CMC Medicare & Medicaid Funding 2 — Questions and Answers
Question 1: Under Medicare Part B, which documentation is required from the treating physician before a power wheelchair can be approved?
- A written order and face-to-face examination within 6 months of the order (Correct answer)
- A telephone authorization and a therapist's recommendation
- A prescription dated within 30 days with no examination required
- A hospital discharge summary and a DME supplier quote
Correct 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.
Question 2: A beneficiary needs a power operated vehicle (scooter) but also qualifies for a power wheelchair. Medicare will typically fund whichever device:
- The beneficiary prefers regardless of clinical need
- Is least costly that still meets the beneficiary's medical needs (Correct answer)
- The physician recommends even if a less expensive option exists
- The DME supplier has in stock and can deliver fastest
Correct 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.
Question 3: Under the Medicare Durable Medical Equipment competitive bidding program, beneficiaries in contract areas must obtain complex power wheelchairs from:
- Any Medicare-enrolled DME supplier nationwide
- Only suppliers that won a competitive bidding contract for that area (Correct answer)
- Suppliers chosen exclusively by the treating physician
- Any supplier the beneficiary selects regardless of contract status
Correct 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.
Question 4: Which Medicare coverage group classification applies to a power wheelchair with power seat elevation and power tilt features?
- Group 1 Standard Power Wheelchair
- Group 2 Standard Power Wheelchair
- Group 3 Complex Rehabilitative Power Wheelchair (Correct answer)
- Group 4 Standard Power Wheelchair
Correct 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.
Question 5: 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:
- Filing a complaint with the state insurance commissioner
- Requesting a fair hearing directly from the federal government
- Submitting a redetermination or internal appeal to the Medicaid agency (Correct answer)
- Filing a lawsuit in federal court
Correct 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.
Question 6: Medicare's 'in the home' requirement for mobility equipment coverage means the device must be primarily used:
- Exclusively indoors and never taken outside
- In the beneficiary's home environment, which can include immediate surroundings (Correct answer)
- Only in skilled nursing facilities covered under Medicare Part A
- In any public location where the beneficiary spends time
Correct 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.
Question 7: Under Medicare Part B, what is the standard beneficiary cost-sharing responsibility for approved durable medical equipment?
- 0% — DME is fully covered with no cost sharing
- 10% after the deductible is met
- 20% of the Medicare-approved amount after the annual deductible (Correct answer)
- 50% coinsurance for any DME item over $500
Correct 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.
CMC Medicare & Medicaid Funding 2
Under Medicare Part B, which documentation is required from the treating physician before a power wheelchair can be approved?