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Medicare funding policy: timeline

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December 8, 9, 10, 2003 Four DMERCs issue identical web bulletins on their respective web sites “clarifying” current Medicare coverage policy for power wheelchairs and power operated vehicles. [1] Regarding coverage, the web bulletins state “If a patient can bear weight to transfer from a bed to a chair or wheelchair, the patient is considered non-ambulatory,” resulting in the so-called “one step rule.” The bulletins also describe documentation that the DMERCs will review and accept upon an audit to determine medical necessity, and stated that the following information, in the medical record would be necessary: The distance that the patient can walk (a) independently and (b) with the assistance of a walker or other ambulatory aid; Strength and function of the upper and lower extremities (including tone, range of motion limitations, etc.); The diagnosis that is associated with the limitations.

February 24, 2004 CMS holds Special Open Door meeting to receive public input regarding DMERC bulletins and Medicare Coverage of Power Wheelchairs

March 19, 2004 CMS sends an e-mail to Capitol Hill announcing it will retract the December 2003 DMERC web bulletins.

March 31, 2004 CMS holds Open Door Forum on Medicare coverage of Power Wheelchairs

April 28, 2004 Senate Finance Committee, Oversight and Investigations Subcommittee holds a hearing to discuss the recent fraud in Harris County Texas regarding the provision of power wheelchairs and how CMS and the DMERCs allowed it to occur. Witnesses from the government included the GAO, OIG and CMS; a clinician (Laura Cohen, PhD, PT) and a consumer representative (Henry Claypool) also testified. CMS announced its “three pronged initiative to address the issues: 1. Draft and issue coverage guidance; 2. Develop more stringent Medicare Supplier Standards; and 3. Develop new codes for power wheelchairs. [2]

June 14, 2004 CMS holds Listening Session (DC) to announce the members of the Interagency Wheelchair Workgroup and proposed timeline to develop and finalize Medicare coverage guidance on power wheelchairs and POVs. CMS listens to comments from the public about what the coverage clarification should state.

June 28, 2004 California Federal District Court rules that CMN is the only documentation that CMS has authority to require to substantiate medical necessity.

July 16, 2004 Senators Charles Grassley (R-IA) and Max Baucus (D-MT) write a letter to HHS Secretary Tommy Thompson urging need for the agency to balance consumer access with efforts to combat fraud and abuse.

July 26, 2004 Interagency Wheelchair Work Group (IWWG) convened and charged with reviewing CMS’s mobility device prescription policy, evaluating the available evidence on mobility devices, and recommending policy for appropriate prescription of mobility devices. 30-day public comment period opened.

September 1, 2004 CMS held a public forum on coding for power wheelchairs.

October 6, 2004 CMS holds first meeting of Program Advisory and Oversight Committee (PAOC), a group of 22 individuals charged with advising CMS as it implements competitive bidding for DME, per the MMA.

November, 2004 US Government Accountability Office (GAO) released second report “CMSs Program Safeguards Did Not Deter Growth in Spending for Power Wheelchairs”

December 6-7, 2004 CMS holds second meeting of PAOC.

December 16, 2004 CMS announces opening a National Coverage Determination (NCD) to review its criteria for wheelchair coverage under Medicare beginning 30-day public comment period.

February 3, 2005 CMS releases proposed decision memorandum for new coverage criteria for wheelchairs and scooters and releases new coding for power wheelchairs expanding from 4 to 43 codes. New power wheelchair codes must be used for all wheelchair claims by January 2006. All manufacturers must submit results of wheelchair testing to SADMERC by September 1, 2005 for code qualification.

February 28 - March 2, 2005 CMS holds third meeting of PAOC.

May 5, 2005 CMS releases a new National Coverage Determination (NCD) for mobility assistive equipment (MAE). The medical necessity of all MAE - including manual and power wheelchairs, walkers, canes, crutches, and scooters - is addressed by this NCD. To now qualify for MAEs, a disability must impact one’s activities of daily living as carried out in the home.

July 2005 Members of both the House and Senate present bipartisan “Dear Colleage” sign-on letters to HHS requesting modifications to the “in the home restriction.”

August 26, 2005 CMS issues an Interim Final Rule (IFR) called, “Conditions for Payment of Power Mobility Devices. This IFR, to be effective October 25, 2005, changes the criteria for prescribing and documenting power mobility devices. This IFR requires physicians to conduct a face-to-face evaluation with each patient, to provide an extensive written order to the power mobility device supplier, and to do so within thirty days of the evaluation.

October 2005 Members of the Senate request that CMS postpone the October 25, 2005 implementation of the new Medicare policy on powered mobility.

October 25, 2005 CMS’s IFR “Conditions for Payment of Power Mobility Devices” becomes effective.

December 30, 2005 President Bush postpones CMS’s IFR released on August 26, 2005.

April 5, 2006 CMS releases the final ruling on powered mobility, to be effective June 5, 2006.

June 5, 2006 CMS’s IFR becomes effective after being reissued by CMS. The new IFR version differs from the original, released on August 26, 2005, in that physicians now has 45 days to provide a written powered mobility device order.

July 2006 Senators Bingham (D-NM) and Santorum (R-PA) introduce The Medicare Independent Living Act of 2006 to change Medicare’s “in the home” criterion for power mobility devices, as outline in the NCD.

August 2006 Final local coverage determination (LCD) for power mobility devices is made by Medicare. The LCD downcodes the Medicare wheelchair benefit, requires that power mobility devices beneficiaries be unable to independently stand and pivot when transferring from or to the wheelchair as a results of a neurological and myopathical condition, and includes a revision to the “in the home” restriction.

September 20, 2006 A revised LCD is released by CMS. Downcoding is addressed by the revisions. To qualify for a Group 3 power mobility device an individual must be unable to independently stand and pivot and require the use of the PMD only “in the home”..

October 3, 2006 The new fee schedule amounts that relate to new PMD codes are released and scheduled for implementation effective November 15, 2006. The 2006 PMD fee schedule ceiling and floor amounts have been calculated with approximately a 30% reduction in reimbursement. [3]

Author: Laura Cohen