Forcing isolation: Medicare's "in the home" coverage standard for wheelchairs.
Older adults and people with physical disabilities can get Medicare coverage for mobility devices, like wheelchairs, walkers, and scooters, which are necessary for use in their homes. However they cannot get coverage for mobility devices that are solely for functioning outside their home. Since the institution of Medicare's coverage standards for mobility devices, and other kinds of durable medical equipment, nearly four decades ago, advances have been made in three critical areas: improvements in design of mobility devices that allow people to participate more fully in their communities; widespread societal recognition that with appropriate accommodations many limitations on functioning can and should be lifted; and recent court decisions requiring that individuals with disabilities be provided with the necessary supports to live as independently as possible in their communities. The current interpretation of Medicare's coverage standards for mobility devices does not reflect these advances. The Centers for Medicare and Medicaid Services' (CMS) interpretation of Medicare's coverage standard prevents people from getting needed medical equipment to function within their communities. By contemporary medical and legal standards, the [CMS's] interpretation is unreasonable and quite likely unlawful. The Medicare statute neither specifies that durable medical equipment is exclusively for use in the patient's home nor bars consideration of an equipment's use outside the home. There is no indication of Congressional intent to support this limitation of coverage. CMS has both the authority and the responsibility to interpret the Medicare statute so as to be consistent with historical developments in law, technology and social mores. United States Supreme Court precedent holds that agencies are "charged with the administration of [a] statute in light of everyday realities." Everyday realities have changed since Medicare was launched in 1965. Laws such as the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990 and the Ticket to Work and Work Improvements Incentives Act of 1999 reflect a broad, bipartisan commitment to increasing community integration of people with disabilities. This commitment is evident in judicial decisions, including Olmstead v. L.C. ex rel. Zimring, and executive orders, such as President George W. Bush's New Freedom Initiative, a set of proposals to promote opportunities for Americans with disabilities to learn and develop skills, engage in productive work, make choices about their daily lives, and participate fully in their communities. Developing political and legal standards are consistent with medical opinion: the costs of isolation for people with disabilities can include poorer health outcomes and higher systematic health costs. Also, scientific evidence indicates that people who get inappropriate mobility devices given their needs develop secondary medical conditions. In light of technological advances that today make appropriate equipment available and community integration possible, CMS has a responsibility to update its interpretation of the Medicare statute. While CMS must rightly be concerned with costs associated with a more modern interpretation of Medicare's coverage policy, other insurers have found that an appropriate standard has not led to an explosion in the provision of more expensive mobility devices. Specifically, the brief recommends that the Centers for Medicare and Medicaid Services: (1) correct its Medicare coverage policy to cover medically appropriate mobility devices that help maintain or improve functioning for people in the environments they are likely to encounter in their daily routines (both inside and outside of the home), and (2) guard against unnecessary expenses for Medicare by incorporating mandatory equipment evaluations to ensure that people receive equipment that matches their needs. While durable medical equipment encompasses a wide array of assistive devices, this brief will focus on wheeled mobility items, recognizing that this analysis will have varying applications to other durable medical equipment as well.
D006699:Home Care Services; D019458:Insurance Coverage / Q000592:standards*; D006278:Medicare / Q000331:legislation & jurisprudence*; D014481:United States; D014910:Wheelchairs