Does Medicare pay for a Hoveround chair? Here's what you need to know

For over 28 years, Hoveround has provided more Medicare-reimbursed power chairs directly to their customers than any other manufacturer. However, whether Medicare pay for a Hoveround chair depends entirely on meeting specific criteria for medical necessity, not just desiring a particular brand.

Quick Summary

Medicare Part B covers power wheelchairs, including Hoveround models, if a doctor determines it is medically necessary for in-home use. Coverage requires a face-to-face evaluation, a written prescription, and sourcing from a Medicare-approved supplier.

Key Points

• Medical Necessity is Key: Medicare pays for a Hoveround only if it's medically necessary for home use, not just for convenience or brand preference.

• Start with a Doctor's Visit: You must have a face-to-face mobility evaluation with a Medicare-enrolled doctor to receive a prescription.

• Meet Strict Criteria: You must have a significant mobility limitation in your home and cannot safely use a cane, walker, or manual wheelchair.

• Follow the Paperwork Process: The DME supplier, such as Hoveround, will submit your doctor's prescription and documentation to Medicare.

• Prior Authorization May Be Needed: Certain models may require prior authorization, adding a review step by Medicare before approval.

• Understand Your Costs: After meeting the Part B deductible, Medicare pays 80%, leaving you with a 20% coinsurance that may be covered by a supplemental plan.

• Appeal a Denial: If your claim is denied, you have the right to appeal the decision with additional medical documentation.

Medicare and Durable Medical Equipment (DME)

Medicare Part B covers certain medically necessary durable medical equipment (DME), which includes power mobility devices like wheelchairs and scooters. A Hoveround chair is a brand name for a type of power wheelchair, and it is not covered simply because it's a specific product. The key to coverage is that the equipment must be considered medically necessary based on a thorough evaluation by a Medicare-enrolled doctor. The Centers for Medicare & Medicaid Services (CMS) sets the national coverage rules that all power mobility device suppliers, including Hoveround, must follow.

The Path to Medicare Coverage

To have Medicare help pay for a power wheelchair, a beneficiary must go through a specific process. Hoveround explicitly outlines these steps and assists its customers with the necessary paperwork to ensure all requirements are met.

1. Doctor's Visit: You must have a face-to-face evaluation with a Medicare-enrolled doctor. This appointment cannot be a general check-up but must be a specific mobility evaluation. The doctor will assess your mobility limitations and determine if a power wheelchair is the right solution for you to perform daily living activities safely inside your home.
2. Written Order: Following the evaluation, your doctor must provide a written order, also known as a prescription or Certificate of Medical Necessity. This order details why the specific device is medically necessary, and it must be submitted to the supplier within 6 months of the exam.
3. Supplier Involvement: You must obtain your equipment from a durable medical equipment (DME) supplier that is enrolled with and accepts Medicare. Hoveround acts as the supplier and handles all the Medicare paperwork on your behalf once they receive your doctor's order.
4. Prior Authorization: Certain types of power wheelchairs require prior authorization before Medicare will pay. The DME supplier will work with your doctor to submit the required documentation for prior authorization. Medicare then reviews the request and sends a decision letter to you and the supplier.
5. Delivery and Training: Once approved, the supplier delivers the chair and provides training on its safe and proper use.

Medical Necessity Criteria for Power Wheelchair Coverage

Medicare has specific, non-negotiable criteria that must be met to qualify for power mobility device coverage. Your doctor and the DME supplier must document that you meet all of these conditions.

To qualify, you must have:

• A mobility limitation that significantly impairs your ability to perform at least one Mobility-Related Activity of Daily Living (MRADL) in your home. Examples of MRADLs include bathing, dressing, getting in or out of a bed or chair, or using the bathroom.
• Documentation showing that your mobility limitation cannot be sufficiently and safely resolved by using an appropriately fitted cane or walker.
• For a power wheelchair (not a scooter), documentation that you do not have sufficient upper body strength to operate a manual wheelchair.
• A home environment where you can actually use the equipment. The doctor or supplier must confirm that it is not too big to maneuver through doorways and living spaces in your home.

Cost and Payment Structure

If you meet all the requirements and your claim is approved, the financial coverage structure is straightforward.

• You must have Medicare Part B coverage and meet your annual Part B deductible.
• After the deductible is met, Medicare Part B typically pays 80% of the Medicare-approved amount for the device.
• You are responsible for the remaining 20% coinsurance.
• If you have a Medigap (Medicare Supplement) policy, it may cover some or all of your 20% coinsurance.
• For most power wheelchairs, you will rent the equipment for 13 months, and ownership transfers to you after that period.

Comparison of Power Mobility Devices Under Medicare

Medicare differentiates between different types of power mobility devices, each with its own coverage requirements. Your medical condition will determine which category is medically necessary for your needs.

Feature	Manual Wheelchair	Power-Operated Vehicle (Scooter)	Power Wheelchair (Hoveround)
Best For	Limited mobility, with adequate upper body strength or caregiver assistance.	Limited mobility, unable to use a cane or walker, but able to stand/sit and operate controls.	Cannot use a manual wheelchair and do not qualify for a scooter.
Key Requirement	Physician's order stating medical need for home use.	Inability to operate a manual wheelchair or other aids safely.	Inability to operate a manual wheelchair or scooter safely due to strength limitations.
Maneuverability	Requires user or caregiver propulsion.	Tiller steering, better for open spaces.	Joystick control, tight turning radius for use in smaller spaces like a home.
Medicare Payment	Typically 80% of approved amount after deductible.	Typically 80% of approved amount after deductible.	Typically 80% of approved amount after deductible.
Prior Authorization	Generally not required.	May be required depending on type.	Often required.

What to do if your request is denied

If Medicare denies your prior authorization request or claim, you have the right to appeal the decision. A denial can happen if the documentation is insufficient or if Medicare determines the device is not medically necessary. You or your DME supplier can resubmit the request with more detailed documentation from your doctor to justify the medical need. For more information on the appeals process, visit the official Medicare website.

Conclusion

In summary, Medicare can and does pay for a Hoveround chair, but it is not an automatic process. The decision hinges on a documented medical necessity that proves you cannot use a less complex mobility aid to function safely within your home. The process involves a face-to-face evaluation by your doctor, a written order, and potentially prior authorization, all handled through a Medicare-approved supplier like Hoveround. By following the outlined steps and ensuring your doctor's documentation is comprehensive, many beneficiaries can receive their power mobility device with minimal or no out-of-pocket cost.

For more detailed information on power mobility device coverage, visit the official Medicare website at www.medicare.gov/coverage/wheelchairs-scooters.

Frequently Asked Questions

Will Medicare automatically pay for a Hoveround if my doctor prescribes it?

No, a doctor's prescription is only the first step. Medicare requires that you meet several specific medical necessity criteria and that the DME supplier receives approval, which can include a prior authorization process.

What is considered a 'Mobility-Related Activity of Daily Living' (MRADL) by Medicare?

MRADLs are routine tasks you must perform to live independently at home. Medicare examples include bathing, dressing, getting in or out of a bed or chair, and using the bathroom.

Does my home environment need to be evaluated?

Yes, either your doctor or the durable medical equipment (DME) supplier is required to verify that the power wheelchair can be used safely and effectively within your home.

What if my request for a Hoveround is denied?

If your request is denied, you have the right to appeal the decision. You and your DME supplier can work together to provide additional information to Medicare to justify the medical necessity.

Does my Medicare Advantage plan cover a Hoveround?

Yes, Medicare Advantage (Part C) plans are required to cover all the same benefits as Original Medicare, including medically necessary power wheelchairs. However, costs and network rules may differ.

Can I get a Hoveround for use outside my home?

Medicare coverage for power mobility devices is primarily for use inside the home. While some use outside the home is allowed, it cannot be the sole reason for needing the device.

Will Medicare pay for repairs to my Hoveround?

Yes, Medicare Part B covers repairs for power chairs, but you will need documentation from your doctor confirming the continued medical necessity of the equipment.