Who pays for wheelchairs, cushions, and other seating equipment in LTC?
The answer is two-fold:
Long Term Care Residents:
If your patient lives in the facility, then Medicare pays the facility to provide for the needs of the resident. Each facility can have their own policies on what they will purchase, however they are mandated to provide what is medically necessary for each resident.
- Speak to your rehab director and find out the facility policy.
- Ask which distributor your facility has a contract with. Distributors are most often used for facility purchases as pricing is often better than with a dealer/supplier.
- See Federal Guidelines summarized below.
Short Term Rehab Patients:
Always think of prognosis with these patients. If you have a patient who will be going home and you know they will not be a functional/safe ambulator, then you can help them get the equipment they need when they go home. Medicare/Medicaid/Insurance will pay for wheelchairs and seating equipment when they are discharged from the facility. So what should you do?
- Establish a good relationship with a local dealer/supplier who understands wheelchair seating, the medicare criteria, and documentation requirements for reimbursement (there’s a difference!)
- Invite the dealer/supplier to come to the facility with samples that your patient can try to determine the best options prior to discharge.
- Ask the dealer/supplier to help you understand what the Medicare Criteria is for wheelchairs and seating equipment to determine what they qualify for and how to document OR refer to Permobil’s justification charts to help you determine what they qualify for, and how to document in your daily notes for that equipment.
- When the patient is discharged, Medicare/Medicaid/Insurance will pay for the appropriate equipment based on criteria and documentation
Federal Guidelines Summary:
A NF participating in Medicaid must provide, or arrange for, nursing or related services and specialized rehabilitative services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
There is no exhaustive list of services a NF must provide, in that unique resident needs may require particular care or services in order to reach the highest practicable level of well being. The services needed to attain this level of well-being are established in the individual’s plan of care.
Specific to each state, the general or usual responsibilities of the NF are shaped by the definition of NF service in the state’s Medicaid state plan, which may also specify certain types of limitations to each service. States may also devise levels of service or payment methodologies by acuity or specialization of the nursing facilities. (1)
Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that:
- A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and
- A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
- The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident’s clinical condition demonstrates that a reduction in range of motion is unavoidable; and
- A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.
- A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. (2)
1. 42 CFR 483.25 - Quality of care. (2018). Retrieved from https://www.law.cornell.edu/cfr/text/42/483.25
2. Nursing Facilities | Medicaid.gov. (2018). Retrieved from https://www.medicaid.gov/medicaid/ltss/institutional/nursing/index.html
Ana Endsjo, MOTR/L, CLT
Clinical Education Manager LTC Division
Ana Endsjo has worked as an occupational therapist since 2001 in a variety of treatment settings. She has mainly worked with the geriatric population, dedicated to the betterment of the treatment of the elderly in LTC centers. Her focus has been on seating and positioning and contracture management of the nursing home resident. With this experience, her hope is to guide other therapists, rehab directors, nurses, and administrators through educational guides, blogs, webinars, and live courses in her role as Clinical Education Manager for the long term care division.