Wheelchairs 101: Understanding Wheelchair Options, Coverage and the Acquisition Process
Written By: Dr. Katie Wadland, PT, DPT, Board-Certified Geriatric Clinical Specialist
Owner: Healthy Aging Physical Therapy
As a physical therapist, I have had the privilege of working with many individuals who rely on wheelchairs to maintain their independence and quality of life. The reasons for needing a wheelchair are as diverse as wheelchair users themselves, and a well-matched chair can make a world of difference. From those with new spinal cord injuries who require an agile, lightweight manual chair to take the place of walking in the setting of traumatic paralysis, to the patient who has had a stroke and now needs a specialized ‘hemi-chair’ designed for propulsion with one side of the body, each journey is unique.
While many people initially see a wheelchair as a step back, I often see it as a step forward. A wheelchair can open doors to independence, freedom of mobility, and a reduced reliance on caregivers. Although I sometimes encounter hesitation or pushback when bringing up the idea of a wheelchair, I frequently find that once the process is complete, my patients experience newfound freedom and vastly improved quality of life.
In my current practice, I most often work with patients with neurodegenerative diseases, like multiple sclerosis (MS) or Parkinson’s Disease, who can still ambulate part of the time but may need a wheelchair with custom features, like the ability to tilt-in-space, elevate seat height or powered mobility, to manage fatigue, enable longer-distance mobility, support posture in the presence of kyphosis and scoliosis and maintain independence in their daily tasks. Most recently, I had the opportunity to help my own mother obtain a custom power wheelchair. After living with Parkinson’s disease (PD) for 20 years, her postural impairments began affecting her ability to breathe, function, and manage back pain. The chair provided her with much-needed relief and now allows her to access her facility’s dining room even during periods when walking is too difficult due to ‘off times’ and back pain.
(PS: You’ll see some pictures from my mom’s assessment and fitting throughout the blog - special thanks to Derek Logan, PT, ATP from REQ for your help with this process!)
No two reasons for needing a wheelchair are the same. This is why a thorough assessment by a knowledgeable therapist, in collaboration with a skilled vendor, is essential to finding the best solution for each individual’s needs. At Healthy Aging Physical Therapy, we frequently provide wheelchair assessment training in conjunction with a variety of local vendors and I’d like to take this opportunity to shed some light on what this typically entails.
Wheelchairs, Scooters and Powered Mobility Options
When it comes to mobility devices, there are many options to consider. The choice between a standard wheelchair, a custom manual or power chair, or a scooter depends on the user’s specific functional and medical needs. Each type of mobility aid comes with its own set of features, costs, and considerations.
Scooters
Scooters are three - or four-wheeled motorized devices for individuals who can sit upright and operate controls but require assistance for longer distances due to weakness or cardiopulmonary conditions. Scooters are an excellent choice for those with some mobility but who experience fatigue with walking. They are often not covered by insurance and usually require an out-of-pocket investment ranging from $800 to $3,000. Many scooters can break down or fold up for transportation and can be tried at local durable medical equipment vendors and pharmacies.
PS: The above image is from the movie Thelma. If you haven’t seen it yet, stop reading and go watch it:)
Transport Wheelchairs
Transport wheelchairs are often purchased online or at medical supply stores and are the lightest, most easily transportable wheelchairs available. They typically have small wheels and limited seat and lumbar support; this enables them to be light enough to transport easily in and out of the car, but are also not designed for long term use as they do not provide adequate postural support for the user. Transport wheelchairs are not typically covered by insurance (unless you meet the criteria for a standard chair, but cannot self-propel and have a 24/7 caregiver who can assist) and cost anywhere from $100-$300 typically.
Standard Manual Wheelchairs
Standard manual wheelchairs are the most basic option covered by insurance, and are often used for short-term needs or rental purposes. These chairs are manually propelled and typically cost between $100 and $500. They are ideal for individuals who do not require specialized features and need a temporary mobility solution. Medicare and other insurance plans may cover standard wheelchairs if they are deemed medically necessary, and are often issued during hospital stays in a ‘rent to own’ manner in which the Medicare beneficiary pays a small amount a month for thirteen months and then ‘owns’ the wheelchair.
Custom Manual Wheelchairs
Custom manual wheelchairs are tailored to the user’s specific dimensions and functional requirements. These chairs may include lightweight frames, adjustable seating, and positioning supports to enhance comfort and postural alignment. They are commonly used by individuals with conditions such as spinal cord injuries or neurological disorders. Custom manual wheelchairs generally cost between $1,500 and $5,000, depending on the materials and features. Custom manual wheelchair acquisition requires a wheelchair assessment by a therapist and vendor team, a visit with a doctor who will provide documentation to certify medical necessity, and insurance coverage often requires detailed documentation to justify the need for customization.
Power Wheelchairs
Power wheelchairs are motorized devices designed for individuals who have limited upper body strength or severe postural issues. These chairs can include advanced features such as recline, tilt-in-space, and elevation to address complex needs. Power wheelchairs are best suited for individuals with conditions like MS, Parkinson’s disease, or other impairments that significantly limit strength and mobility. The cost of a power wheelchair can range from $2,000 to over $20,000, depending on the level of customization and technology. Medicare typically covers power wheelchairs, but only after a thorough assessment to establish medical necessity. These assessments need to be provided by a therapist and vendor team, and the individual will also need to visit with their doctor who will need to complete additional paperwork (‘Face to Face’ visit) to support the medical necessity of this device.
Fun Fact: The average custom power chair weighs between 200 and 300 pounds. And, no, you cannot lift it into the trunk of your car!
Beyond Mobility: Other Important Reasons to Consider a Wheelchair
While mobility is often the primary reason for a wheelchair, there are several other important considerations that influence the need for a specific type of chair.
Preventing Skin Breakdown and Pressure Ulcers
For individuals who spend long hours in their wheelchairs, proper seating and support are critical to prevent skin breakdown and pressure ulcers. Specialized cushions, adjustable seat angles, and recline and tilt-in-space features can help individuals redistribute pressure and protect vulnerable areas, ensuring comfort and long-term skin health.
Providing Postural Support
Postural support is essential for individuals with trunk weakness or structural deformities. A well-designed wheelchair can enhance alignment, improving not only comfort but also critical functions like breathing and digestion. For example, we might choose to increase the seat angle (aka ‘seat dump’) and use a contoured seat back to improve pelvic alignment and maintain a healthy posture throughout the day, reducing pain and fatigue.
Enhancing Functional Abilities
Wheelchairs with advanced features can improve functional abilities in daily life. Elevating seat mechanisms, for instance, allow users to reach higher surfaces such as kitchen counters and cabinets, enabling tasks like cooking and cleaning. Additionally, alternative drive options like head controls or adapted joysticks can enable mobility even in users with limited hand function.
Reducing Caregiver Reliance
By addressing mobility and functional needs comprehensively, a wheelchair can reduce reliance on caregivers. This increased independence not only improves the user’s quality of life but also eases the burden on family members and care teams and can improve family dynamics considerably.
How do I get a Custom Wheelchair?
Acquiring the right wheelchair is a multi-step process that involves collaboration between the patient, therapist, and vendor. Here is what to expect:
Initial Wheelchair Assessment: Your therapist and vendor team will conduct a comprehensive assessment of the individual’s mobility, strength, posture, and functional needs. This evaluation helps determine the type of wheelchair that will best meet the user’s requirements. These can be done in a Wheelchair Clinic or at-home with a provider like Healthy Aging Physical Therapy. You will have the opportunity to trial a chair similar to the one you will likely end up with to see if it would be a good fit.
Therapist/Vendor Collaboration: The therapist works closely with the wheelchair vendor to determine the best type of wheelchair for you, and identifies any necessary modifications or adaptations to meet your needs. They then work together to fill out the necessary paperwork and complete a Letter of Medical Necessity.
Documentation Submission: The prescribing physician, therapist and vendor provide detailed paperwork, including the assessment findings and justification for medical necessity. This documentation is submitted to Medicare or other insurance providers for approval.
Approval and Order Placement: Once the paperwork is approved, the vendor places the order for the wheelchair. Once approved, the equipment is ordered and the wheelchair is prepared for you. For custom manual or power chairs, this step may involve further adjustments and fittings.
Delivery and Fitting: Once the wheelchair is ready, your vendor and therapist will meet with you again to deliver the chair and provide any additional modification that may be needed. Things like the arm rest height and head rest position will need to be set for you specificically to ensure the best fit. If there are any larger issues, your vendor may take pieces of the chair back to be adapted as needed.
Wheelchair Training: Now the fun begins! Just like learning to drive a car, learning to drive your new wheelchair will take some practice. Your therapist will work with you to learn to drive it forward, backwards and to turn so you can safely and efficiently navigate your home and community.
Timeline for Custom Chairs: The entire process, from evaluation to delivery, can take anywhere from 6 to 12 weeks if everything goes smoothly. This timeline depends on the complexity of the chair and the speed of approval from insurance providers and can take up to 6 months at times if there are delays along the way.
Will Medicare Pay for my Wheelchair?
Medicare provides coverage for wheelchairs under its Part B Durable Medical Equipment (DME) benefit, but specific criteria must be met. Most commercial plans also have a DME benefit that is typically based on, or similar to, Medicare standards. Coverage is available when a physician prescribes a wheelchair for use in the home due to a medical condition that limits mobility. Here’s an overview of how this coverage typically works:
Eligibility Requirements: Once you meet with your therapist and vendor team to trial your wheelchair and determine your needs, a physician must then conduct a face-to-face assessment and document the medical necessity of the wheelchair. This documentation is then submitted to Medicare for review.
Types of Wheelchairs Covered: Medicare covers basic manual chairs (rent to own), custom manual chairs, and power wheelchairs if the features are medically justified.
Scooters: Medicare may cover scooters in limited circumstances, such as when mobility is restricted both inside and outside the home, but this coverage is less common.
Costs: For approved devices, Medicare typically covers 80% of the cost, leaving the user responsible for the remaining 20%, either out-of-pocket or through supplemental insurance.
Modification and Replacement: Generally speaking, Medicare expects your custom chair to last at least 5 years. Should your chair require modifications or repair within that five year time frame, you will need to work with your vendor to fix your current chair in most situations. If modifications are required due to a change in your medical status, they may be covered by medicare, but repairs due to wear and tear may be an out of pocket cost. After five years is up, you may be eligible for a new chair should you demonstrate medical necessity for a new chair at that time.
Choosing the right wheelchair is a collaborative process that requires a deep understanding of the individual’s needs and goals. By working closely with a skilled therapist and an experienced vendor, users can find a solution that not only meets their medical requirements but also improves their quality of life. Whether it’s a lightweight manual chair for someone with a spinal cord injury or a custom power chair for postural support, the right match makes all the difference.
At Healthy Aging Physical Therapy, we are proud to offer custom wheelchair assessments in the comfort of your home. This approach can be incredibly beneficial, not only for individuals who may find it difficult to access a clinic but also for tailoring recommendations to fit seamlessly into your living environment. By evaluating how a wheelchair will work within your home - from navigating doorways to accessing essential spaces - we can ensure the best possible outcome for your mobility and independence. If you or someone you know could benefit from an in-home wheelchair assessment, we encourage you to reach out to learn more about how we can help.
