Medicare & Medicaid Funding Flashcards

Under Medicare Part B, which documentation is required from the treating physician before a power wheelchair can be approved?

Answer: A written order and face-to-face examination within 6 months of the order

Medicare requires a written order and a face-to-face examination by the treating physician within 6 months prior to the order for complex power wheelchairs.

A beneficiary needs a power operated vehicle (scooter) but also qualifies for a power wheelchair. Medicare will typically fund whichever device:

Answer: Is least costly that still meets the beneficiary's medical needs

Medicare uses the least costly alternative principle, covering the least expensive device that adequately meets the beneficiary's medical needs.

Under the Medicare Durable Medical Equipment competitive bidding program, beneficiaries in contract areas must obtain complex power wheelchairs from:

Answer: Only suppliers that won a competitive bidding contract for that area

In competitive bidding areas, Medicare beneficiaries must use contract suppliers for covered DME items or risk denial of claims.

Which Medicare coverage group classification applies to a power wheelchair with power seat elevation and power tilt features?

Answer: Group 3 Complex Rehabilitative Power Wheelchair

Power wheelchairs with power seat elevation and power tilt are classified as Group 3 Complex Rehabilitative Power Wheelchairs under the Medicare coding system.

A Medicaid recipient's wheelchair claim is denied because the device is deemed 'not medically necessary.' The FIRST step in the appeals process is typically:

Answer: Submitting a redetermination or internal appeal to the Medicaid agency

Most state Medicaid programs require an internal redetermination or reconsideration before a beneficiary can request a formal fair hearing.

Medicare's 'in the home' requirement for mobility equipment coverage means the device must be primarily used:

Answer: In the beneficiary's home environment, which can include immediate surroundings

Medicare requires that the mobility device be necessary for use within the home environment, which includes the immediate surroundings such as a porch or yard.

Under Medicare Part B, what is the standard beneficiary cost-sharing responsibility for approved durable medical equipment?

Answer: 20% of the Medicare-approved amount after the annual deductible

Medicare Part B covers 80% of the approved amount for DME after the annual deductible, leaving the beneficiary responsible for 20% coinsurance.