In our previous blog, NPL Home Medical Insurance Liason, Martin Travis, introduced himself and his role. In this instalment, he covers eligibility for custom wheelchairs in nursing homes in Ohio, and how he can help ensure patients receive the devices they need.
For many patients in nursing homes, receiving a custom wheelchair results in a massive increase in their quality of life: their mood is elevated as pain is relieved, they are able to participate in meaningful activities and they can often socialize once more.
Unfortunately, while Ohio Medicaid has provisions for custom wheelchairs in nursing homes, the daunting application process and time required for evaluations can prevent applications from being made.
In this blog, our insurance liaison, Martin Travis, details the eligibility requirements for custom wheelchairs in nursing homes in Ohio, the application process and the appeals process.
Custom wheelchair considerations
Before we consider the eligibility requirements for custom wheelchairs in nursing homes, it’s helpful to consider some signs and symptoms that residents may be displaying that would indicate a positioning and wheelchair assessment may be required.
Appearing uncomfortable and restless
Low desire to get out of bed or into a wheelchair
Redness or pressure wounds on the sacrum or ischial tuberosities
Leaning forward or to the side
Falls from wheelchairs
Inability to propel the chair
Inability to reach wheels or reach the ground with their feet
Requesting multiple pillows to sit on
If a resident presents with any of these initial indicators, upon a closer look, they may benefit from a custom wheelchair.
What is a custom wheelchair?
The Ohio Code defines a custom wheelchair as
“A wheelchair that has a customized seating system. A custom wheelchair, therefore, cannot be easily used or adapted for use by another individual.”
This is why custom seating needs must first be identified before considering applying for a custom wheelchair.
Ohio Medicaid defines customized seating system as “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.”
Custom seating indications
So, what are indications that custom seating may be required? For therapists, we may quickly notice apparent problems when we first see a resident sitting in their wheelchair, but maybe we aren’t so sure how to articulate or detail the specific problems that necessitate custom seating. There may be many subtle problem areas that add up to one big problem.
The following are key areas to consider first are provided by the Ohio Department of Medicaid:
Other skeletal deformities
Range of motion impairments
Upper and lower extremity dysfunction
Skin conditions or susceptibility to pressure wounds
Inability to self-pressure relief or reposition
Bowel and bladder dysfunction
Custom wheelchair coverage
So we’ve identified someone who may benefit from custom seating and mobility. The next question is: who will pay for it?
Medicare and most private insurances do not cover custom wheelchairs for residents in the nursing home, however, Ohio Medicaid benefits will cover custom wheelchairs if the criterion of medical necessity is met.
Ohio Medicaid MyCare Plans
MyCare Plans are required to provide the same benefits as a traditional Medicaid and follow the same Ohio Medicaid guidelines. These MyCare plans can cover more than traditional Medicaid, but they cannot cover less.
It’s important to note that OAC 5160-1-1 states (E) “The definition and conditions of medical necessity articulated in this rule apply throughout the entire Medicaid program…” This goes along with rule 5160-58-02 MyCare Ohio plans: covered services (A) “A MyCare Ohio plan (MCOP) must ensure members have access to all medically-necessary medical, drug, behavioral health, nursing facility and home and community-based services (HCBS) covered by Ohio Medicaid.”
The two main Ohio Administrative Codes (OAC) that dictate eligibility are OAC 5160-1-1 Medicaid medical necessity: definitions and principles and 5160-10-16 DMEPOS: Wheelchairs.
To summarize 5160-1-1 as it pertains to wheelchairs, Medicaid covers items that prevent or treat illness, injury, disease, or its symptoms, emotional or behavioral dysfunction, intellectual deficits, cognitive impairment or developmental disability and without the requested item, this resident would be expected to suffer prolonged, increased or new morbidity; impairment of function; dysfunction of body organ or part; or significant pain and discomfort.
The first 6 general requirements for medical necessity are:
It meets generally accepted standards of medical practice,
It is clinically appropriate in its type, frequency, extent, duration, and delivery setting,
It is appropriate to the adverse health condition for which it is provided and is expected to produce the desired outcome,
It is the lowest-cost alternative that effectively addresses and treats the medical problem,
It provides unique, essential, and appropriate information if it is used for diagnostic purposes (This one does not apply to wheelchairs,
It is not provided primarily for the economic benefit of the provider nor for the sole convenience of the provider or anyone else other than the recipient.
Further, more wheelchair-specific criteria are outlined in OAC 5160-10-16 Number (7):
(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.
The evaluation process
Essentially, once custom seating needs are identified, we use an algorithmic approach to decide what kind of wheelchair will be the least restrictive, safest and most conducive to the applicant’s needs.
First, we consider walking devices such as canes, walkers, crutches, etc. Most of the time we already know these are inappropriate and can rule these out immediately. The resident may be able to walk with assistance, but this is not functional ambulation and should not be their only means of mobility. If the resident is non-ambulatory or is a non-functional ambulator, we can start with manual wheelchairs. If the resident is unable to propel any form of a manual wheelchair, despite trialling various types and adaptations, we move on to powerchairs. If they lack the safety, cognition, vision or any other skill capacity required for safe powerchair mobility, we go back to more of a total assist mobility device such as a tilt-in-space wheelchair.
After determining the type of wheelchair, we can identify other beneficial features to include in the wheelchair, such as power tilting, reclining and elevating leg rests, and various forms of controlling the device from a basic hand toggle to a complex head array system.
All these features must have supportive documentation to show medical necessity. For example, orthostatic hypotension, lower extremity lymphedema, or sacral pain can support the need for tilt/recline/elevating leg rests.
Letter of Medical Necessity
One way we can ensure all the criteria are being covered before submitting a request to Medicaid is by completing an Ohio Certificate of Medical Necessity, or Letter of Medical Necessity. This form is provided by Ohio Medicaid, and somewhat blocks-out areas for the therapist to organize the patient information.
Page 1: This contains basic patient information, ICD-10 codes, and 3 “most important clinical or functional factors to consider.”
Page 2: This is for manual wheelchair requests, such as ultra-light wheelchairs, tilt-in-space, and manual with power assist features.
Pages 3 and 4: These are for Power Mobility Device (PMD) requests for simpler powerchairs like “Jazzy’s” or more complex Group 3 Powerchairs that have tilt/recline, and elevating leg rests.
Page 5: This is for extra parts and accessories that aren’t included in the basic equipment package.
Page 6: This is arguably the most important page: it refers to the custom seating component. Chairs without custom seating will not be covered by Ohio Medicaid in the nursing home. The resident must have problems that necessitate a custom seating system in order to qualify for the wheelchair.
Page 7: This is for repair requests only. Your wheelchair vendor will have a representative that is very knowledgeable with Letters of Medical Necessity and ensure that if there is a need, it will be identified and addressed.
As therapists, we can all attest to the powerful impact that custom wheelchairs can have on our patients' lives.
I hope this guide has provided therapists in Ohio with valuable information and will aid them in securing custom wheelchairs for their patients wherever necessary for their well-being.
If you have any questions about this guide, please do not hesitate to get in touch with me using the button below.