manual wheelchair in addition to a PMD, significantly improves an individual's mobility and is cost-effective.(3) Repair, including replacement of existing parts or accessories.(a) Custom wheelchairs 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 needed for the repair of a wear item, such as a caster bearing, tire, arm pad).(b) Constraints and limitations. (i) For a wheelchair not purchased by the department, submission of documentation of the medical necessity of the wheelchair itself is needed 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.(ii) Payment is not permitted for temporary replacement equipment (a "loaner wheelchair") provided while an individual's wheelchair is being repaired .(iii) No payment is made for routine maintenance.(4) Rental. (a) Custom manual wheelchairs. PA is needed.(b) Non-custom manual wheelchairs for individuals not living in a LTCF. No PA is needed for the first three months. PA is needed for rental periods after the first three months.(d) Constraints and limitations.(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.(iii) During a rental period and for ninety days afterward, all rental amounts paid are applied toward purchase. The total of the rental amounts cannot exceed the purchase amount.(5) Evaluation and management.(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.(D) Additional Constraints and limitations. (1) After delivery, the supplier needs to maintain documentary evidence that the following statements are true concerning a wheelchair and any related accessories:(a) They were delivered to the individual for whom they were prescribed;(b) They are consistent with the items described in the CMN; and(c) They correspond exactly to the items listed on the submitted claim.(2) Claim payments for which there is insufficient documentation are subject to recovery.(3) A PA request needs to specify all relevant information (e.g., HCPCS code, manufacturer, model). A PA request for repair needs to 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 specified item.(5) Payment will 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 needed to "grow" a wheelchair if the combined cost of the parts and related labor is less than the cost of a new wheelchair.(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.(E) Claim payment. (1) 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";(b) For 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;(c) 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(g) For 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.(ii) 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).(v) 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 http://www.irs.gov). (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 medicare amount.(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.(4) The payment provisions of this rule supersede entries in appendix DD to rule 5160-1-60 of the Administrative Code that pertain to wheelchairs, parts, accessories, or related services.Ohio Admin. Code 5160-10-16
Effective: 7/1/2021
Five Year Review (FYR) Dates: 4/16/2021 and 07/01/2026
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02, 5165.01, 5165.47
Prior Effective Dates: 04/07/1977, 12/21/1977, 12/30/1977, 01/01/1980, 03/01/1984, 05/01/1990, 12/30/1991, 07/01/1994, 08/01/1995, 08/01/1997, 04/01/1998, 10/01/2004, 10/27/2005, 04/01/2006, 07/31/2009 (Emer.), 10/29/2009, 04/25/2011, 12/31/2013, 01/01/2017, 06/12/2020 (Emer.)