Wheelchairs

Maine Care members are entitled to one wheelchair (standard, customized or power wheelchair) every five (5) years. Members who meet the eligibility requirements for both a prosthetic device necessary for functional mobility and a wheelchair must choose between the prosthetic device and the wheelchair. In addition, the member must sign a letter confirming this choice. Prior to the provision of a standard, customized or power wheelchair or power operated vehicle, the provider must submit a document indicating the necessary modifications or structural changes have occurred to allow for free access of the wheelchair through all entryways of the home.

Standard Wheelchair: before Maine Care will reimburse for a standard, manual wheelchair, the following criteria must be met:

• The member’s condition is such that without use of a wheelchair the member would otherwise be bed or chair confined.
• The primary purpose is not to allow the member to perform leisure or recreational activities.
• Payment is made for only one wheelchair at a time.
• A member’s residence must be handicapped accessible to meet the needs of the equipment being requested as Home/Environmental modifications are not covered.

Customized Wheelchairs: Maine Care will reimburse for customized, specially sized wheelchairs when all the criteria for a standard wheelchair are met. A physician’s or PCP’s certification or prescription that a special size is needed is not required if it can be determined from the information on file or other sources that a specially sized wheelchair is needed to accommodate the physical size of the member or the physical environment where the wheelchair will be used.

Power Wheelchairs: In addition to meeting all the criteria for a standard wheelchair, the Department reserves the right to request a second opinion of its choice from an occupational therapist, physical therapist, physiatrist, physician or PCP concerning medical necessity of the prescribed equipment for any request for authorization prior to provision for a power wheelchair. An itemized list of all necessary parts and adjusted acquisition cost and usual and customary price shall be provided to the Department, as well as documented medical evidence justifying the need for the prescribed equipment. A power wheelchair is considered medically necessary for individuals who lack the capacity to ambulate at least one hundred (100) feet. The inability to climb stairs is not considered a medical necessity indication for an electric, motorized or power wheelchair. Needs related to job, vocational school or college are not considered to be medically necessary. The inability to navigate rough terrain outside the home is not considered a medically necessary indication for a power wheelchair.

If the Maine Care member resides in a nursing facility or other setting where there is continuous supervision, the provider will need to document the member’s medical necessity to be independently mobile beyond what can be provided by staff.

Stair climbing or gyroscopically guided wheelchairs are not covered for Maine Care members.

Power wheelchairs must be prior authorized by Maine Care even if the member is eligible for Medicare.

For Maine Care members who are also eligible for Medicare, the following procedure must be followed. Providers must submit a request for reimbursement to Medicare Part B for the initial purchase of an electric wheelchair for those individuals who are eligible for reimbursement under that program:

1. The total payment will be no more than the established Maine Care allowance for electric wheelchairs;
2. The payment to the provider shall be reduced by any amounts paid by Medicare;
3. Maine Care allowance in non-assigned cases shall not be limited by the Medicare determination of medical necessity or allowable reimbursement rate; and,
4. Services initially prior authorized by Maine Care will reflect a reduction in reimbursement equal to Medicare average payment. Subsequent adjustments will be authorized following a review of all Medicare Explanations of Benefits or written correspondence.

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