Rollin Positive wrote:
When the orders were sent to Medicare they review it then send it to my insurance (Aetna Medicare Advantage) and it was approved 100% in 2 weeks!
and in my case would have been 4 to 5 times more expensive than buying a used one.
DSquare wrote:I've been following this thread. My son is due for a new chair this spring and he wants a group 4 mainly because of the additional speed. I found this on Cigna's website, dated April 2020, regarding funding for group 4 chairs.
Group 4 PWC with enhanced features for use outside the home (HCPCS code K0868–K0871, K0877–K0880, K0884–K0886) when the individual's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity and the Group 3 multiple power option criteria are met AND the enhanced features are needed for the individual to participate in the activities of daily living in school and/or employment*.
A Group 4 PWC (HCPCS code K0868–K0871, K0877–K0880, K0884–K0886) for use outside of the home for leisure or recreational activities is considered a convenience item and not medically necessary.
I would think since he is still in high school that would qualify him for a group 4 chair.
DSquare wrote:I've been following this thread. My son is due for a new chair this spring and he wants a group 4 mainly because of the additional speed. I found this on Cigna's website, dated April 2020, regarding funding for group 4 chairs.
Group 4 PWC with enhanced features for use outside the home (HCPCS code K0868–K0871, K0877–K0880, K0884–K0886) when the individual's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity and the Group 3 multiple power option criteria are met AND the enhanced features are needed for the individual to participate in the activities of daily living in school and/or employment*.
A Group 4 PWC (HCPCS code K0868–K0871, K0877–K0880, K0884–K0886) for use outside of the home for leisure or recreational activities is considered a convenience item and not medically necessary.
I would think since he is still in high school that would qualify him for a group 4 chair.
ex-Gooserider wrote:DSquare wrote:I've been following this thread. My son is due for a new chair this spring and he wants a group 4 mainly because of the additional speed. I found this on Cigna's website, dated April 2020, regarding funding for group 4 chairs.
Group 4 PWC with enhanced features for use outside the home (HCPCS code K0868–K0871, K0877–K0880, K0884–K0886) when the individual's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity and the Group 3 multiple power option criteria are met AND the enhanced features are needed for the individual to participate in the activities of daily living in school and/or employment*.
A Group 4 PWC (HCPCS code K0868–K0871, K0877–K0880, K0884–K0886) for use outside of the home for leisure or recreational activities is considered a convenience item and not medically necessary.
I would think since he is still in high school that would qualify him for a group 4 chair.
The key thing sounds like finding things he NEEDS to do in school (i.e. related to academics, not sports or after-school clubs) that he can't readily do with a Group 3 chair... How to define those things may be a challenge, especially in high school. My recollection (long time back and before I was hurt) was that HS was essentially indoor activities that didn't involve much that couldn't be handled by making the school provide "reasonable accommodations' as required by the ADA...
College would probably be easier to get justification since there are more activities on a campus (going between buildings, etc) and if living in a dorm or apartment presumably one could add in all the ADL's of general living that wouldn't count as 'in school' if living at home....
Just my guess...
ART
ex-Gooserider wrote:FWIW, I'm on a couple of mailing lists for RESNA (the North American rehab manufacturers / dealers association) and a DME supplier magazine and according to them there is actually consideration underway to have Medicare cover seat lift / standing systems in power chairs... Much lobbying from the industry side, and they are also making a case that there is enough evidence of medical benefits to justify it....
The state level (but mostly federally funded) MedicAID systems are all over the map, with a lot of variation in what they will cover, etc. Again most are at some stage in considering coverage, but where they are in the process varies....
I am just dreading turning 65 in a couple more years and having to go on MedicARE instead of (or in addition to) Mass. Health, our state's MedicAID system...
ex-Gooserider
Commonwealth, also called Commonwealth of Nations, formerly (1931–49) British Commonwealth of Nations, a free association of sovereign states comprising the United Kingdom and a number of its former dependencies who have chosen to maintain ties of friendship and practical cooperation and who acknowledge the British monarch as symbolic head of their association. In 1965 the Commonwealth Secretariat was established in London to organize and coordinate Commonwealth activities.
Burgerman wrote:Commonwealth, also called Commonwealth of Nations, formerly (1931–49) British Commonwealth of Nations, a free association of sovereign states comprising the United Kingdom and a number of its former dependencies who have chosen to maintain ties of friendship and practical cooperation and who acknowledge the British monarch as symbolic head of their association. In 1965 the Commonwealth Secretariat was established in London to organize and coordinate Commonwealth activities.
I am confused. You use the american super confused system?
swalker wrote:Regarding a Group 4 wheelchair, Rollin Positive said:Rollin Positive wrote:
When the orders were sent to Medicare they review it then send it to my insurance (Aetna Medicare Advantage) and it was approved 100% in 2 weeks!
I think the fact that Rollin Positive has a Medicare Advantage plan is a very key difference.
For those who don't know, in the US, Medicare is a government health insurance program available to qualifying folks over the age of 65 or who are sufficiently disabled.
Medicare has several options. Loosely stated, the base portion, called Part A and paid for by the Government, only covers 80% of the cost of treatment and then only for treatment provided in a hospital setting. An optional portion paid for by the patient, Parth B, provides coverage outside of a hospital setting, subject to a deductible.
A Medicare Supplement policy is an optional policy provided by an non-government insurance company, paid for by the patient, that provides varying degrees of standardized coverage, depending the option selected.
A Medicare Advantage policy replaces Medicare and must provide the same coverage as Medicare, but can optionally provide much more.
Most folks would either get a Medicare Advantage policy or get Medicare Parts A and B along with a Medicare Supplement policy (and potentially other options I have not mentioned)
Rolling Positive apparently has a Medicare Advantage policy, and his insurance company is apparently more lenient about which wheelchairs they will fund.
I have Medicare Parts A and B along with a Medicare Supplement policy. Neither Medicare Parts A and B nor my Medicare Supplement insurance company willingly cover a group 4 wheelchair, unless there is a medical necessity for a capability only available on the group 4 wheelchair. This must be a medical necessity for carrying out essential Activities of Daily Living (ADLS) inside my house.
So, why don't I have a Medicare Advantage policy if they appear to provide better coverage? Because none are available that would allow me to see doctors within 100 miles of where I live. So, I am essentially excluded from the Medicare Advantage policy market.
It is a confusing mess, but the bottom line is that getting "Medicare" to cover a group 4 wheelchair is quite the challenge, and in my case would have been 4 to 5 times more expensive than buying a used one.
Steve
benjamin wrote:ex-Gooserider wrote:FWIW, I'm on a couple of mailing lists for RESNA (the North American rehab manufacturers / dealers association) and a DME supplier magazine and according to them there is actually consideration underway to have Medicare cover seat lift / standing systems in power chairs... Much lobbying from the industry side, and they are also making a case that there is enough evidence of medical benefits to justify it....
The state level (but mostly federally funded) MedicAID systems are all over the map, with a lot of variation in what they will cover, etc. Again most are at some stage in considering coverage, but where they are in the process varies....
I am just dreading turning 65 in a couple more years and having to go on MedicARE instead of (or in addition to) Mass. Health, our state's MedicAID system...
ex-Gooserider
Commonwealth resident here. I’m in my 30s work full-time on commercial insurance but will say leave it to Rollin’ he knows his stuff. I actually just bought a spare F5 (non-VS new style) with all power functions, light package, and anterior tilt.
I would look at some of the SCO (Senior Care Options) plans from Tufts or Commonwealth Care Alliance. SCO (also known as a “DSNP” for Dual eligible special needs plan) combines your Medicare and Medicaid benefits. Tufts I believe covers Group 4 for both government and commercial but you should call member services and confirm.
Rollin Positive wrote:Steve in talking back and forth I am sure you told me but the chair that was stolen was a F5? Cash buy or insurance?
expresso wrote:https://icsny.org/disability-advocates-praise-new-york-state-medicaid-changes/
means outdoor chairs can be billed allowed - means group 4 - i am sure insurance may still push back - its new and they all will be notified by the state - if they deny - fair hearing will approve anyway - so if you doing a chair today -
and you need a group 4 outdoor chair - insist on one with the vendor - who ever it may be - if they say no - show them this and if they dont want to place the order - find another vendor and report them - file a complaint etc, -
change always take some time for all parties to get used to the new norm.
Rollin Positive wrote:benjamin wrote:ex-Gooserider wrote:FWIW, I'm on a couple of mailing lists for RESNA (the North American rehab manufacturers / dealers association) and a DME supplier magazine and according to them there is actually consideration underway to have Medicare cover seat lift / standing systems in power chairs... Much lobbying from the industry side, and they are also making a case that there is enough evidence of medical benefits to justify it....
The state level (but mostly federally funded) MedicAID systems are all over the map, with a lot of variation in what they will cover, etc. Again most are at some stage in considering coverage, but where they are in the process varies....
I am just dreading turning 65 in a couple more years and having to go on MedicARE instead of (or in addition to) Mass. Health, our state's MedicAID system...
ex-Gooserider
Commonwealth resident here. I’m in my 30s work full-time on commercial insurance but will say leave it to Rollin’ he knows his stuff. I actually just bought a spare F5 (non-VS new style) with all power functions, light package, and anterior tilt.
I would look at some of the SCO (Senior Care Options) plans from Tufts or Commonwealth Care Alliance. SCO (also known as a “DSNP” for Dual eligible special needs plan) combines your Medicare and Medicaid benefits. Tufts I believe covers Group 4 for both government and commercial but you should call member services and confirm.
Ben Thank you for the kind words..
I think more then anything I just fight more then most!
So on your chair you funded it through your work insurance correct?
What did you have before the F5?
How are you liking the F5? Pros and Cons?
Rollin Positive wrote: (Much trimmed)
Our community in the US have become or are extremely passive when it comes to our needs?
We seem to take what is told to us from this industry and the funding industry/insurance as the final word and never push back or rarely push back
In the last year I have talked with people that are looking for a big sign that says "Group 4 funding this way"
But we are dealing with an industry that rewards chair funding with commission so that dictates behavior
If a person can sell you a group 3 and get if covered vs a group 4 that he or she may have to work harder proving needs which do you think they will push?
As I posted before I was in a F3 bought by my wifes insurance with state of Arizona as I was getting ready to retire 2015
6 months out 5/2020 I started doing research on people that had group 4 chairs via social media and the common thread was nothing done special other then documentation of need which is the same as for group 3 and the orders placed for group 4 and not allowing the DME reps to downgrade to a group 3
Chairs funded Permobil F5's non stander, Permobil M5 (mid wheel) Frontier v6 and Bounder
I don't recall anyone was declined
3 months out I had a talk with both my NuMotion ATP and my local Permobil rep and both said I cant fund a group 4
I asked if I needed to go to a different DME (wheelchair store) and NuMotion said no
A month out I had a teleconference with my neurologist and he wrote up my needs sent the rx to the NuMotion rep
2 weeks out I had a in person meeting with PT/OT and the NuMotion rep and we went over chair model and features needed and they worked together on making sure there orders matched and at the end of that meeting the OT literally sent his order to Medicare a few weeks out NuMotion sent there's to Aetna (Medicare Advantage) NuMotion has to get the cost of each base and features and "k codes" added to there order
In 1 week it was 100% funded!
I think my point is in helping expresso last week we sent an email to the CEO of NuMotion who sent that email to the east coast VP who told me specify group 4 chairs can not be funded
But I just had a group 4 chair paid for 2 months earlier and the CEO was aware of it
So one end doesn't know what the other end is doing or what's being approved
Waiting for expresso to get his chair before I address group 4 again as not to mess up his order
But if I was you don't take no for an answer and put the order in at worse if it gets declined check with the insurance and some make you wait 6 months to resubmit others let you just put in for a group 3 after the denial
expresso wrote:yes i feel Numotion should have - could have done more to get this moving - lets not forget - its your insurance that will either make it easy for you or not - and mines did not make it easy - they denied two appeals - means months go by - i am left with doing a fair hearing - which means many more months go by -
90 days only works if all goes smooth - paper works gets done and sent in to insurances - the moment the insurances get the order - it then can 30 to 45 days to get approved or denied - if both your insurances are so great and both approve it - then yeah you have a chair in 90 days - but that dosnt happen in real life 90% of the times
i hear more and more stories of the process taking much longer now - even if we take Numotion out of the picture -for a moment - its also the Clinic you visit that has to do paper work - in my case its was i believe both the Clinic and Numotions fault for many things - but what delayed mines was the insurance who denied it twice -
its very similar to what happens in the UK - BM gets chairs and payments sent to him to do as he wants - and the rest of them never get the same deal - it actually seems worse there with the chairs they are being offered 4mph chairs - thats ridiculous even for in door use -
unless you really need a group 4 chair for some reason - i wont even stress it make your life difficult for nothing - but if you do need one - then do it - just be prepared -
expresso wrote:yes i feel Numotion should have - could have done more to get this moving - lets not forget - its your insurance that will either make it easy for you or not - and mines did not make it easy - they denied two appeals - means months go by - i am left with doing a fair hearing - which means many more months go by -
90 days only works if all goes smooth - paper works gets done and sent in to insurances - the moment the insurances get the order - it then can 30 to 45 days to get approved or denied - if both your insurances are so great and both approve it - then yeah you have a chair in 90 days - but that dosnt happen in real life 90% of the times
i hear more and more stories of the process taking much longer now - even if we take Numotion out of the picture -for a moment - its also the Clinic you visit that has to do paper work - in my case its was i believe both the Clinic and Numotions fault for many things - but what delayed mines was the insurance who denied it twice -
its very similar to what happens in the UK - BM gets chairs and payments sent to him to do as he wants - and the rest of them never get the same deal - it actually seems worse there with the chairs they are being offered 4mph chairs - thats ridiculous even for in door use -
unless you really need a group 4 chair for some reason - i wont even stress it make your life difficult for nothing - but if you do need one - then do it - just be prepared -
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